An expert panel was convened by Medical Acupuncture to discuss integrative medicine within the U.S. Department of Veterans Affairs (VA).
DR. BENJAMIN KLIGLER: We are here today to talk with some of the leaders in integrative medicine and acupuncture in the VA and hear from them on: What are the newest developments? What are the challenges we are facing right now in the VA? What are we learning as we bring integrative health to veterans in a more widespread and impactful way?
So, first off, what would you say is the most important innovation taking place in the VA system right now, in using integrative medicine?
DR. STEPHEN EZEJI-OKOYE: The start of the whole health pilots in each Veterans Integrated Service Network [VISN] is one of the biggest innovations that is really going to promote integrative medicine. The commitment by each VISN to launch a flagship site to promote integrative health really moves this from being something which is done primarily by people who already had an interest in integrative care to raising the awareness of it, both across entire facilities as well as across the VISN.
This has potential to promote integrative health as a vital part of the health and well-being of veterans.
DR. DAVID DRAKE: I think of it as more of an environmental energy. Since the creation of the Office of Patient Centered Care and Cultural Transformation, which then formed the Integrative Health Coordinating Center [IHCC], there's been an interest and desire to make whole health a priority.
Prior to the creation of the IHCC, it was a challenge practicing whole health, but at this point it is like a huge wave that is gaining energy. The integrative health medical environment in the country, if not the world, is becoming widespread and well accepted. I feel we are headed in that direction. This is a very exciting time for me personally and professionally.
DR. JULI OLSON: The grand idea of moving away from disease-based care is now moving into the execution phase, and that is really exciting. We have come to a point now where there are specific structures in place that allow it to happen.
There are so many innovations that are coming in order to execute that vision— for example, the introduction of a qualification standard for licensed acupuncturists, allowing the VA to hire licensed acupuncturists to provide acupuncture care.
DR. KLIGLER: Right, and in terms of the conversation about whole health and the new environment and atmosphere that Dave mentioned, part of that is committing to an interdisciplinary approach and tapping the different healing professions for everything they have to contribute. The VA has done that among the conventional healing professions—for example, with nursing and psychology—but is now branching out to include some of the integrative professions like acupuncture, more thoroughly, and it is a really important innovation.
DR. KAVITHA REDDY: One thing I will add is the vision of reaching our younger population to engage in the whole health system and integrative medicine now, when they have the biggest chance of delaying or even preventing disease progression downstream.
We have also seen a new executive order which allows for better transitioning from active duty—in utilizing the VA system for the first year that they are out—for full mental health services if they need them. The key to this executive order is that they get a chance to come through a whole health orientation to learn about what whole health means and the use of integrative medicine, and then to participate in initial whole health classes so they can identify their health and well-being goals. That is incredibly innovative for those folks transitioning out of service.
DR. KLIGLER: One of the major breakthroughs with this is that previously, separating service people had to go through a qualification process in order to enter the VA, and this order mandates an entire bypass of that, at least for the first year of their transition, so that there really are no obstacles to recently separating service people from accessing VA care or mental health, which is a new way to look at the VA. It will be interesting to see where that goes.
DR. ROBERTA A. LEE: I see whole health not so much as an innovation, but as a process of organization, and I think it is amazing that the VA has implemented a system that really brings to the forefront empowerment of the veterans regarding their own health. In their deployments, a lot of their orientation is to take orders. So, it is even more important to remind people that they do have this governance over their health.
One of the most powerful aspects of the whole health introduction is being able to get financial reimbursement and acknowledgement across the board for all providers in the whole health system, including the newly recognized acupuncturists. We have, in this system, the opportunity to look at the efficacy of having an integrated system, which has been a challenge in the civilian infrastructure because there are so many different participants that do not have the investment to relate to one another. So, I am very excited about this.
DR. KLIGLER: Great point. The commitment to rigorously looking at the outcomes of these innovations is very important. We have a major commitment from VA Office of Research and Development to look at the impact on patient-reported outcomes, cost and utilization, and staff satisfaction, and measuring what happens as we deliver more integrative health in terms of those outcomes—what kind of impact do we have?
That is another particularly unique thing that the VA is capable of doing because of being a large integrated health system with access to a large collective data mine of what is happening in the system. We are really excited about the opportunity to help learn some lessons about what works best and how to deliver this kind of strategy.
Let us move onto the next question, which is, what would you say is the biggest barrier to making integrative approaches more widely available to veterans?
DR. REDDY: I do think that there are a few barriers, especially as we work at implementing whole health across the system. Some of the biggest ones that we have seen have to do with credentialing people to deliver these services and then the space and time to deliver them.
