BIG SUR, CA—Leaders of major national organizations representing holistic healthcare practitioners, along with pioneers in the research and practice of natural medicine met in March at the Esalen Institute to try to identify obstacles that hinder the evolution of a more collaborative, humanistic, truly integrative healthcare system.

	The Esalen Institute, Big Sur, California, was host to a recent summit that brought together leaders from key holistic medical organizations to identify economic, political and interpersonal factors that obstruct greater collaboration between health practitioners. Esalen has attracted thought leaders in health and medicine since the early 1960s. Photo courtesy Esalen Institute.

Amid the splendor of the central California Coast in early Spring, representatives of the American Holistic Medical Association (AHMA), the American Association of Naturopathic Physicians (AANP), the American Holistic Nurses Association (AHNA), the American Board of Holistic Medicine (ABHM) the American College for the Advancement of Medicine (ACAM), as well as leaders of consumer health advocacy groups and independent research institutions took an honest look at the economic, political, institutional, and personal issues that inhibit collaboration between MDs, naturopaths, chiropractors, nurses, massage therapists, herbalists and practitioners of Ayurveda, Chinese medicine, and other non-allopathic systems.

This is the first time leaders of these organizations have gathered on common ground to hear one another’s perspectives.

“Complementary and alternative medicine professionals all talk about collaborative practice, but I don’t see a lot of it happening. There are reasons it is not happening, and I wanted to explore these reasons,” said Bill Benda, MD, Esalen’s medical director, and a graduate of the University of Arizona’s Integrative Medicine Fellowship. Dr. Benda and Nan Dunne, ND, president of the AANP, organized the summit.

The stated goal of the 3-day weekend was, “To dig deeply inside ourselves to discover and unblock the collaboration we have been talking about for 20 years.” The holistic field is brimming with high-minded dialogs and “White Papers” about integration and collaboration. But in the trenches, successful collaborations are still rare.

Economic inequities, lack of understanding between various practitioner groups, and historical turf boundaries certainly play their parts in the status quo. More importantly, individual practitioners are often afraid to reach a friendly hand over the perceived fences and connect with others who have different training.

“We want to (collaborate), and yet there are parts of each of us that are reluctant. We revert back to well-established roles, and we avoid what we really sweat about,” said Dr. Dunne.

Esalen: Epicenter of Holism

There could hardly be a more apt setting for this sort of gathering. Esalen Institute has served as the epicenter of the human potential movement for more than 40 years. From its roots as a meeting place for visionaries like Aldous Huxley, Fritz Perls, Gregory Bateson, and Ida Rolf, Esalen has hosted thousands of conferences and workshops on a vast array of health practices. Much of the groundwork for what has become the holistic or “integrative” medicine movement was initially laid at Esalen.

From 1971 to 1974, the Institute ran an intensive program on Humanistic Medicine, that involved 20 physicians, nurses and healthcare practitioners who committed one weekend each month for three years, to learn about then-exotic subjects like biofeedback, acupuncture, meditation, Rolfing, Gestalt therapy and other non-allopathic methods. Participants in that 3-year experiment included: Ken Pelletier, PhD, Rachel Naomi Remen, MD, Dean Ornish, MD, Andrew Weil, MD, and others who’ve become recognized leaders in integrative medicine.

“In many ways, this gathering is a reincarnation of the first conference on humanistic medicine which took place in 1971,” said Dr. Benda. The summit was funded through generous support from the Esalen Institute, the AANP, the North American Board of Naturopathic Medical Examiners, and independent donors including Peter Amato, Mary Stranahan, DO, Mary Ellen Klee, and Ann Cole.

Sukie Miller, PhD, a psychologist, who with her husband Stuart was among Esalen’s founders, recalled the history of the humanistic medicine program. “We felt the healthcare system should be more humane, and doctors needed to know about these other healing approaches. The healthcare system was too authoritarian. We wondered how to translate principles of humanism into healthcare.”

Over the past 30 years, many techniques and principles explored at Esalen have filtered into mainstream medicine. Guided imagery, biofeedback, acupuncture, meditation and stress reduction—once considered “fringe” or “non-scientific”—have been validated by clinical research and are now widely practiced in the nation’s hospitals, clinics and medical schools.

