William Manahan, MD: Curating the Integrative Movement

William Manahan, MD, is assistant professor emeritus of family medicine and community health at the University of Minnesota Academic Health Center in Minneapolis, Minnesota. He has served on the board of directors of the American Board of Integrative Holistic Medicine as well as the board of directors for the Northwestern Academy of Homeopathy. He is a past-president of the American Holistic Medical Association (now known as the Academy of Integrative Health and Medicine). He was the founding program director for Minnesota’s first rural family medicine residency program. He currently is the cochair for the Minnesota Holistic Medicine Group, which is composed of 800 health care practitioners in Minnesota who come together regularly to do multidisciplinary education and referrals. Presently, he is working to help transform primary health care into a more holistic, heart-centered, and joyful experience for patients and practitioners.

Integrative Medicine: A Clinician’s Journal (IMCJ): What originally sparked your interest for pursuing a career in medicine and healing?

Dr Manahan: It’s an interesting story. In my first 2 years of college, I went to be a teacher and a coach. After 2 years of college basketball and track, I realized it wasn’t nearly as much fun in college as it had been in high school—and I also was not the star that I had been in high school—and it had been totally fun in high school.

Later in my sophomore year, I went to a guidance counselor who gave me a career affinity test. Number 1 for me was a rancher, number 3 was a farmer, and number 8 was a physician. I don’t recall the ones in between. I looked at the results for about 15 seconds and said, “I think I’ll be a physician.” He asked, “Why? Have you thought about that before?” I said, “No, I’ve never thought about it.” He asked, “Why would you pick that?” I said, “I don’t know, I just make quick decisions, I guess.”

In retrospect, I realized that I had worked on a farm for 3 of the previous 4 summers, either a farm or a ranch out in Montana. Those workers are incredibly independent, and I only realized that in retrospect 20 years later. Why did I pick ranching and farming? Because they have tremendous independence and they are outside all day. But it was the independence that drew me in and I eventually realized that was the reason I struggled with the medical system, because they so often don’t allow you to be the independent person that many of us are.

That was how I got into medicine. I looked at that list and decided. I liked helping people, and so that seemed like a good profession.

IMCJ: Where did you go to medical school?

Dr Manahan: The University of Minnesota is where I graduated and then I went to a rotating internship, which almost everybody did in the 60s. After that, half of the interns would go out into general practice—which is what I planned to do—and half of them would go into a specialty like surgery, pediatrics, psychiatry, or internal medicine.

It’s very different now. That system was much better because you could pick your specialty after your internship when you actually had some experience seeing patients. Now, students have to pick their specialty sometime in their senior year, and they have not had much clinical experience. It is not a good system; they have to pick their specialty too soon.

I did that year of rotating internship in Santa Barbara, California, and then I would have gone out into general practice. But my wife and I went into the Peace Corps instead and spent 2 years in Malaysia. We transferred for a third year in Ghana, and when we returned to the United States in 1970, family medicine as a specialty had started. It was felt that general practice clinicians needed more training, so instead of a 1-year internship, there is now a 3-year family-medicine residency.

I remember getting the brochure and thought that I could use more training. There were 8 programs at that time in the United States. The one in Oklahoma City looked really good because it promised that almost all of the 2 years would be in an outpatient clinic, not hospital rotations. I knew from my 3 years in Peace Corps that that the practice of general medicine was outpatient; you’re not in a hospital much. So, I went to Oklahoma City and did 2 years of family medicine and then moved back to Minnesota, where I have been the rest of my life.

IMCJ: What experiences in medical school shaped your perspective?

Dr Manahan: In our third year, we had to write a paper during our obstetrics rotation on any aspect of obstetrics. During the third or fourth delivery I had watched on my rotation, the woman delivering had her sister standing by her side, and she kept talking to her in a gentle tone and it was very easy and nice labor and delivery. The mother had almost no pain, it seemed. She was so relaxed, and the baby came out easily, and it was all nice.

Afterward, I asked this woman, “What were you doing?” She said, “I’m a hypnotherapist and I was doing hypnosis with the mother.” So I asked, “What do you mean, you did hypnosis?” She replied, “It’s just a relaxing state that it promotes.” And I said, “Wow!” I knew what the theme of my paper was going to be.

I went to the library and I got the librarian to look up journals for me. Three or 4 articles from around the world came up. None in the United States, but 1 from Mexico, 1 from South America, and 2 from Europe, that talked about hypnosis in labor. Of course, the results were staggeringly good. They described fabulous results: less time in the hospital, shorter labors, better APGARs on the babies, everything.

