E S E A R C H
by Janet Kahn
You know the old joke that starts,
“How do porcupines mate?” and answers, “Very carefully”?
Well, integrating allopathic medicine and the various forms of complementary
and alternative medicine (CAM) can also get prickly at times, especially
when you get past the fun visioning stage and have to ask, “How
do you actually create integrated health care?” And there
we are, back at the mating question, and there are two parts to
the answer. The first is, “Very carefully,” and the
second, equally important, answer is “Together.”
A beautiful example of collaboration
occurred in early June, when about 70 health-care educators representing
nine CAM disciplines, conventional medicine and holistic nursing,
met for three days at Georgetown University to address the question
of how to educate health-care students for a new world of integrated
care. We looked at that question because we believe that if you
want to integrate health care, you need to integrate health-care
education, or at least the design of it, at some substantial level.
The meeting was called the “National Education Dialogue to
Advance Integrated Health Care: Finding Common Ground” (NED).
This was a remarkably successful gathering that bodes well for healthy
collaboration across health-care disciplines.
The foundation of
NED was a creation of the Education
Task Force of the Integrated Healthcare Policy Consortium. Some
of you may recall that one of my early columns reported on the National
Policy Dialogue to Advance Integrated Health Care, held in November
2001. The success of that summit led its ad hoc steering committee
to incorporate as the consortium to provide a stable base for ongoing
work that was emerging from that conference. NED, and the work that
preceded and follows it, is an important part of that.
It would be misleading to suggest that
the consortium created NED alone. The whole point, after all, is
collaboration, and it took a lot of that to plan an event as successful
as this was. Individuals from two other important organizations
were involved in the NED planning team. One is the Academic Consortium
of Complementary and Alternative Health Care (ACCAHC), composed
of organizations representing the educational institutions and accrediting
bodies in a number of CAM disciplines. Cynthia Ribeiro, of the American
Massage Therapy Association’s Council of Schools and the Western
Institute of Neuromuscular Therapy in Laguna Hills, California,
and Dawn Schmidt of the Commission on Massage Therapy Accreditation
and the Brenneke School of Massage Therapy in Seattle, Washington,
represents therapeutic massage within ACCAHC. Other disciplines
included are acupuncture, chiropractic, midwifery, nutrition and
ACCAHC is made up primarily of disciplines
that are licensed and accredited by a United States Department of
Education-recognized agency, yet seeks to support emerging professions
that are not yet clearly regulated, such as ayurvedic medicine.
The fact that massage therapists were
present at these meetings is a reflection that many other health-care
professions do accept massage as a potentially helpful modality.
But the lack of clear credentialing within our field, and uneven
training standards at our educational institutes, is an impediment
to integration. It’s an issue the massage field will have
to tackle sooner than later.
The other organization represented
in the planning process, and at NED itself, is the Consortium of
Academic Health Centers of Integrative Medicine (CAHCIM). This is
a group of 29 medical schools that already have some sort of integrated
clinic and CAM education, and that have banded together to move
the world of medical education forward on this front. The consortium’s
Web site: (www.imconsortium.org)
states it this way: “Our mission is to help transform healthcare
through rigorous scientific studies, new models of clinical care,
and innovative educational programs that integrate biomedicine,
the complexity of human beings, the intrinsic nature of healing
and the rich diversity of therapeutic systems.”
A small number of CAM and conventional
health-care educators worked together to plan this conference so
it would have maximum benefit. They were led by NED Director John
Weeks, who spearheaded the effort with ACCAHC Director Pamela Snider,
Finally, before I get into describing
the conference itself, I want to let you know about the other massage
therapists who were there in case you want another view on NED.