So, as we look at bringing in more providers of things like yoga and tai chi and meditation, we have to be cognizant of who can provide these services—ensuring they have proper scope of practice and competency to provide that care. In addition, these approaches require larger group room areas and space, and VA is trying to be mindful of how much space it has and really reducing its footprint. Trying to negotiate that is certainly a barrier, although utilizing community partnerships has been very helpful. And then there is simply the time. We want to make sure that our staff are very productive in the care that they deliver to veterans and have the time to deliver more of these integrative approaches.
DR. LEE: Whole health is an introduction of a new infrastructure and we have national initiatives which are very powerful within this infrastructure introduction, but we also have other national initiatives that have existed prior, and, as with any institution with a long history in a transition of change, not all of the objectives are aligned.
Being able to change so that there is more efficiency in the entire system is always a challenge in a system as large as the VA, as much as it is a very powerful opportunity. And for all of us flagship sites that are enacting this at the local level, we do not have the power to change some of these national initiatives. So, I would say that is one of the largest challenges.
DR. KLIGLER: Right, and VA always is trying to balance the emerging national priorities without telling the field in every individual facility that they have to do 75 different things at the same time, and that is sometimes in conflict. So we are working hard on that.
DR. LEE: I think part of it is borne out of the largesse of the system. There are so many competing interests and in order to be able to make this more efficient, you have to have an aerial view of all the different places where the system is moving, and that is tough.
DR. EZEJI-OKOYE: One of the main barriers lies in the need for more education and raising the awareness of providers and veterans about the importance that healthy behaviors and self-care play in their overall health and well-being. Then, being able to connect that to integrative health approaches as a mechanism to achieve some of the goals that the veterans may have.
There may be an easier connection with some of the existing, more disease-based modalities for treating conditions such as chronic pain, but the role of self-care and the role of healthy behaviors, while recognized as important in medicine, is still something that providers need to think about how to incorporate. I see that as key to being able to promote integrative approaches more widely.
DR. OLSON: Yes, and I would add access or capacity. There is a lot of concern from facilities that they are going to open the floodgates to things like acupuncture or massage, and they will not be able to dose them appropriately. So, when you go back to thinking about how we are going to utilize a lot of the data we have from people using these services, that is where we are going to have a great impact—to be able to figure out what is the appropriate dosing for certain complementary and integrative health [CIH] modalities.
DR. KLIGLER: That is a great point, and it is one challenge, especially around the question of maintenance treatment with something like acupuncture or chiropractic for somebody with longstanding chronic pain. When you look at the published evidence in the literature, there is not a lot of guidance as to whether, after someone has their basic treatment, should they have once a month acupuncture, once every three months, once every two weeks, and that is something that is both a barrier and an opportunity.
One example: We are trying to launch a pilot with a facility in the western United States looking at a maintenance approach and particularly if veterans are signed up for a maintenance approach with something like acupuncture and also have a self-care approach, like yoga or tai chi or meditation, and does that facilitate long-term improvement. There is a lot to learn and a lot of challenges there.
DR. DRAKE: The VA system has been so focused on what we see as an old model of disease treatment—diagnose and treat—that I think some of the regulatory aspects, the guidelines that the VA presents to us, have not been flexible enough to allow whole health practices.
The VA regulations were created without integrative medicine in mind and the integrative medicine wave has grown so fast over the course of the last couple of years that the VA is now making changes, and we are now having those discussions. We are looking at things like: Is consent necessary? Which consent is necessary? And even with some of the modalities that are delivered, such as reiki or massage, what type of parameters do we have around those things?
Some of those questions have been answered, but we are still in the process of creating more guidance to help facilities come up to speed.
DR. KLIGLER: Yes; we are, in many respects, bringing things into the conventional health care system that have not been brought on this kind of scale, so there is a lot of learning to do all around.
The next question is: What is an important lesson you have learned in the past year about bringing integrative care to veterans?
DR. OLSON: I have been happy to realize how much veterans do want the whole health approach. But what has been surprising to me is, no matter the approach, I think patients often are looking for a quick fix, and training and teaching them to understand incremental improvements is something that the whole system needs to focus on.
I think people are often looking for that one treatment that is going to fix their multitude of conditions, and this is where the whole health approach comes into play, where people are learning that by adding all these things up, they should be 70% better, and that includes the self-care that they will be doing.
So, it has been fun to work with veterans and see them get that idea that you put all these things together, and that is where their great improvements come from.