Still, Dr. Miller voiced frustration at the relatively slow pace of progress. “I came here to hear something new,” she told participants at the current gathering. “As glorious as Esalen may be, we tend to preach to the choir. I’ve been to thousands of these kinds of gatherings, and heard all this stuff about the dynamics between physicians and other practitioners for years. Where’s the block?”

A Changing Health Care Landscape

“Things are definitely different than they were 20 years ago, but still, things are going down the paths of least resistance,” said Dr. Dunne. “We all agree that the system we have sucks, but how will it change? What do we have to let go of, and what do we have to do, to accelerate positive changes?”

Dr. Weil, an alumnus of the original Esalen humanistic medicine program, believes the healthcare landscape is vastly different now than it was in 1974. The greatest changes have been economic. “Back then, there was no perceived crisis in healthcare, no sense of economic collapse,” he told Holistic Primary Care in an interview. “Doctors could pretend nothing was wrong and just do business as usual, ignoring the consequences and the consumers. Now, there’s huge disarray. Physicians and patients are both unhappy.”

Public support of holistic healthcare has grown massively since the 1970s, said Ana Micka, President and CEO of Citizens for Health, the nation’s largest health-related consumer advocacy and public policy group. “The medical professionals are only here because the consumers are moving. There are millions of people hungry for this, and looking for leadership. Millions are looking beyond what the standard model of medical care tries to give us. We need to put decisions back into the hands of consumers, and to respect and honor their decisions.”

Economic Inequities

While out-of-pocket consumer spending on supplements, herbal medicines, and holistic health services has soared in recent years, the balance of economic and political power in healthcare remains invested in a model focused largely on disease care, driven by pharmaceutical company interests, and overseen by the insurance companies and HMOs. For the most part, established systems still exclude the vast majority of holistic practitioners and their techniques.

“Many of the people I went to [naturopathic medical] school with cannot make a living at it,” said Karen Fuller, ND, who lives in New York State. “I’m practicing in a state without ND licensure, and I can’t make a living. I’m invisible by and large, and I make my living doing social work.” Only 14 states currently have licensure for NDs. The vast majority of insurance plans do not cover their services.

Research funding for natural therapeutics has increased considerably over the last decade, thanks in large measure to the NIH’s National Center for Complementary and Alternative Medicine (NCCAM) and its current annual budget of nearly $130 million. But this is still small change compared with the volume of dollars spent by the pharmaceutical industry and government agencies on conventional medical research.

“The top of the evidence hierarchy is only available to certain power levels because it requires access to certain very high levels of institutional support, funding sources, technology. The system is totally structured and ranked. There’s a built-in rankism to the structures of ways of knowing,” said Wayne Jonas, MD, who was director of the original Office of Alternative Medicine within NIH, which later evolved into NCCAM. He is now director of the Samueli Institute for Information Biology, an independent, non-profit international research institution.

Drug companies, equipment manufacturers, and academic medical research community have a huge financial and philosophical investment in maintaining a particular view of health and illness, largely to the exclusion of other viewpoints. “No one ever discusses the biases that determine the research funding streams. At the top of the evidence chain, you have a bioconcentration of bias,” said Sheila Quinn, Director of Special Projects for the Institute for Functional Medicine, and a leader of the Integrated Health Care Policy consortium.

Participants in the Esalen summit agreed that the macroeconomic situation is not likely to change soon. “I have been spending a lot of my energy going to the conventional power structures, raging against the non-level playing field. The change is not going to happen that way. They are not going to share their power. Yet there is a lot of power with the consumers. This is where my energy has to go, to helping find a clear message to articulate to the public,” said Jane Guiltinan, ND, the AANP’s president elect.

Corporate America: An Untapped Ally?

The nation’s corporate leaders will likely play a major role in the future of integrative healthcare. Joe Pizzorno, ND, one of the founders of Bastyr University, and the editor of Integrative Medicine: A Clinician’s Journal, believes there is a golden opportunity to win business leaders as allies for integrative, humanistic healthcare.

“We have to go to the payors, to Corporate America. Recently, I had a meeting with the vice-president of human resources for a Fortune 25 company. He is incredibly frustrated with healthcare. He’s close with people in similar positions at Kraft, GE, and UPS. They are desperate for healthcare solutions. We need to go to the heads of corporations. They do not care (about medical turf battles). They want real solutions,” said Dr. Pizzorno.