I wrote this fabulous paper, and a few weeks later, toward the end of the rotation on obstetrics, I got the paper back. I got a D-. I went to my assistant professor, who had been my supervisor, and I asked, “What’s the deal here?” Because I majored in English in college, I know what writing a paper can be. If he would have given me a B-, I wouldn’t have thought it was the right grade, but I would have accepted it. But he gave a D-. The assistant professor said, “We didn’t correct these papers, the university’s chair of obstetrics did. You’ll have to see him.”

So, I made an appointment and a day later, I went into this huge room where the chief of obstetrics was sitting. I showed him my paper and said, “I’m wondering why I got a D- on this.” He looked at it and said, “This kind of crap has no place in scientific Western medicine.” I replied, “Well, there were actually 3 or 4 articles from the scientific literature that also show what I’m saying: Hypnosis in labor can be really helpful. It shortens labor, everything.” He took the paper, threw it at me, went back to writing on his desk, and gave a “humph.”

I took the paper, turned around, and as I walked out, it was like I had been struck with a good-fairy cloud. I suddenly realized that I never had to trust Western medicine or people in authority again. I’ll never forget that. As I walked out the door, it was like I was enveloped with this light, and the realization that he’s the head of obstetrics at the University of Minnesota, and he doesn’t know anything; he doesn’t know enough to read a paper and get over his biases. Instead of being upset, I had a euphoria that I had some major breakthrough in my life, realizing that I didn’t have to trust authority.

I grew up a good Catholic boy in rural Minnesota, a town of 2000, and you just trusted the priest and the teachers and the nuns and your parents—and of course, college professors and the head of obstetrics. That was a major event that shifted my whole way of thinking, and I started questioning everything.

Sometimes bad things become the best things that ever happen to you. You lose a job, you get a divorce, you get a D on a paper, and they become the best things that ever happened to you because they change your life trajectory.

IMCJ: How did serving in the Peace Corps affect your approach to medicine?

Dr Manahan: I worked part-time at an Aborigine hospital outside of Kuala Lumpur, Malaysia. It was a great experience because it was like an army hospital. Cots lined the walls of a huge room, and maybe 20 patients stayed in that room, but between every cot they always left enough space for a family member to put down a tarp and sleep there during the night. Most of the patients in the hospital would have a family member sleep with them, right there on the floor, all night.

The families would be out around the hospital area. It was right by the jungle, as it was an Aborigine hospital, and they would have little tarps there for protection from the rain. They would cook food and bring it in to the patients, so if they weren’t on some sort of special diet or something, patients would be eating the home cooking they were used to.

I looked at that and thought, “Wow. This is great.” One, the family members were right by this person 24/7, so they were giving support; and two, the person was often eating the food they were used to. By that time, I had spent 3 years in hospitals—the third and fourth year of medical school and my year of internship—and observed that, at that time, families were kept away from the patient, except of an hour or 2 a day, and of course, patients got hospital food.

That was a major realization. When I came back to the United States, I tried to change the system of allowing more visiting hours for family to be there a lot of the time and, if not on a restrictive diet, to allow patients to eat food the family brings in. That led to becoming a big advocate for the father’s presence in the delivery room. At the time, fathers were not allowed in the delivery room.

IMCJ: Were there any other experiences early in your career that were transformative?

Dr Manahan: In my first or second year of practice, one of my patients, who was also a friend, came to our house while we were finishing a meal. She was waiting until we’d finished, and one of my sons was wheezing. I said, “Yeah, he has asthma.” She said, “Well, for god’s sake Bill, of course he has asthma because he drinks so much milk and eats cheeses and ice cream.” I looked at her and asked, “What are you talking about?” She said, “Well, dairy is a major cause of asthma.” I said, “Suzie, that’s the stupidest thing I’ve ever heard. Dairy doesn’t cause asthma.”

A week later, she brought me a book by Frank Oski, MD, called Don’t Drink Your Milk! You probably haven’t heard of Frank Oski, but at the time he was the chair of pediatrics at Johns Hopkins Medical Center. So, this was not from some podunk doctor practicing in rural Minnesota, like me. It was from one of the top-5 medical centers in the United States, and the chair of pediatrics wrote a whole book on all the bad side effects of dairy.

Now, this was the 1980s. I read the book, and Dr Oski gave a lot of references, but they were almost all from Europe. So I got the librarian at the hospital to find me all these articles. I read them, and they were all just right on. Besides intolerance with lactose, the casein—the amino acid—causes all sorts of problems like eczema, bed wetting, asthma, and bronchitis; there were good studies to prove it. That changed my life because I started taking people with a lot of problems off dairy for a 2-week trial, and everything they’d dealt with for years would often go away.