There were nine of us: Pat Benjamin, author of Tappan’s Handbook
of Healing Massage Techniques, from The New School for Massage,
Bodywork & Healing in Chicago, Illinois; Cathy McInturff Ayers
of the Potomac Massage Training Institute, in Washington, D.C.;
Mary Ann DiRoberts of the Muscular Therapy Institute, in Cambridge,
Massachusetts; Whitney Lowe of the Orthopedic Massage Education
and Research Institute in Sisters, Oregon; Jan Schwartz of Cortiva,
which owns schools across the United States; and Les Sweeney, vice
president of Associated Bodywork & Massage Professionals. Benjamin,
Ribeiro and Schwartz had all done background work with ACCAHC or
the NED planning team, and McInturff Ayers and DiRoberts each sat
on panels describing their schools’ relationships with medical
schools, including participation in medical students’ education.
Now, on to the conference content.
The path to integration
Let’s start with the basics.
The official statement of NED’s vision of integrated health
care “is multidisciplinary and enhances competence, mutual
respect and collaboration across all CAM and conventional health
care disciplines. This system will deliver effective care that is
patient centered, focused on health creation and healing, and readily
accessible to all populations.”
It is a good goal. But how do we get
there? Through education. “Students who are educated in an
environment of mutual respect, inter-relationship and collegiality
between disciplines will be more likely to practice quality integrated
health care than those educated in separate silos,” according
to the conference program.
The three-day dialogue at Georgetown
focused on how we can create such educational environments and experiences
given the segregated reality we start from. The challenges are quite
diverse in nature, so sessions addressed issues of organizational
culture, curriculum content, inter-institutional arrangements, internal
challenges of some specific disciplines, and the challenges of being
change agents within larger (sometimes stodgy) institutions.
One of the basic issues in any cross-cultural
encounter, of course, is language. Here, we had to ask what do we
each mean by “integrated health care.” An opening session
gave a glimpse into collaboration already under construction. CAHCIM
had offered a definition of integrative medicine in a paper it had
published earlier in the year. ACCAHC and the NED planning team
suggested a revision they felt gave a little more weight and respect
to CAM professions, and CAHCIM endorsed that suggestion. Thus, the
current agreeable definition reads, “Integrative Medicine
is the practice of medicine that reaffirms the importance of relationship
between practitioner and patient, focuses on the whole person, is
informed by evidence, and makes use of all appropriate therapeutic
approaches, healthcare professionals and disciplines to achieve
optimal health and healing.”
But language challenges aren’t
always so easily resolved. One of the trickier language issues that
emerged from the conference is the realization that one group’s
“profession” is another group’s “modality.”
Take massage as an example. To us, massage is our whole enchilada,
our profession, and we want it referred to as a health-care profession.
For naturopaths, massage is a modality in which they receive training;
it is just one tool in their repertoire. Naturopathic medicine is
their profession and massage is a modality. So, to address possible
language confusion, the ACCAHC Glossary and Terms Task Force, headed
by massage therapist Jan Schwartz, offered definitions of terms
such as approach, therapy, profession and modality.
We also searched for common ground
in the session “Toward Shared Values, Knowledge, Skills and
Attitudes.” Background work suggested that the values statements
the individual disciplines have crafted over the years indicate
a lot of agreement, and that it would be good to have a shared values
statement for our work. When it came down to voting on the one we
were presented with, however, we ran into problems. The values underlying
the statements are probably shared, but the statements themselves
were wordy and sometimes vague and did not get general endorsement.
So, that group is back to the drawing board.
However, if you want to see an example
of clear values, check out the American Holistic Nurses Association’s
values statements listed under “About AHNA,” and “Standards
of Practice” (www.ahna.org).
For another reflection of values, look at the recent article by
the education working group of CAHCIM, “Core Competencies
in Integrative Medical School Curricula: A Proposal,” published
in the June 2004 edition of Academic Medicine.
A lot of NED’s value derives
from the fact that many of the participants have been on the frontlines
of this work for some years, experimenting with different models
of collaboration and working to establish the kinds of quality control
and regulation that integration requires. Four meaty sessions offered
us a chance to hear from some of these folks and see how applicable
this is to our own institutions. This is key, because although we
can develop models of integration, the rubber meets the road location-by-location
With titles like “Enhancing
Inter-Institutional Relationships” and “Recent Experience
in Collaborative Educational Program Development,” the presentations
took us inside a number of collaborative efforts, shining lights
on the challenges and successes.