DR. REDDY: My example goes back to implementing integrative care within VA. It is an important lesson that I have learned about partnerships and developing those strong connections across the system. There are a lot of disciplines in VA that have invested time and energy in building education-related integrative care, whether that be nutrition or socially looking at their surroundings or personal development.
There are a lot of people that have had interest over time, and bringing them together in a coordinated fashion, where veterans can access resources and really understand how it supports their goals, is an important lesson so that we are not duplicating efforts or recreating the wheel and are really creating something sustainable over time.
DR. KLIGLER: I would expand on that. Something we have all been learning is how much momentum there has been already in VA for this change, and Dave was alluding to this earlier, that yes, we are having a lot of specific breakthroughs around integrative health over the last year or two with our new policy directive and acupuncture qualification standard, but the move towards orienting care around what is most important to the veteran has really been going on in VA for 10 years or more.
One of the things I have personally realized is that despite the fact that, as Juli was saying, people want a quick fix, there is also an understanding that the way to be successful is to put the veteran at the center of care and to make their priorities and their goals the focus, and that ultimately that is the way we are going to move forward.
That is a pretty widely held belief across the system, too. A lot of work has gone into that already, and I feel like I have just begun to recognize how powerful that is and how we are building on a wave that has already been kind of rolling for a number of years already. It is very exciting.
DR. DRAKE: One of the things I have learned is that this is a long journey and we need to take it one step at a time. With that I have learned patience. Even when it comes with a system change, it takes small steps on a long journey.
Like you were just referring to, Ben, there is an energy with the providers who are seeing and helping each individual veteran—that keeps the entire thing going and has kept us going for years now.
So, even when there are roadblocks in the facility, for example, or even when you are trying to get things approved or you do not get things approved, those people continue to move forward. So I have learned patience, but I have also learned a great appreciation for my fellow practitioners.
DR. KLIGLER: I have only been in the VA for 2 years now, but the level of commitment and dedication and shared sense of mission among VA clinicians is just astounding and really not something that you see widely in the outside academic health care system. This concept that although there might be disagreements about exactly how we do it, we are all here for the same reason, and that is a very powerful tool that we have working in our favor.
DR. LEE: Yes, the depth and breadth of enthusiasm that I have discovered locally for the whole health approach, and also acknowledging there have been decades of early adopters—it has been a pleasure to discover this exists within my own local sphere.
We are pushing a new level of wholeness with the whole health movement, and there is this challenge of moving people away from the “quick fix” and emphasizing the multilayered aspect. I absolutely agree with others that now spelling out what “healing” is as opposed to “fixing” is a great concept to start delving into. I do not think it is well understood—although people understand that they want to look at their whole selves, this concept of how things move into wellness and that it does not necessarily have to have a medical outcome to it is still a novel perspective.
DR. EZEJI-OKOYE: One of the things that is important is to make sure that you are meeting people where they are. Not everyone is on the same continuum of seeing the value in whole health, and it is important to engage them where they are in terms of their understanding and in terms of their belief system and be able to take the time to talk about the promise of whole health, to talk about the evidence, and making sure that you are accurate about what the evidence says and does not say.
Then we need to show how it ties into the goals of the patient or what the provider may want to achieve for their patients. So, it is really more about being able to take the time to have a conversation and to try to reach a point of shared understanding about how we are on a shared journey to meet the needs of our veterans, and that whole health represents a new way—actually, in many respects, an old way—of being holistic and having a biopsychosocial approach to healthcare.
DR. KLIGLER: Thank you, very inspiring listening to you all. The last question we have is: What are the future prospects and uses of acupuncture and integrative medicine in the VA? What are some of the specific goals you see for us as we move it forward?
DR. DRAKE: I would say, specifically for acupuncture services, that the last 6 months have probably shown more progress than the prior 6 years. There is definitely a huge energy and a huge demand for not just acupuncture, but for whole health services overall. A big part of that is because of the flagship sites that Stephen made a reference to earlier as well.
I think the future is incredibly bright. I feel fortunate to be involved in the VA and being able to practice the kind of medicine that I do—both for my own health, and as a practitioner.
As far as where things will be in a couple of years, I think we are going to see whole health services presented the very first time that the veterans come in. So, that whole change in perspective and how the veteran and the patient sees it, but also the way the VA delivers it, is going to be fully manifested in a few years.
DR. EZEJI-OKOYE: Integrative health is taking a much larger role in the management of chronic disease and in the treatment of conditions that are of major concern to veterans—in particular, things like the chronic pain field, and acupuncture has a large role to play there. I think the whole movement toward greater self-care really lends itself to many integrative health practices in that this continued focus on defining what it means to be healthy and defining well-being, moving away from a disease-based focus, and realizing that there is an interaction of multiple things from the biopsychosocial field that would really lend itself to integrative health becoming a much bigger player as people explore this further.
