Individuals with multiple chronic health conditions (MCC) often face an overwhelming set of self-management work, resulting in a need to set care priorities. Yet, much self-management work is invisible to healthcare providers. This study aimed to understand how to support the development and sharing of connections between personal values and self-management tasks through the facilitated use of an interactive visualization system: Conversation Canvas. We conducted a field study with 13 participants with MCC, 3 caregivers, and 7 primary care providers in Washington State. Analysis of interviews with MCC participants showed that developing visualizations of connections between personal values, self-management tasks, and health conditions helped individuals make sense of connections relevant to their health and wellbeing, recognize a road map of central issues and their impacts, feel respected and understood, share priorities with providers, and support value-aligned changes. These findings demonstrated potential for the guided process and visualization to support priorities-aligned care.

Journal of Integrative and Complementary MedicineVol. 28, No. 4 In MemoriamInsurance Commissioner Deborah Senn (1949–2022): A Personal Memoriam on Her Role in an Origin Story for the Integrative EraJohn WeeksJohn WeeksAddress correspondence to: John Weeks, www.johnweeks-integrator.com, Seattle, WA, USA E-mail Address: jweeks.jacm@gmail.comwww.johnweeks-integrator.com, Seattle, WA, USA.Search for more papers by this authorPublished Online:11 Apr 2022https://doi.org/10.1089/jicm.2022.0548AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 28Issue 4Apr 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:John Weeks.Insurance Commissioner Deborah Senn (1949–2022): A Personal Memoriam on Her Role in an Origin Story for the Integrative Era.Journal of Integrative and Complementary Medicine.Apr 2022.287-289.http://doi.org/10.1089/jicm.2022.0548Published in Volume: 28 Issue 4: April 11, 2022PDF download

The Journal of Alternative and Complementary MedicineVol. 26, No. 4 EditorialFree AccessCall to Action: Announcing the Traditional, Complementary and Integrative Health and Medicine COVID-19 Support RegistryJohn WeeksJohn WeeksAddress correspondence to: John Weeks, johnweeks-integrator.com, Seattle, WA 98116 E-mail Address: [email protected]Editor-in-Chief, The Journal of Alternative and Complementary MedicineSearch for more papers by this authorPublished Online:10 Apr 2020https://doi.org/10.1089/acm.2020.29083.jjwAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail In collaboration with numerous global organizations, we have moved forward with a clinical registry aiming to capture key case, treatment/supportive care, and outcome variables related to the use of traditional, complementary, and integrative health and medicine products and practices in response to the COVID-19 crisis.—Ryan Bradley, ND, MPH, Director, Helfgott Research Institute; TCIHM COVID-19 Registry Principal InvestigatorThe NeedThe variability in guidance by national governments on potential value relative to COVID-19 through traditional, complementary, and integrative products, practices, and practitioners is nothing short of astounding. The Chinese government credits its swift turnaround to an "integrative" method through which patients received Traditional Chinese Medicine plus biomedicine.1,2 The Indian government issued a memorandum that was a composite of practices viewed as potentially useful by the various branches of its AYUSH ministry (Ayurveda, yoga, Unani, Siddha, homeopathy, and naturopathy).3On the contrary, North American and European governments are typically silent on these practices,4 unless to warn of possible harm and overselling.5 The guidance from these federal bodies is typically limited to what may be called "healthy waiting"—social distancing, mild exercise, stress reduction, no smoking, and limiting alcohol.6 The view is that if there is no hard evidence that product x reverses COVID-19, it is not worth mentioning. This position is, of course, a double standard: no practices have definitive evidence for benefit against COVID-19, yet providers with other stripes are using experimental practices and off-label drugs every day in their desperate to ease patient suffering and elicit hope.In these Europeans and North American countries, practitioners of integrative, nutritional, naturopathic, Chinese, and other traditional medicine tend to practice philosophically more closely to the Chinese and Indian government perspective. Multiple organizations—the University of Arizona Andrew Weil Center for Integrative Medicine,7,8 the American Nutrition Association (ANA),9 and the American Association of Naturopathic Physicians (AANP)10 among them—responded to COVID-19 by developing resource sites with respectful caveats and then linked professionals and members of the public to potentially useful supportive practices