What Is the Commitment to Interprofessionalism in Integrative Health and Medicine?

“Historical power inequities across professions”—this heavily laden phrase is the handiwork of a multidisciplinary set of practitioners who were convened by the Fetzer Institute in 1994 to guide communities of providers toward what they would call “relationship-centered care.”¹ The 5 words are declared as the second of 2 bullets in a “knowledge” box in a chart displaying knowledge, skills, and values the group associated with optimal practitioner-to-practitioner relationships (Table).

Table.

Practitioner-to-practitioner Relationships in Relationship-centered Care

Area	Knowledge	Skills	Values
Self-awareness	• Knowledge of self	• Reflect on self and needs	• Importance of self-awareness
		• Learn continuously
Traditions of knowledge in health professions	• Healing approaches of various professions and across cultures	• Derive meaning from others' work	• Affirmation and value of diversity
	• Historical power inequities across professions	• Learn from experience in a healing community
Building teams and communities	• Perspectives on team-building from the social sciences	• Communicate effectively	• Affirmation of mission
		• Listen openly	• Affirmation of diversity
		• Learn cooperatively
Working dynamics of teams and communities	• Perspectives on team dynamics from the social sciences	• Share responsibility responsibly	• Openness to others' ideas
		• Collaborate with others	• Humility
		• Work cooperatively	• Mutual trust, empathy, support
		• Resolve conflicts	• Capacity for grace

Reprinted with permission from: Tresolini CP; the Pew-Fetzer Task Force. Health professions education and relationship-centered care. San Francisco, CA: Pew Health Professions Commission; 1994:36.

I view that charge as a pole star for navigating interguild dealings. Empathy must guide the acquisition of such knowledge. How many practitioners of any stripe can say they've gone to school on the historic relationship to power for, for instance, nurses, chiropractors, traditional healers, medical doctors, and practitioners of East Asian medicine? Yet there sits that seemingly fathomable charge, glowing like a watery beacon, a distant goal in the boggy depths of interguild relationships.

What a thought: To work best interprofessionally, must one know the inner power experience of both the colonizers and the colonized?

This hard lesson returned to mind as I encountered 2 work products in recent weeks. One is a recent qualitative analysis of different organizational definitions used for such terms as integrative health, integrative medicine, and integrated care.² The study found significant variation on how much these nominally whole system–focused organizations are explicitly interprofessional. The second is the way the professional makeup of the advisory council of the National Center for Complementary and Integrative Health (previously the National Center for Complementary and Alternative Medicine) at the US National Institutes of Health fails to reflect an interprofessional charge mandated by the US Congress.

This column explores these and other integrative health and medicine choices amidst the broader global emergence of interprofessional education and practice.

The first forays of what we now know as integrative health and medicine began in the mid-1990s. Efforts were made to integrate new types of what were called complementary and alternative medicine practitioners with conventional medical delivery. The main categories of concern were licensed practitioners of chiropractic, acupuncture and Oriental medicine, massage therapy, and naturopathic medicine. Through a 1998 to 2002 exploration called the Integrative Clinic Benchmarking Project,³ I reported evolving efforts for inclusion.

This early integration work was engaged amidst pent-up excitement about getting all of these formerly polarized and excluded practitioners into the same room. A new era was dawning. Questions posed and ensuing models were all over the map in that emergent era. Should all patients first see a medical doctor? What if the doctor knows nothing about, say, the potential value of acupuncture? Can patient care include a session with multiple practitioners present? Can such care at least be preceded by a multi-practitioner case conference? What is needed in reporting and in an information system to support care from multiple traditions? How do we cross the language barrier between the medicine of the East and that of the West? The main focus of this work is captured in the first bullet in the knowledge box in the Table on practitioner-to-practitioner relationships: One must have knowledge of the “healing approaches of various professions and across cultures.”

In time, however, these often philanthropically backed clinical initiatives bumped up against economics. Putting 3 or 5 or even 2 practitioners in the room for a consult was prohibitively expensive. With rare exceptions, team time was not reimbursed. A center's interprofessional sessions devolved to weekly or bimonthly meetings in which business and clinical issues shared the agenda. Pressing issues of the former tended to take up additional time. Interprofessional exchanges became less formal. Practitioners began to make the best use of encounters in hallways and lunchrooms.