One example of a success is the collaboration
between the Potomac Massage Training Institute (PMTI) and Georgetown
Medical School. PMTI students work with Georgetown medical students
in the anatomy labs for one-and-one-half hours. Georgetown medical
students visit PMTI at a later date to receive massage and education
about application and techniques for four hours.
There were many more examples, too
many to list here, but suffice to stay it is the individuality of
these collaborations that really stand out. This results from the
character of the institutions that collaborate, the needs of the
community they are serving—whether through clinical or educational
service—and the simple matter of what potential collaborators
exist in an area, that really stand out. Here in Vermont, for example,
as the University of Vermont College of Medicine considers potential
integrated collaboration, it would be silly to think about collaborating
with a chiropractic college, because there isn’t one within
I think it is too soon to really know
what the impact of this conference will be. The nine massage therapists
who attended held a teleconference afterward to talk about how to
bring the information and perspective of that meeting into our profession.
We asked ourselves, for example, what implications it had for massage
schools. If others who attended are behaving similarly in their
professions, then the ripples of NED have not yet even begun to
Still, I think there are some take-home
messages for our field. First, as John Weeks said in a press release,
“Those who are educated in silos are likely to practice in
silos. To create the kind of thoughtful, respectful integration
of healthcare that patients are requesting, we need to integrate
the education that all healthcare professions’ students receive.”
From existing examples of collaboration we learn that student exchanges
“A key issue in creating integrated
care is giving medical and CAM students proximity to each other
and experiential learning about each other’s disciplines,”
DiRoberts told me. “Educational models are needed where these
opportunities exist. Survey courses about CAM are useful, but more
than this is needed to truly equip practitioners to cross-refer
and collaborate on care.” Part of this power is that when
students actually get to know each other their biases about the
“other” kinds of practitioner evaporate.
A second message is: Don’t be
shy. I was very surprised while at one roundtable, when a medical
educator said he wanted to work with a massage school, and was aware
of a number in his area, but had not reached out because he didn’t
have money to compensate them and felt it would be disrespectful
to come empty-handed. The massage educators at the table told him
clearly that he should make the call. The massage school might say
no, but he should not presume that. There are other kinds of exchanges
that have value.
For example, a massage school might
provide a chance for medical students to experience massage in exchange
for massage students having access to the medical school’s
cadaver lab. Or a massage school might provide faculty to lecture
on massage, or students to give supervised treatments in a community
health clinic, in exchange for the intrinsic value, and/or in exchange
for access to the medical-school library. The possibilities are
many. So when I say don’t be shy, while we were encouraging
the medical educators to reach out to us, it is also possible for
us to reach out to them.
Third, there are two areas in which
massage education can improve that will help the integration process.
First, all the CAM educators, I believe, came away humbled with
the knowledge that we teach as little to our students about one
another as medical schools teach their students about us. What massage
school do you know that educates about chiropractic, homeopathy
and naturopathic medicine, making sure students know when and how
to refer? The other area for improvement is in our education standards.
ACCAHC works with schools—from all CAM disciplines—that
are accredited by a Department of Education-recognized accrediting
body. That simply is the standard. Schools that meet that standard
will have more opportunities open to them.
The final report from the NED is expected
in September, past this publication’s deadline. I look forward
to it and can tell you that you will find more in it than I was
able to put in one column. The medical world has certainly learned
that CAM is here to stay, and it is accommodating to that reality.
I think it is also true that efforts to integrate and collaborate,
in clinical care and in professional education, are happening faster
than most of us thought possible. As medicine comes to grips with
a population manifesting all manner of stress-related symptoms and
illnesses, there is an important role for massage. Let’s step
up to the table.
Janet Kahn, Ph.D., has been a
massage therapist since 1970, and a researcher since 1978. She is
past president of the American Massage Therapy Association Foundation
and a current member of the NIH National Advisory Council on Complementary
and Alternative Medicine. She is a consultant for hospitals, massage
schools and medical schools on complementary-medicine research and