Those 3 events very clearly changed my life and changed the lives of my patients, and they were blessings, all 3 of them. Suzie, the neighbor, is still a friend of mine. She still reminds me about the dairy/asthma connection. She is a psychologist and we still laugh about that event, and how my friend and patient basically changed my whole perspective of how food really makes a difference in people’s lives.

IMCJ: How long was it before you were exposed to mind-body practices?

Dr Manahan: Well, this was in the 70s, when I was having this transformation, practicing in rural Minnesota, Mankato, Minnesota, a town of 30 000 to 40 000. I had grown up 20 miles away, in a town of 2000, so I know rural Minnesota.

In 1978, the American Holistic Medical Association was started by C. Norman Shealy, MD, PhD, in La Crosse Wisconsin, who is a neurosurgeon, and Gladys McGarey, MD, MD(H), who is a family physician in Phoenix, Arizona. Its second meeting was in 1979, in La Crosse. My wife, who was a nurse, said, “Bill, I got this thing in Nursing Journal today, that in 3 months there’s going to be a holistic conference over in La Crosse, Wisconsin.” I asked, “What’s holistic medicine mean?” She explained it to me, that she thought it was just looking at a bigger picture of how we can heal, and so we decided to go over.

That’s where I was exposed to these incredible people. There were physicians, and some nurses, who were giving these talks. Dennis Burkitt, MD, talked about fiber in the diet. We had all knew about Burkitt’s lymphoma. He was a British surgeon who had served in Africa. There were a couple of doctors talking about something that wasn’t called mind-body medicine then, but it was called the incredible effect that stress could have on your body: headaches, gut problems, and more. They had the science and the literature to back it up, and so I started getting interested in the mind-body concepts.

When Jim Gordon, MD, started his center for mind-body medicine, I got to know him well and became attached to that. I took the course. Jim has been an incredible innovator and leader in mind-body medicine, sort of like Andrew Weil, MD, has been in holistic, integrative medicine. Did you know those two were classmates at Harvard? I’d say to myself, “I’m glad I wasn’t in their class, taking tests that they were taking.” They both are geniuses, and the two of them have really been the two major figures, I would say, in transforming at a very early stage, American medicine. It’s just that it takes 40 or 50 years to actually change, so it hasn’t quite happened yet.

IMCJ: When did you take up the baton and try to get other doctors and clinicians to open their minds and look at this?

Dr Manahan: It started in 1979, when I went to that second American Holistic Medical Association meeting. Then we went back, it might have been in La Crosse again in 1980, and it was mainly doctors then. As part of the American Holistic Medical Association, or AHMA, conference, we had a 2-hour meeting and I was arguing about something. Jim Gordon was on the board of the AHMA at that time, and he looked at me and said, “Those are good points. Why don’t you join the board?” I asked, “What do you mean?” He said, “We need a few new members on the board.” And so I got on the board of AHMA right then.

Suddenly, I was involved at the national level with these other 8 or 10 people on the board who all think like I do. It was like I found Jesus. What I remember is that they all loved Western medicine. At times, Western or conventional medicine is denigrated by holistic doctors, but my experience has been the doctors involved in holistic and integrated medicine love Western medicine, and—at the same time—it has some things wrong with it that we would like to help transform. Acute care is doing a wonderful job, but how we deal with chronic care patients can definitely use some improvement. Our push has been to keep the best of conventional medicine AND add to it the incredible knowledge, skills, and wisdom of traditional Chinese medicine, naturopathic medicine, herbal medicine, Ayurvedic medicine, and the many other healing practices. We have seen that pharmaceuticals and surgery can only help a certain segment of the population that have chronic diseases.

That is why I started teaching in medical schools and why I became a clinical professor at Mayo Medical School, only 80 miles away from me in southern Minnesota. Mayo would send second-year and fourth-year students to my practice to work with me for 2 to 4 weeks, and then I also took family medicine residents from the Mayo program for a month at a time. Through the 70s, 80s, and early 90s, I had a total of approximately 80 to 90 Mayo medical students or residents working with me in my office. That was the way I loved to teach, because rather than standing up and talking to 80 or 150 students, I worked with 1 student for 2 to 4 weeks right in my office. That is such a great experience for both the student and for me. That was my favorite kind of teaching, the one-on-one in my office.

IMCJ: How did you reconnect with the University of Minnesota Medical School?