This fervor to find the right model in these pioneering integrative centers predated, but circled around the heart of, what is now known as the movement toward interprofessional education (IPE) or with the patient care goal in mind, interprofessional practice (IPP). Such education is adamantly that in which practitioners from 2 or more disciplines learn with, from, and about each other.⁴

One might have expected that these rich, if economically endangered, interprofessional explorations in integrative health and medicine might have been a way for the integrative medicine movement to share its experience and perhaps thereby gain cultural authority. Yet until now, the medical doctor–led integrative profession has been a near no-show in the larger movement's conferences and organizations.

A part of the reason may be that significant organizations in the field do not fundamentally define their work as an interprofessional engagement. In a recently published qualitative report,² authors Beth Rosenthal, PhD, MPH, MBA, and Anthony Lisi, DC, examined 11 keynotes in multiple English language definitions used by organizations and scholars. These keynotes included concepts such as patient-centeredness, treatment of the whole person, references to determinants of health, evidence-based care, and interprofessionalism. The relevant finding is that notable variances were found regarding the latter theme. Among those not referencing interprofessionalism are some of the most significant influencers in the US and global movement: University of Arizona Center for Integrative Medicine, US Institute of Medicine of the National Academy of Sciences, and the Bravewell Collaborative of philanthropists. The authors conclude,

A key difference between the definitions is use of the terms modality/therapy/intervention/treatment vs the terms professionals and discipline. This is a critical distinction because using [these terms] rather than the terms professional or discipline discounts the importance of delivering the modality/therapy/intervention/treatment in context of its discipline, by practitioners who are educated and trained in the discipline. Leaving disciplines and health professionals out of the definition effectively leaves out the rich experience and context of the discipline, and de-values interprofessionalism.²

Notably, a portion of these differences in meaning may be explained by misuse of language. Many in the integrative health and medicine movement confound the value of a practitioner or a profession with the value of one or more of the therapies provided. Acupuncture or chiropractic may be called a modality. Whole systems such as Ayurvedic medicine and naturopathic medicine may be listed as complementary therapies. The misuse is particularly striking when members of these professions engage this objectification and diminution self-referentially. Is this possibly a legacy of colonial-like power structure in which other professionals—whether nurses or pharmacists or massage therapists—were effectively owned in former power and reimbursement relationships with medical doctors?

Interprofessionalism, with its concepts of horizontal collaboration and requirements to understand historical inequities, is an antidote.

A striking reminder of historical inequality and the ongoing power struggle is the makeup of the National Advisory Council to the most significant funding agency globally that is specifically charged to research complementary and alternative medicine. The agency was established in the United States by an act of the US Congress in 1998 amidst the first explosion of interest in complementary and alternative medicine. The act is itself interprofessionally prescient: In 6 places, the short piece of legislation reminds the new agency that they are to explore not just single agents or therapies but “modalities, systems, and disciplines.”⁵ To support that mission, an advisory council was to be created in which “at least half of the members & shall include practitioners licensed in one or more of the major systems with which the Center is concerned.”

Another effectively interprofessional characteristic of the law was the requirement that “the provision of support for the development and operation of such centers shall include accredited complementary and alternative medicine research and education facilities.” Schools from multiple fields should become research centers.

The first council, appointed in 1999, reflected the mandate's fostering of team care. The group was laden with practitioners whose professions had formerly been excluded from access to the research agency: 2 licensed chiropractors, 2 licensed massage therapists, 2 naturopathic physicians, and 2 practitioners licensed in acupuncture and Oriental medicine. To ease the inter-professional exchange, each appointee was dual-degreed in research or a conventional healthcare field.