DR. RICHARD NIEMTZOW: What is interesting is I have had many opportunities to travel to China, and my spouse is a Chinese physician and was in private practice in Beijing, China, and still works at university hospitals. As the VA and also the military goes forward with integrative medicine, it is rather astonishing for me to realize on my trips to China that almost all of the hospitals have a Western department and, of course, the Eastern department or what we call an acupuncture department, where patients may profit from a joint consultation.
And I see as part of the future where we have tumor boards, for instance, for oncology patients, where the surgeon, the medical oncologist, the radiation oncologist are able to make recommendations. I have a feeling that later on, as we all progress in this area, there will be the combined consultations to decide what will be the best route, best therapy, for patients.
As we look at integrative medicine in terms of self-care and prevention, there are some major establishments in China that actually recognize the use, for instance, of acupuncture and other modalities in the way of prevention. It is also outstanding to know that the Chinese military offers to the troops these little kits for self-aid and disease prevention. There might be some acupuncture needles in the kit, there may be some herbs, there may be some other things that help maintain their health.
So, I see us traveling along this path, but I think it might be good to look at some of the side roads in various countries, not only China, but other countries that have different types of medicine as we become more educated, that can be put together and useful, especially for our veterans.
DR. KLIGLER: Thank you, Richard. That is a great idea. It is true that in the past few years we have actually managed to move more successfully upstream into the active duty services with this whole health, integrative health approach. So that even when our service people are still on active duty, they are already getting oriented to the notion that they can be in charge of their health, and orient their health around what is important to them, and use all kinds of integrative methods and approaches.
This has been a goal for a number of years and there has been a lot of conversation, but I think we could make a lot more progress in moving upstream with this proactive, health-promoting, open-minded approach. We do not want to just wait until someone is out of the service and a veteran and develops a problem that they need help with that we bring this approach to them, but this is actually part of what we teach them while they are in the military, that this is an important way to look at your health. That is something that potentially we can hope for and look forward to over the next few years.
DR. OLSON: I think the ability to get a lot of data on CIH services will really help us all become better clinicians, so that is something that I am really excited about. Also, I am looking forward to, hopefully, the inclusion of acupuncture in other large health care systems based on its success in the VA.
DR. LEE: I think there is great opportunity to look at best practices based on the aggregated data of this project. I am hopeful that we will also be able to extend the impact of our holistic or integrative services by adding supplements into our VA formulary. This is a challenge, as supplements have varied evidence for efficacy. Some supplements have very little data but are enduring in traditional medical systems because they work. And we may find ourselves developing new protocols to evaluate these types of supplements.
If we could somehow find a pathway to get this started, it would be very powerful. Many veterans do not have out-of-pocket resources, so this is one opportunity I am hoping for.
DR. REDDY: I enjoy thinking about future state and I hope that we are both successful in implementing whole health in our system—where acupuncture is just one piece of an integrative personal health plan for patients—and also in helping awaken the healing-oriented approach in the patient, in the veterans themselves. There are so many ways to help manage their health and well-being, in particular, to help manage their chronic pain and suffering that they have been through.
So, I am hoping that we get past interventions and focus on a larger plan for the individual.
DR. KLIGLER: Thanks to you all. We are riding a pretty powerful wave at this point, and there is a huge amount of potential for the future as far as where we go with integrative health in the VA.
I will add a couple of comments in that there are a number of outside factors that I think are propelling this wave. Some of it is a widespread recognition now about the need to treat pain with nonpharmacologic approaches, and certainly in integrative health we have some of the best evidence for nonpharmacologic approaches to pain. We really have that in our favor.
Then, another part of that wave is a growing awareness nationally that people need to be taking more control over their health and need to be orienting their health around what is important, and that health systems need to be responding to that. We are really fortunate that VA has been building momentum in this area.
DR. NIEMTZOW: I would like to thank all of you on behalf of the journal and our readership—the journal goes out to over 140 countries and you have clinicians from many different orientations. In my opinion, and I am a veteran and I do receive service at the Washington VA hospital, I find it to be top notch and I think other clinicians around the world at their institutes can take a real hard look at our VA system and to a certain extent get some good ideas to help improve care to their own patients.
DR. KLIGLER: Great; thank you to all for participating in this panel.
Author Disclosure Statement
No competing financial interests exist.