Dr Manahan: They wanted me to give lectures on holistic medicine to the students. Each class had 150 students, and there would always be 8 to 10 students who were interested in the bigger picture. They knew that I was active nationally, so they would contact me in Mankato to come up on a Saturday. They would have a conference on complementary and alternative medicine, and I would be one of the speakers.

Then, they wanted to form a club, and so I was coming up every month on a Saturday morning, for a complementary and alternative medicine club, or a holistic medicine club—whatever they were calling it at the time. Then I started, more regularly, serving as faculty at the university. In the 90s, they asked me if I would start a rural family-medicine residency program in southern Minnesota.

I did, and so we started a training program in Waseca, a small town near Mankato. Students would do their first year in Mankato, which had a population of 40 000 (so it had a bigger hospital). Then the last 2 years of residency took place 40 miles away in Waseca. That was a town of about 8000, and they had a small hospital. That was Minnesota’s first rural family-practice residency, so I then became a full-time faculty member at the University of Minnesota. Our program was one of the 6 University of Minnesota family-medicine residency programs, but all of them were located in bigger cities. This was the first one in a rural area.

I had the hubris to think that I could bring integrative and holistic medicine into a rural family practice residency training program, but after 3 years, I realized I couldn’t do it. The time was not right, and our patients, in general, were not ready for a more nonpharmaceutical approach. In retrospect, I realize that I was at an age where you think you can pretty much do anything and everything. It wasn’t the right time, and I was not the right person. I do hope that it encouraged the Academy of Family Medicine to begin to broaden their curriculum a bit.

IMCJ: Was that the in-road you used to start pushing the university to build a little bit of integrative practice into the medical school?

Dr Manahan: I would love to take credit for having some small part in helping the Mayo Clinic and the University of Minnesota Medical Center become a bit more integrative, but I think that would be stretching it quite a bit. At both places, even though I was on faculty, my ideas were considered quite radical—and not really worthy of serious discussion.

I would say the students had more to do with bringing integrative medicine into the medical schools. They began some complementary and alternative clubs for holistic medicine. Also, patients just started getting more interested. They started asking about it. But I would say neither Mayo Medical School nor the University of Minnesota Medical School are, even now, doing much in the holistic and integrative field. They pay lip service to it, but it is pretty isolated and unusual. Conventional medicine is still conventional medicine in most medical centers. And, maybe that is okay. The older I get, the less I know!

Different holistic and integrative clubs come and go in the medical school, and over the last decade, I have not been part of them, because I got so discouraged trying to find time and space and energy in the medical school system for them. It seems to me that medical school education regarding nutrition has hardly changed from 1960 to 2016. It is discouraging and frustrating for sure.

IMCJ: Still clinging to Ancel Keys’s ideas that “a calorie is a calorie?”

Dr Manahan: That’s right. I’m exaggerating a little, but it’s because I am frustrated. I am frustrated that we’re so tied into old systems of doing things, and it is so hard to change. One of the things I find peace with is that Western, conventional allopathic medicine is really so good in acute care medicine. If you have a kidney stone, a broken leg, a concussion, a heart attack, a stroke, need your gall bladder out, or need your hernia repaired, we do a really good job.

But allopathic medicine is not, in general, made for chronic disease. We do okay with hypertension and some chronic diseases, but we struggle to go upstream and truly find the causes for those problems or set of symptoms. It would be really helpful to do a large number of studies comparing allopathic treatment of hypertension or type 2 diabetes with a more holistic approach done by naturopathic doctors or functional medicine practitioners. Take 100 people with hypertension or type 2 diabetes. Give them the best of standard, conventional medical care done by MDs or DOs. Then take another 100 people with hypertension and turn their care over to the best of naturopathic and functional medicine care. Then follow them for 10 years. I can guarantee you that those 100 patients who saw the naturopathic and functional medicine practitioners would be doing much better, and they would be on considerably fewer pharmaceuticals. How do I know? Because the more holistic practitioners would go upstream and would treat each person as a unique individual with a unique problem. Rather than figuring out the medication routines, they would figure out the unique lifestyle, environment, and genetics of each individual. Then treatment would be tailored to suit that specific individual.

Those are 2 of many chronic diseases that are so amenable to lifestyle change. I believe that other systems of medicine will probably do a better job of treating them than conventional medicine, because we only pay lip service to doing lifestyle and environment change, and then we put them on medications. Their blood sugar or their blood pressure then returns to normal, but we have failed to go upstream and figure out why they were abnormal. As Dale Bredesen, PhD, says, it is like fixing 1 hole in a leaky roof but leaving 4 others unrepaired.