Yet in the ensuing 15 years, despite the growth of cadres of dual-degreed, licensed scientists of each of the fields, the council has regressed toward the conventional academic health center and medical doctor mean. As of February 2015, just 2 of the 18 members were licensed in the newly included professions. The agency's leaders, despite declaring in its 2011-2015 strategic plan that “[complementary and alternative medicine (CAM)] practitioners are the key holders of knowledge related to the potential application of CAM interventions and disciplines,” apparently have the view that a medical doctor with some background in one or more complementary or integrative modalities counts for filling that Congressional quota. Notably, neither lawmakers, the members themselves, nor the increasingly (re)-excluded professions has raised a protest. Is this acceptance of disempowered behavior of the dis-included professions also a legacy of former and present power relationships? Bottom line: this is a significant step back for interprofessionalism.

We see hopeful signs in another US agency that the historic disrespect is shifting. The US Center for Medicare and Medicaid Services has opened a dialogue with the chiropractic profession in which they are grappling with a downstream problem born of demeaning a profession as a “modality.” The agency has until this time only covered adjustment performed by chiropractors. Unlike the case with medical doctors, nurses, and osteopathic doctors, none of the time a chiropractor spends as a health-care professional in evaluation and management of patients is reimbursed. The present dialogue is exploring what amounts to a payment-level interprofessional elevation to a level playing field for the chiropractic profession. (Notably, licensed practitioners of acupuncture and Oriental medicine, naturopathic medicine, and massage therapy are not yet included at any level by the agency.)

The chiropractors appear to have an interprofessional ally in the Harvard Medical School. A recent publication on the institution's Harvard Health website positions chiropractors as far more than tools for adjusting the lower back of patients with acute pain. The language used is chiropractic's repositioning interprofessionally. The document begins by speaking of the field as “a healthcare system.” Then it continues, “While the mainstay of chiropractic is spinal manipulation, chiropractic care now includes a wide variety of other treatments, including manual or manipulative therapies, postural and exercise education, ergonomic training (how to walk, sit, and stand to limit back strain), nutritional consultation, and even ultrasound and laser therapies.” The copy then becomes directly interprofessional: “In addition, chiropractors today often work in conjunction with primary care doctors, pain experts, and surgeons to treat patients with pain.”⁶

The integrative health and medicine field must consciously apply itself to becoming a fully interprofessional movement if it is to break its own shackling to unequal and harmful power structures of the past. The broader interprofessional education and practice movement has provided exceptional tools to advance such mutual respect. A Health Canada–funded, decade-long effort led by IPE missionary John Gilbert, CM, PhD, FCAHS, produced an exceptional interprofessional framework in 2010.⁷ In the United States, the Josiah Macy Jr Foundation–backed Interprofessional Educational Collaborative (IPEC) published 4 competency fields in its 2011 Core Competencies for Interprofessional Collaborative Practices.⁸ The North American Academic Consortium for Complementary and Alternative Health Care endorsed the IPEC set, with a significant addition relative to self-care and added 2 fields in its 2011 Competencies for Optimal Practice in Integrated Environments.⁹ The 2 additional areas related to evidence-informed practice and institutional culture and practice.

Each of us can do something daily to ratchet this movement toward greater interprofessional respect. I take my guidance from a moment many years ago playing a regular Monday night basketball game with a group of friends. One player, a high-strung attorney for the city, was having a lousy game. He was loudly and repeatedly cursing at himself. Finally a fellow player grabbed the game ball, stopped play, and turned to the speaker of the self-hating language: “Buddy, I know I wouldn't stand by and allow you to talk that way if you were talking to someone else. I don't know why I should allow you to treat yourself that way.”

All of us serve the future of interprofessional respect if we take a pledge to quietly correct our colleagues whenever they use—in reference to others or themselves—dis-empowering, demeaning, and objectifying language of “modality” or “therapy” when they mean to be referencing the human beings who are part of our interprofessional teams. Long journeys start with single steps.

Biography

John Weeks has been active as a writer, organizer, executive, consultant, and speaker in the movement for integrative health and medicine for more than 30 years. His leadership-focused Integrator Blog News and Reports (theintegratorblog.com) and now his Global Integrator Blog are go-to sources on breaking developments in policy, business, academics, and interprofessional activity.