and natural agents cited by the existing suggestive science. These methods might have value in preventing, supporting, complementing, or rehabilitating. While there is no direct evidence at this time, other than some uncontrolled studies on Traditional Chinese Medicine out of China,11 some of these approaches may also have the potential to be effective treatments directly against the virus' activity.The Integrative Medicine COVID-19 Support RegistryIn this context, the Traditional, Complementary and Integrative Health and Medicine Support Registry12 is a critically important tool for the community of professionals and patients using these natural agents and supportive practices. The origins and intent of the Registry are captured at the top of this editorial in the explanatory note from Ryan Bradley, ND, MPH, the director of the Helfgott Research Institute, based in Portland, Oregon.The registry is housed on a secure server at the Helfgott Research Institute. Institutional Review Board approval (as "exempt") was secured through the National University of Natural Medicine. Bradley, the project's principal investigator, is an experienced clinical researcher and epidemiologist with a portfolio of peer-reviewed papers in natural products, mind–body therapies, diabetes, heart disease, and whole-practice research. He is also a JACM Associate Editor who has been a recipient of multiple National Institutes of Health grants.Less than a week after creating the registry, a multidisciplinary set of organizations and institutions endorsed the registry. They have begun recruiting their members to participate (a partial list is given in Table 1). In some cases, Memoranda of Understanding have been developed. Examples are the AANP and the ANA, each of which link directly to the registry from their resource sites.Table 1. Initial Supporting OrganizationsWebpage:https://redcap.nunm.edu/redcap/surveys/?s=PE3EHAYDT3Lead agencyHelfgott Research Institute/National University of Natural MedicineSome initial supporting organizationsAcademic Collaborative for Integrative HealthAcademy of Integrative Health and MedicineAmerican Association of Naturopathic PhysiciansAmerican Nutrition AssociationAssociation of Accredited Naturopathic Medical CollegesCanadian College of Naturopathic MedicineIntegrative Complementary and Traditional Health Practices Section-American Public Health AssociationIntegrative Health Policy ConsortiumMaryland University of Integrative HealthNational Ayurvedic Medical AssociationOregon Association of Naturopathic PhysiciansSouthern California University of Health SciencesTraditional, Complementary, and Integrative Medicine (TCIM) Network of the AmericasUniversity of SydneyUniversity of Technology, SydneyWorld Naturopathic FederationThe fields in the registry include basic demographic information such as location and professional training, followed by basic information about goals and therapeutic agents used via quick response lists: Patient symptomsCOVID-19 statusComorbiditiesTherapeutic goals ("prevention, treatment, health promotion, recovery/convalescence, rehabilitation, other")Immune support (12 agents, plus "other")Antiviral agents (13 noted, plus "other")Respiratory health (15 noted, plus "other")Inflammation (18 noted, plus "other")Pharmaceutical drugs (17 categories)Other contributions to health (8 noted, plus "other")Case outcome.The registry collects longitudinal data so that practitioners can return to the registry via a survey access code and update information, such as outcomes, while patients/clients remain under their care. Practitioners can also download their own case information to augment their records, or organize case reports. Note that the drop-down choices on therapies may require users of Traditional Chinese Medicine, Ayurvedic, or other products and practices from other traditional medicine systems to use the "other" box.Intended UseWhere is the value? A FAQ provided by Helfgott (see Table 2) describes initial plans for intended use. The first is simply to determine characteristics of care. The second is to report contributions of integrative practitioners to COVID-19 management and risk reduction. The third is particularly useful for moving governments toward greater proactivity on integrative practices, if warranted: "Provide data for the generation of hypotheses regarding both promising and potentially harmful treatments and protocols." Not mentioned is the learning that will come to any practitioner through the process of entering a subject in the registry, and the added value in recognizing patterns for those who choose to submit multiple entries. The Helfgott team anticipates that the data may be published in various forms. The potential mid-range uses include education and research, as well as advocacy work "to promote the contributions of integrative practices globally."Table 2. FAQs Regarding the Integrative Medicine COVID-19 Support Registry1. Will