My solution to the problem at this time would be that we need to have acute care medicine practiced by conventional allopathic or osteopathic doctors, and we need to have chronic care medicine practiced by naturopaths, chiropractors, Ayurvedic and traditional Chinese medicine, or TCM, practitioners, and primary-care-trained nurse practitioners and physicians’ assistants. There would be some movement, back and forth between systems, but in general, I believe that we need a major shift in how chronic care medicine is practiced in the United States. The MDs would continue to be trained to do what they’re trained to do best, and that is acute care medicine.

MDs are trained to make a diagnosis and then treat that problem. That approach is really important if you have a stroke, a heart attack, a broken bone, or a bad infection. But in chronic care medicine, the diagnosis isn’t very important. If I have 10 patients see me with asthma, I have 10 or 20 different reasons why those people have their asthma. Therefore, there needs to be 10 or 20 different treatments. Each person needs an individualized treatment for their asthma, or their irritable bowel, or their chronic pain, or their migraine headache, or their GERD—any of those diseases. We need to individualize by going upstream and figuring out why. That is something that Western medicine does not spend enough time doing. The what, the diagnosis, is really important in acute care, but the why is far more important in chronic and long-term problems.

Fifty years from now, we’ll look back and say, “How could you just diagnose depression and then treat most patients with an SSRI? That’s just crazy.” They’ll look back like we look back at bleeding—bleeding George Washington to death—and say, “How could you not know that continuing to draw a pint of blood out of somebody would kill him?” We’re going to look back in 50 or 100 years and say, “In irritable bowel, why would you not look at what they are eating? Why, with migraine headache, would you not do this and this and this? Why, with recurrent bronchitis, would you not look at how they breathe; at what they eat; or at what they breathe?” Our system for practicing chronic care medicine appears to me to not be much different from what I was taught in the 1960s. Make a diagnosis and give a pharmaceutical treatment. Yes, we do pay lip-service to having the patient make some lifestyle changes, but we do not really spend our energy in that domain.

IMCJ: Do you think the HMO system, and the standard-of-care regimen that fits in with that, has made medicine a little bit more inflexible and put more inertia in the system towards staying put?

Dr Manahan: One-hundred percent. It’s the same thing: If you come to me with a problem, I can make a diagnosis and give you a pharmaceutical in 15 or 30 minutes. But, actually, with that type of problem—with your GERD or your irritable bowel or your migraine headache or your depression—I probably need to spend 1, 2, or even 3 hours with you to get upstream and figure out what the 3 or 5 or 10 things that affect you to cause this problem. One by one, we begin working together to eliminate those 3, 5, or 10 things, and then you would not have this problem.

I used to jump up and down when my patients had a chronic problem. I’d say, “That’s really great. You have irritable bowel or GERD.” They’d say, “What are you talking about?” I’d reply, “This is your body, in its wisdom, trying to knock on your head a little bit to tell you something in your life is out of focus. Something is not going right.”

This is not to blame the patient; this is to exalt the patient and say, “Your body’s doing a great thing. Now, we’ll work together over the next 3 or 6 months, and we’ll find out the combination of things that are causing you to have depression or migraine headaches or irritable bowel or GERD, and then we’ll get to the source of it. I’ll be with you, and if I can’t figure it out and I don’t have the tools to do it, I’ll send you to a TCM practitioner or an Ayurvedic practitioner or a chiropractor, an osteopath, or an herbalist. But, I will stay with you until together we can solve your problem.”

It’s like a puzzle. The patient puts in some pieces and I’ll put in some pieces, and if we’re lucky, about half the time, we’ll be able to solve the puzzle. But about half the time, we’re going to need help. I tell them, “You’re going to have to see a psychologist or you’re going to have to leave your job or we’re going to have to see what a TCM or an Ayurvedic practitioner would say about this.” Most of my patients seemed to really understand that. Also, my enthusiasm for helping them heal used to help the patient on their healing pathway. They suddenly looked at it through entirely different eyes, and that is what chronic care medicine has to turn into. We have to quit blaming the patient and, instead, exult the patient and say, “Wow, this is great that your body is giving you migraine headaches. Now we just have to figure out why.”

The analogy I would use is when that blinking red light on your dashboard comes on. Is that really bad or is that pretty good? They would say, “Well it’s both. It’s bad it’s coming on, but I’m glad it’s coming on because it’s going to help my car be better.” I’d say, “Exactly. This disease, these problems you’re having, are the blinking red light. It’s sad that it has to happen; you’re mad that it has to happen. But it’s the best thing that’s happened to you, because working together here, it’s going to change your life and eliminate the things that are causing problems.”

