Research Matters
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

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 naturopathic medicine.

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, N.D.

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 and collaboration-by-collaboration.

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 100 miles.

Take-home messages

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 be seen.

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 are powerful.

“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.

Step up

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 curriculum development.

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