my entry be linked back to me or my practice?The registry provides the option of including your contact information so that the investigators can contact you for more information about the case, including its outcome. However, this entry is completely voluntary.2. Will the registry collect any Protected Health Information (PHI)?No. No PHI is included, and the data collection platform is completely HIPAA compliant.3. Can I enter more than one patient/client per record?In order to record accurate outcomes for each case, ideally each case would be entered in an individual record. However, if identical care and identical outcomes are observed for multiple patients, it allows for the number of cases to be entered.4. Can I return to my registry entries?Yes. Upon submission of a record, a survey access code is provided. We strongly recommend you store this code in your patient/client record so you can return to the registry and update content as needed.5. Can I print or otherwise access my entries?Yes. Upon submission of a record, you can generate a PDF that includes your entries for your records.6. I'm hesitant to report adverse treatment experiences or observations. Why should I do so?It is very important for the community to learn about potentially adverse treatment outcomes. This is as critical as learning about favorable treatment outcomes. Your entry will not be linked to you or your practice unless you provide your contact information.7. I'm hesitant to describe my practice because I practice in an unregistered jurisdiction. Why should I do so?The registry only collects practice data at the country level. Therefore, it is impossible to determine the licensure status unless when regulated at the country level. As above, your entry will not be linked to you or your practice unless you provide your contact information.8. How will this information be used?The information will be used to: (1) determine characteristics of care, (2) report contributions of integrative practitioners to COVID-19 management and risk reduction, and (3) provide data for the generation of hypotheses regarding both promising and potentially harmful treatments and protocols. These goals can only be accomplished with broad participation. These data may be published and may be used in advocacy work to promote the contributions of integrative practices globally.What You Can Do: A Call to Action in the Time of COVID-19These values of the registry will be more significant the greater the participation. If each practitioner entered a single case example, the result would be tens of thousands of entries from around the world. If you are an integrative practitioner who is working with COVID-19 patients, or individuals concerned that they might have the virus, register the case! If you are a researcher, administrator, or organizational leader who works with complementary, functional, integrative, naturopathic, and traditional medicine professionals, alert them to the registry! Send a brief article and a link in your e-newsletter. Host information and a link on your organization's Web site. Then, do all of this again and again to catch those who need to be told twice or a third time or be reminded.N of 1As a human being on planet Earth, I have a chance of contracting COVID-19. As a 68-year-old who has the damaging sequelae of a successful radiation and Cisplatin treatment 11 years ago, my chances of dying are higher. As a citizen of the United States, the most knowledgeable agency related to these approaches, the National Institutes of Health National Center for Complementary and Integrative Health, warns me that "there is no scientific evidence that any of these alternative remedies can prevent or cure the illness caused by this virus. In fact, some of them may not be safe to consume."6 Yet, as a long-time participant in the movement for more evidence-informed health and medicine, I am familiar with the research that suggests there may be multiple tools that may be valuable to anyone who breaks out of the binary perspective that such choices are not worth considering if they haven't been proven against COVID-19 itself.This Traditional, Complementary and Integrative Health and Medicine COVID-19 Support Registry can be a critical tool for breaking down this polarization. The power of the registry to support greater understanding and integration will depend on interested professionals in the global traditional, complementary, and integrative communities powering it up by contributing. Please do, and let others know. This registry could prove lifesaving, if not for COVID-19 in this pass through, perhaps for its second, or for the next challenging virus that follows SARS-CoV-2.The registry is located here: https://redcap.nunm.edu/redcap/surveys/?s=PE3EHAYDT3References1. Zhang Ziyu. Answer bank: how integrative medicine helps in COVID-19 treatment. Online document at