That is the template for chronic care medicine in future years. I’ve been discussing this approach for 30 years. It hasn’t quite happened yet, but I’m optimistic.

In Minnesota, we used to have 2 naturopaths or maybe 3. We got them licensed 10 years ago, and I think we now have about 100 naturopaths. Minnesotans hardly know what naturopathy is, but the naturopaths get it, the chiropractors get it, and of course the TCM and Ayurvedic practitioners get it. Now, for the first time, Western medicine is starting to get it with what we call functional medicine. The Cleveland Clinic, bless their souls, they understand that Western medicine better change what it’s doing, or it’s going to be left in the dust. Cleveland Clinic got it and started a functional medicine clinic.

There’s a funny story. I was so excited a year ago, telling my TCM practitioner friend, “Functional medicine’s going to change medicine. It’s going upstream finally, to figure out why things are happening. What in your lifestyle is happening? What in your environment is happening? What in your genetics is happening?” I said, “Jennifer, this is so exciting because it’ll just change Western medicine.” She looked at me with hard eyes and said, “Bill, this is what Chinese medicine and Ayurvedic medicine have been doing for a couple of thousand years, going upstream to figure out why.” I looked at her and said, “Whoops, you’re right. I only see the world through my Western-medicine eyes,” and she said, “Yes, and that’s okay. I understand. You at least try harder than others at understanding other kinds of medicine.”

She was right. Functional medicine is basically doing what other medicines have done for years. That’s why I love functional medicine. I think functional medicine will be the chronic care medicine of the future. It takes the wisdom of other systems of medicine and it puts it in a Western medicine type of approach.

IMCJ: You’ve put together a pretty dynamic group that meets several times a year here in Minnesota. How did that get started? Talk about that group and what it is doing now.

Dr Manahan: Like many good things in life, if we’re really selfish, some good things can happen.

IMCJ: Like Confucius’s concept of enlightened selfishness?

Dr Manahan: That’s a nice way to put it. Back in the 80s, I was president of the AHMA, and I was going to board meetings every 3 months. I would fly to some city, and from Thursday until Sunday, I would spend these 4 days with 12 or 14 holistic doctors from around the United States. It was just so great to be with medical or osteopathic doctors who felt and thought like I did.

I would get home and I would be like a balloon: For several days, I would be filled with excitement, and then, gradually coming back to the reality of not having colleagues who felt like I did, the air would leak out of the balloon. We lived in Mankato, 80 miles away from the Twin Cities. My wife, Diane, said, “I know 3 or 4 nurses in the Twin Cities who are holistic.” And I said, “I know a holistic physical therapist.” So, Diane and I connected with those 4 nurses, the physical therapist, and 1 Reiki practitioner.

We decided to meet at a nurse’s home in Saint Paul on a Saturday morning in 1989. I said, “I just want to be around people who think like me, my tribe. Why don’t we go around the room and say what you do, who you are, and what’s exciting you in your practice?” There were maybe 10 of us, and that was so much fun. I had a piece of paper, writing down what some of them said. One nurse was talking about Reiki, and I remember having no idea what Reiki was.

At the end of the meeting, they said, “Let’s meet every month.” I said, “I’m not driving an hour and a half or 2 hours to meet every month, but how about quarterly?” So now we meet 3 or 4 times a year, although we may not meet in the summer. Then they wanted to meet on an evening and I said, “I am not able to come to the Twin Cities in the evening. I have to drive home and get up for work the next day. Saturday morning is the only time.” So they agreed, and here we are, 29 years later, still meeting 3 or 4 times a year on a Saturday morning.

IMCJ: That group is a little bigger than 10 or 12 practitioners now, correct?

Dr Manahan: The group now has 830 members. It is 250 physicians, 130 nurses, 60 naturopaths, 60 chiropractors, and 80 psychologists and MSW workers—representatives from every kind of healing: Ayurvedic, TCM, chiropractic, and dentists. We probably have 30 dentists.

At the meetings, when we’d go around the room and introduce ourselves, I would take notes about who was doing interesting things. Afterwards, I would approach them and say, “At our next meeting, would you talk for half an hour about Reiki?” Or, “Would you talk at our next meeting about massage?” Or, “You, as a physical therapist, you say you’re doing this. I’ve never heard of that, would you talk about that?” It was totally selfish; when I would hear something that interested me that I didn’t know anything about, I would say, “Would you talk about that at the next meeting?”