To win the hearts and minds of corporate leaders, as well as public advocacy groups, leaders of the holistic health movement must come together to create a coherent vision of what this diverse and fragmented field has to offer. More importantly, they must back that message with good research showing the clinical and economic value of the holistic, humanistic approach.

“A dollar is a storage device for social energy. To get those dollars, and that social energy behind us, we need a clear, supportable, well-articulated message,” said David Matheson, Bastyr’s Director of Public Affairs, and a long-time veteran of public policy efforts to support natural medicine in Washington State. “We are currently in an adaptive moment. We need to be uncomfortable long enough until new learning comes in, and new solutions become possible.”

From “Either/Or” to “Both/And”

Crafting a clear mandate will require greater bridge-building within the practitioner community, and a willingness to look honestly at the strengths and failings of each approach. This will inevitably create personal and professional challenges for all health professionals. Larry Palevsky, MD, a pediatrician who is incoming president of the AHMA, articulated the difficulty: “The hardest aspect of holism is to be able to hold multiple perspectives that may seem opposed with one another, and yet are all true. It is very hard to hold the ‘And.'”

At the ground level, individual practitioners—whatever their training or clinical approach—feel threatened by the knowledge, therapeutic practices, and economic power belonging to other “camps.” Many long-time practitioners of “alternative” medicine feel that after decades of being marginalized, suppressed or openly attacked by conventional allopathic medicine, their methods are now on the verge of being co-opted by the medical mainstream as popular interest forces conventional physicians to take a closer look.

“One big fear I have regarding collaboration is that in the collaborations there will be winners and losers, and the things I care about will be the losers,” said IFM’s Sheila Quinn.

Some of the non-MD participants at the Esalen gathering pointed out that MDs have the legal right to practice almost any technique they choose to, and that they are supported by licensure and credentialing laws, not to mention third-party reimbursement. For example, an MD with relatively little training in acupuncture can usually practice it more freely, and more easily obtain reimbursement than an oriental medicine practitioner with vastly greater acupuncture training.

Several of the MDs quickly countered that while conventionally-trained doctors appear to have more officially sanctioned authority, they are also at greater risk if they step outside the relatively narrow standards of allopathic medicine. “I am always on the line as far as the medical boards go. We can lose our licenses,” said ACAM President Kenneth Bock, MD. “I practice many things outside the conventional standards of care, so I am always at risk.”

AHMA’s immediate past-president, Karen Lawson, MD, concurred. “My entire career for the last 14 years has been in a place of discomfort, full of leaps in the dark. But I believe we have to do this.”

Dr. Palevsky challenged the myth of the “All-Powerful Allopath,” by attempting to convey the widespread dissatisfaction and frustration felt by many conventional physicians. “I’m not as powerful as you think. I’m working 80 hours a week. I have no family time, and I’m being pinched from all sides. My malpractice insurance is so high, I’m barely able to make ends meet, and I can’t really deal with all the chronic disease patients coming to me. I’m burnt out.”

If practitioners outside conventional medicine fear suppression or take-over by the mainstream, conventional doctors fear that “alternative” practitioners are taking patients away. “I’m afraid that you, the CAM professionals, actually have the power. I know that all the information we get in medical school is not all there is to know. You might know some things better, and I’m afraid that you will take my patients away from me,” said Dr. Palevsky.

Dr. Dunne contended that conventional physicians may be more afraid of ridicule from their conventional colleagues than they are of either competition from or collaboration with practitioners outside the allopathic circle.

Organizational Roadblocks

Despite the difficulties, some individual practitioners are finding ways of stepping across interdisciplinary borders and working together for the good of their shared patients. The organizations representing various holistic health professionals have been far slower in opening their doors. Over the last decade, organizations like the AHMA and ACAM have been challenged by proposals to allow NDs to join as full members. Such proposals have consistently been voted down.

Dr. Bock said ACAM faced this issue last year. “I was a huge advocate for including NDs. But it is a democratic organization and it was voted down, 60% to 40%.” ACAM remains open only to MDs and DOs. “A lot of the members were nervous about the competition presented by NDs.” Similar proposals arising within the AHMA have repeatedly been defeated by the group’s MD and DO membership. Likewise, full membership in the AANP is restricted only to graduates of accredited 4-year naturopathic medical schools. All of these organizations have provisions for “associate membership,” and allow professionals from other disciplines to attend annual conferences.

