Integrative Medicine and the Health of the Public A Summary of the February 2009 Summit (2009) / Chapter Skim
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Genomics and proteomics are bringing personalized risk assessment, prevention, and treatment options within reach; health information technology is expediting the collection and analysis of large amounts of data that can lead to improved care; and many disciplines are contributing to a broadening understanding of the complex interplay among biology, environment, behavior, and socioeconomic factors that shape health and wellness. Although medical advances have saved and improved the lives of millions, much of medicine and health care have primarily focused on addressing immediate events of disease and injury, generally neglecting underlying socioeconomic factors, including employment, education, and 1
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. Care coordination that emphasizes wellness and prevention, a hallmark of integrative medicine, is a major and growing need for people both with and without chronic diseases.
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This is the background to the IOM's Summit on Integrative Medicine and the Health of the Public. Integrative medicine may be described as orienting the health care process to create a seamless engagement by patients and caregivers of the full range of physical, psychological, social, preventive, and therapeutic factors known to be effective and necessary for the achievement of optimal health throughout the life span.
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1 The summit was designed to consider how integrative concepts can fit within a number of initiatives for transforming the health care system, including patient-centered care; personalized, predictive, preventive, participatory medicine; mind-body relationships; the expanding science base in genomics, proteomics, and other fields; health care financing reform; shared decision making; value-driven health care; and team-based care processes. The agenda was divided into five half-day sessions, each with a keynote speaker, a panel of expert presenters, and audience discussion.
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Conceptually inclusive. Integrative health care means different things to different people, but common elements describe a care process in which patients and caregivers work together to foster seamless engagement of the full range of health factors -- physical, psychological, social, preventive, and therapeutic -- known to be effective and necessary to achieve optimal lifelong health.
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In integrative health care, the seamless inte gration of the care processes, across caregivers and across insti tutions, is the most fundamental organizational principle. Whether through the use of patient navigators or health coaches, whether through care support tools and electronic health records that support the patient focus, or whether through payment sys tems pegged to patient outcomes, every aspect of system design should further the goal of integration.
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Policy opportunities. Policies that encourage integrative health care would define value in terms that emphasize outcomes, ele vate patient insights, account for family and social factors, en courage team care, provide supportive follow-up, and contribute to the learning process.
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SUMMIT IN BRIEF Summit Overview and Background (Chapter 1) Setting the stage for the summit discussions, Dr.
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The Vision for Integrative Health and Medicine (Chapter 2) The panel discussion on vision underscored the notion that the current health care system is fragmented and not oriented to health promotion or disease prevention.
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Victor Sierpina noted that clinicians will need a different kind of education to work in a more integrative and communitybased way. Panelists discussed options for more integrative care efforts, including expansion of the pool of primary care providers suggested by Sierpina and use of multidisciplinary care teams.
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Wagner and others suggested that the mindset and principles of primary care may provide a sound foundation for integrative health care, but to effectively move to an integrative approach, primary care will also need to change. An important element of the transformation is to recognize that, for the 40 to 50 percent of the population suffering from chronic conditions, the distinctions between prevention and treatment begin to break down since the interventions are much the same.
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She said that overhauling the current health care mindset would require a physician–patient partnership, including working together to fashion a whole person medical record that embeds the key elements for planning a patient's health future, the use of teams to manage the care process, and reoriented training to make these changes possible.
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The session on the science base highlighted the complex interplay of biology, behavior, psychosocial factors, and how the environment shapes health and disease. The keynote address for the session was delivered by Dr.
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McEwen noted that psychosocial factors including stress, loneliness, and depression, trigger brain-mediated responses in neural, endocrine, and immune systems, and, in time, have adverse effects on various organ systems and disease states. People with high levels of stress can be found throughout society, observed Adler, who noted that those in lower socioeconomic strata are particularly vulnerable.
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They discussed strategies for changing curricula, including interdisciplinary approaches, team-based training, and expansion of core competencies in healthy living and wellness. An often-mentioned point in this session, described by Dame Carol Black in her keynote address, is the need to expand interdisciplinary and multidisciplinary education to promote effective teamwork.
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Adam Perlman, who detailed the related approaches, barriers, and opportunities. To inform the change process, demonstration projects were noted as useful in developing more effective educational models for integrative health practitioners.
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The keynote address for the session on economic and policy issues was delivered by Senator Tom Harkin who shared his optimism about meaningful health reform by referring to President Obama's recent remarks before a joint session of Congress, in which he predicted that Congress would pass a comprehensive health reform measure in 2009 and that the centerpiece of the reform would be a new emphasis on prevention and wellness. Harkin noted that, unlike previous occasions, public sentiment is now clearly that the health care system is substantially dysfunctional and in need of dramatic change.
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For every dollar spent on medical costs for treating chronic diseases, many of which are preventable, he suggested, another $4 is lost through decreased productivity. He acknowledged the difficulty that small physician practices have in providing services such as care coordination, primary prevention, and community outreach, and supported development of community health teams that would include nurse practitioners, social workers, and behavioral health workers to collaborate with these practices to make these services available.
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The final session of the summit was devoted to an open review of key points of the summit discussions, including a panel conversation among the moderators of the five previous summit sessions, followed by closing comments from Fineberg and Snyderman. In the panel discussion, participants noted the clear emphasis throughout the summit on reorientation of care to perspectives that emphasized prevention, were person centered and life span long, accommodated multidisciplinary team engagement, and tended to the social, home, and relationship environments so important in influencing individual and population health.
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Returning to the Rorschach blot that Fineberg discussed in his opening remarks, Snyderman reiterated that everyone had arrived at the meeting with some image of integrative medicine. Those images were probably different in virtually every mind, and while the summit had not led to a precise and universally accepted view of integrative health care -- nor was that the intention -- it had clearly led to much greater understanding, to identification of common elements, and to appreciation that at its center is an individual with unique requirements for maintaining health, preventing disease, and health care services.
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SUMMARY 21 children, with their different socioeconomic backgrounds and opportunities, their different racial and ethnic identities, their different family dynamics, and their different futures. Snyderman also noted that Fineberg was wise to ask people, near the end of the plenary, what they had learned, what for them was different.
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