That’s all we did for the next 10 years. Every meeting would start with going around the room, telling people what they did and what excited them. I would sit there taking notes, and then at the end of the meeting, I would say, “Would you talk about this at our next meeting?” We met in people’s homes up until about a decade ago. For a while, 15 practitioners would come and then 30. The group kept getting bigger. I remember when we had 60 in this doctor’s living room. I said, “I think it’s getting too big.” She said, “No, I think I can handle it. We can push the dining room table out and move into the dining room.” She loved having us in her house. When we got 50 or 60 at a meeting, we started moving into buildings that had conference rooms.

Now that I’ve retired, my wife has died, and I moved up to Minneapolis because of teaching at the University of Minnesota Medical School, I’ve had a lot more time to spend with the group. So, I started bringing more people into the group who wanted more connection with like-minded practitioners. Gradually, the group has grown to about 830 practitioners today, from all different disciplines. We get 100 to 150 at our meetings, so we have a thriving holistic community here in Minnesota.

IMCJ: Does the group have any formal mission?

Dr Manahan: Right from the beginning, my mission was 3 things for the Minnesota Holistic Medicine Group. One was to bring like-minded health care practitioners together. It didn’t matter whether they were chiropractors, naturopaths, psychologists, MDs, DOs, or any other licensed practitioner in Minnesota. Two was to learn from each other, and 3 was to refer appropriately to each other. It is really hard for me to refer to someone in another discipline if I don’t know them. I don’t want to necessarily refer you to just anybody—I don’t even like referring you to another MD or DO if I don’t know that other practitioner. That’s the same with regard to acupuncture, chiropractic, or naturopathy. I want to know the person.

Those 3 aspects are the key to the group, and I think that has led to a large number of integrated, holistic clinics in Minnesota. My last count included 16 to 20 clinics in Minnesota in which all types of practitioners practice together in 1 clinic.

That is really exciting to me, because in 1982, a psychologist friend and I started one of the first integrative clinics in the United States. It was called the Wellness Center of Minnesota, and it was located in Mankato. My idea was to have different kinds of practitioners working together and learn from each other. Helen Healy, a naturopath—one of the first 2 or 3 naturopaths in Minnesota—came down every Tuesday to work with us. We had a physical therapist, a marriage-and-family counselor, a spiritual counselor, me as an MD, my sister who was a nurse who did biofeedback therapy, and a dietician. The physical therapist was an exercise physiologist also, so he did treadmill testing and exercise training and consulting.

Every Tuesday, we would meet over lunch for 2 hours, and we would each present a case. I’d been out of medical school for 16 or 18 years—the stage where you think you have pretty much seen everything and know everything. Once again, hubris. I would sit at these meetings and be staggered at how little I knew, because I would present a patient with a problem that was not resolving. An example might be insomnia. The ideas I had were not working for the patient. Well, Helen Healy, the naturopath, would say, “Did you try this herb or this method?” The psychologist would say, “Did you try that? Or hypnotherapy might work for that.” They were talking about things that I really didn’t know anything about.

My tools were pharmaceuticals, dietary change, and surgery. Each discipline has their own tools, and if your patient doesn’t respond to those, then what do you do? This is a really embarrassing story, but one woman was having chronic abdominal pain, and she had been through the Mayo Clinic and a number of other doctors. She was now seeing me for a more holistic approach, but I was not helping her either. I presented her case at our Tuesday noon gathering. “I’ve been seeing her for 2 or 3 months. I’ve done dietary changes, I’ve done everything, and I can’t think of anything more.” Kathy Sharon, the nurse psychotherapist who was part of my clinic, asked, “Did you ask her about sexual abuse?” I said, “What do you mean, sexual abuse?” I barely knew what sexual abuse was in 1983. Thirty years later, that is hard to imagine, but it was in the 1980s that society began to speak about sexual abuse of children.

Sure enough, it turned out that the woman had been sexually abused. I had Kathy see her for therapy, and her abdominal pain went totally away. Her pain had been going on for 2 or 3 years, she had been through the best at Mayo Clinic, the best at the Mankato Clinic, the best I could do, and none of us could help her abdominal pain at all. It went totally away within a couple of months of seeing Kathy.

Those were the kind of things that happened over and over again. My confidence level about really knowing a lot went from about an A, down to about a C-. We only know what we know, and if you don’t know some things, then your patient will not improve.