Unfortunately, the inter-professional turf battling and rigid organizational boundaries start very early. This Spring, several members of the American Medical Students Association, a group that represents MD and DO students, proposed a measure to allow naturopathic students into the organization. As with AHMA and ACAM, the proposal was nixed. It seems that the walls between various healing arts are built and vigorously maintained even by those not yet fully vested in their professions.

Defining “Us,” Reckoning with “Them”

Participants in the Esalen summit stressed the need for a clear, comprehensive vision of holistic healthcare that can serve as a rallying point for the public, practitioner groups and corporate leaders. So far, a definitive mission statement has yet to emerge.

As participants wrestled with existing turf lines, they also confronted the issue of inclusion as it pertains to this new, broader vision. While they voiced the need for greater open-mindedness and broader inclusion, participants also raised a key question: How inclusive is too inclusive?

IFM’s Sheila Quinn, who has spent years working on public policy to advance integrative healthcare, underscored the dangers of an overly broad vision. “Trying to be all things to all people is exhausting and won’t work. It is about defining our mission and allowing others to define theirs.”

ACAM’s Dr. Bock concurred. “It is unrealistic to think that all of us are going to have a common voice. We all have different backgrounds and ways of viewing things. It is not necessary to have a common voice. We can all contribute to something that can move and grow from this.” He added that integrative medicine, “has become a sort of soup or a smorgasbord—take a little acupuncture or chiropractic, sprinkle in a little massage or herbal medicine. From my perspective, it is much more about the mindset, not the techniques.”

Dr. Pizzorno believes a new agenda, if there is to be one, must be centered on, “A humanistic model based on the biomedical paradigm. A lot of people out there are doing things that are not about this. I think we have to define who we are, and then invite people who are able and willing to work with that.” He added that, “For many years, there was a strong anti-science bias in the ND community, because science was used as a bludgeon by the AMA against us.” He and others have spent much of the last decade advocating for a more scientific approach, but one that is in accord with the core principles of naturopathic medicine.

Put Patients First

In dialogs about integrative medicine, practitioner groups tend to focus more on their own professional needs, often overlooking what their patients are seeking. In this respect, the situation is similar to what occurs between subspecialties in conventional medicine. Sonja Simpson, RN, President of the American Holistic Nurses Association, stressed that this needs to shift. The patients’ real needs and interests must become paramount.

“To me, everything works best when we take the egos out of the process and focus on our patients and our purpose,” she said. Though nursing at large has been strongly supportive of holistic healthcare, and nurses routinely develop closer and deeper human relationships with patients than do physicians, nurses continue to endure highly restricted scopes of practice, inequitable pay scales, and sometimes outright abuse by healthcare administrators and “higher ranking” health professionals. Ms. Simpson believes the nursing perspective has been largely absent from the integrative healthcare dialog.

“As nurses, in our basic education, we are taught about relationship-centered care and relationship skills. So we come out with a different view. We are moving out of “victim” mode, and coming into the process, but not from a power-grab viewpoint.” She believes her profession, which has struggled with its own sub-disciplinary turf wars, could serve as a positive example of humanistic medicine in action.

Steps Forward

Esalen summit participants were of one mind in recognizing that while a renewed vision may be necessary, a new organization is not. Most recoiled at the idea of creating yet another association. Rather, the effort must be on finding common ground and creating closer relationships between existing groups.

To this end, AHMA’s Drs. Lawson and Palevsky, agreed to work with Ms. Simpson and her colleagues, to develop a day-long inter-disciplinary pre-conference prior to the 2006 AHMA annual meeting. ACAM’s Dr. Bock said he would bring a similar proposal to his organization, and urged his fellow participants, “not to wait until 2006.”

Several participants agreed to take on the task of drafting a vision statement articulating the shared interests and core values of the various holistic and humanistic healthcare disciplines. This statement could then be used as a bridge-builder and a rallying point for future health policy action.

Dr. Jonas said he was willing to offer support for the development of practice-based research networks, and demonstration projects that will hopefully generate data showing the degree to which natural medicine and humanistic healthcare answer the real needs of the public and the business community.

Many of the participants voiced an interest in meeting again next year at Esalen, and continuing the personal and organizational efforts to forge stronger alliances between the healing professions. “The fact is that the current system is broken, and the same patterns that created the problems will not be able to heal them,” said AHMA’s Dr. Palevsky.