Anyway, financially, Blue Cross Blue Shield would not reimburse us. They would reimburse me but would not reimburse anybody working with me. In 1990, after about 8 years, I transferred the Wellness Center of Minnesota into a clinic for the underserved and uninsured. That was my other passion, taking care of poor people. It was for all the people who couldn’t get medical assistance, were not on welfare, and who didn’t have insurance. In rural, southern Minnesota, that turned out to be a lot of people. We changed the name from the Wellness Center of Minnesota to Open Door Heath Center, and now Open Door Health Center is one of the most successful clinics for the uninsured and underserved in southern Minnesota. There are 4 dental chairs, and the clinic sees thousands of people each year. I turned it over the leadership when I moved to Minneapolis, but it remains a good legacy for the Wellness Center of Minnesota.

We tried to use a more holistic approach at Open Door, but like many things, it turned out that dietary change for poor people is pretty difficult when someone doesn’t have enough money to even buy groceries. Social workers and helpers sometimes became much more important than doctors and nurses in helping our patients at Open Door Health Center. It’s the whole question of: What is holistic medicine? I had to shift from dietary change, exercise, stress reduction, and yoga, to getting adequate food, transportation, clothing, and other things to help people holistically with their health problems. Of course, both are necessary. So, one of the first integrative medical centers in the United States became a clinic for the underserved and uninsured, and it’s still going strong in 2018. That feels really good.

IMCJ: Despite the glacial pace of change, do you feel that the climate is better for integrative practitioners today?

Dr Manahan: When I lecture to medical students now, the last 3 or 4 years, I say, “For the first time in 20 years, I would like to be back starting residency, and going into medicine again, because it’s going to be so exciting as you learn—as we learn—how to practice chronic-care medicine. Some of you will go into ER work, some will go into surgery, some will go into hospitals and acute care medicine, but at least half of you will be going into chronic care medicine. If our system of how we deliver chronic care medicine does not change, 65% of you will be miserable and develop signs of burnout.” As many as 60% to 70% of doctors in primary care and those doing chronic care medicine are not very happy. Change is in the air, and I just think it’s going to be transformative.)

I’m really excited about functional medicine and I think it is going to help change how we practice chronic care medicine. I am amazed that big clinics like the Mayo Clinic and others are not racing out to Cleveland Clinic to ask, “Why do you have a waiting list of 2000 patients after only being there a year or 2? What are you doing?” It’s that resistance to change. I am so proud of Cleveland Clinic for having the courage to make the leap to functional medicine and for Mark Hyman, Patrick Hanaway, and the people who are practicing functional medicine.

For instance, I’m keeping a list and I think we have about 80 functional medicine health care practitioners in Minnesota, and about 40 of them are Institute for Functional Medicine, or IFM, certified, or certified by functional medicine. The other 40 are either still taking the courses or are not going through certification but are practicing functional medicine.

There are a lot of different practitioners doing functional medicine now, so if someone asks me, “Who can I send my son to or my grandmother?” I’m going to send them to functional medicine practitioners because they go upstream and try to figure out why that individual has that problem. What is that person’s body, in its wisdom, trying to say? You can see how different that is from the way chronic care medicine is currently practiced in the United States. It’s really exciting; it’s transformational.

The other difference is people. Give a lot of credit to the people, and particularly women. Women between the ages of 25 and 50 are saying, “I don’t want to take a pill for the next 10 years. I want to get to the root cause of why I’m having this problem.” I don’t know how many women I talk to who have gone through 2 or 3 doctors, and finally found a naturopath, a functional medicine doctor, or an Ayurvedic or Chinese medicine practitioner, who is willing to go upstream and get to the root of their problems. Those people are changing health care, too. The patient is the leader.

IMCJ: Demand is going to force a change.

Dr Manahan: ... Even neurology. Last year, I met a chiropractic neurologist, and I said, “What’s a chiropractic neurologist?” I had never heard of that. This guy went back for an extra year of training in neurology, and he’s now taking care of people with postconcussion syndrome and traumatic brain injury.

I sent someone to him who had slipped on the ice and hit her head. She is 64 or 65 years old and had been in the neurology and physical therapy system for about a year and was not getting better—still having headaches, still having symptoms of traumatic brain injury. She saw this chiropractor with all the things he’s learned—he has one whole wall filled with things that you look at while you’re walking and saying things—and within 2 months, she was 100% well. Over everything.

The transfer of who is going to help what has now become so broad. Women seem to get that, and they are not just accepting that “I’m going to have these symptoms the rest of my life.” The questions become: “Who do I see? How do I see them? How do I get in? How do I pay for it? What do I do?” Because the idea exists for so many of these problems now, that there actually are ways to help them and heal them.

I think the medical system might catch up in the next decade to 2, but right now, they’re not making moves very fast to catch up. That’s the story, but change is going to occur. Medical practice will once again be fun and exciting.