https://news.cgtn.com/news/2020-03-02/Answer-Bank-How-integrative-medicine-helps-in-COVID-19-treatment--OwMEVIrznq/index.html, accessed March 28, 2020. Google Scholar2. China Daily. Combining TCM, Western medicine effective against virus. Online document at www.ecns.cn/news/2020-02-21/detail-ifztvsqr0572671.shtml, accessed March 28, 2020. Google Scholar3. Ministry of AYUSH. Advisory for corona virus—homoeopathy for prevention of corona virus infections, Unani medicines useful in symptomatic management of corona virus infection. Online document at https://pib.gov.in/PressReleasePage.aspx?PRID=1600895, accessed March 28, 2020. Google Scholar4. Centers for Disease Control and Prevention. Coronavirus disease-COVID-19 how to protect yourself. Online document at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html, accessed March 28, 2020. Google Scholar5. United States Food and Drug Administration. Coronavirus update: FDA and FTC warn seven companies selling fraudulent products that claim to treat or prevent COVID-19. Online document at https://www.fda.gov/news-events/press-announcements/coronavirus-update-fda-and-ftc-warn-seven-companies-selling-fraudulent-products-claim-treat-or, accessed March 28, 2020. Google Scholar6. National Center for Complementary and Integrative Health. In the news: coronavirus and "alternative" treatments. Online document at https://www.nccih.nih.gov/health/in-the-news-coronavirus-and-alternative-treatments, accessed March 28, 2020. Google Scholar7. Andrew Weil Center for Integrative Medicine. Integrative approaches to COVID-19. Online document at https://integrativemedicine.arizona.edu/covid_19.html#courses, accessed March 28, 2020. Google Scholar8. Alschuler L, Weil S, Horwitz, et al. Integrative considerations during the COVID-19 pandemic. Explore 2020 Mar 26 [Epub ahead of print]; DOI: 10.1016/j.explore.2020.03.007. Crossref, Google Scholar9. American Nutrition Association. Personalized nutrition and COVID-19 resource hub. Online document at http://theana.org/COVID19, accessed March 28, 2020. Google Scholar10. American Association of Naturopathic Physicians. COVID-19 resources and clinic guidelines for NDs. Online document at https://naturopathic.org/page/Covid19Resources, accessed March 28, 2020. Google Scholar11. Li RF, Hou YL, Huang J, et al. Lianhuaqingwen exerts anti-viral and anti-inflammatory activity against novel coronavirus (SARS-CoV-2). Pharmacol Res 2020; 104761. Medline, Google Scholar12. Helfgott Research Institute. Traditional, Complementary and Integrative Health and Medicine COVID-19 Support Registry. Online document at https://redcap.nunm.edu/redcap/surveys/?s=PE3EHAYDT3, accessed March 28, 2020. Google ScholarFiguresReferencesRelatedDetailsCited byTraditional and Complementary Medicines Methods Used by Patients Diagnosed with COVID-195 October 2022 | Complementary Medicine Research, Vol. 30, No. 1Herbal Medicine Intervention for the Treatment of COVID-19: A Living Systematic Review and Cumulative Meta-Analysis20 June 2022 | Frontiers in Pharmacology, Vol. 13How do people interpret health information in the context of an emerging infectious disease? Digital focus groups exploring perceptions of novel health information during the first wave of COVID-19 restrictions in Singapore (Preprint)5 May 2022 | JMIR Human FactorsA naturopathic treatment approach for mild and moderate COVID-19: A retrospective chart reviewComplementary Therapies in Medicine, Vol. 63The Therapeutic Effect of Traditional Chinese Medicine on Inflammatory Diseases Caused by Virus, Especially on Those Caused by COVID-1926 May 2021 | Frontiers in Pharmacology, Vol. 12International policies and challenges on the legalization of traditional medicine/herbal medicines in the fight against COVID-19Pharmacological Research, Vol. 166Emerging paradigms of viral diseases and paramount role of natural resources as antiviral agentsScience of The Total Environment, Vol. 759ROLE OF AYURVEDA AND YOGA FOR COVID-1918 August 2020 | International Ayurvedic Medical Journal, Vol. 8, No. 8Chinese Herbal Medicines During the Covid-19 Pandemic: A Role for Observational Studies Claudia Citkovitz and Rosa N. Schnyer14 July 2020 | The Journal of Alternative and Complementary Medicine, Vol. 26, No. 7Public Health Approach of Ayurveda and Yoga for COVID-19 Prophylaxis Girish Tillu, Sarika Chaturvedi, Arvind Chopra, and Bhushan Patwardhan11 May 2020 | The Journal of Alternative and Complementary Medicine, Vol. 26, No. 5 Volume 26Issue 4Apr 2020 InformationCopyright 2020, Mary Ann Liebert, Inc., publishersTo cite this article:John Weeks.Call to Action: Announcing the Traditional, Complementary and Integrative Health and Medicine COVID-19 Support Registry.The Journal of Alternative and Complementary Medicine.Apr 2020.256-258.http://doi.org/10.1089/acm.2020.29083.jjwPublished in Volume: 26 Issue 4: April 10, 2020Online Ahead of Print:April 6, 2020 TopicsCOVID-19Integrative and complementary therapies PDF download

The Journal of Alternative and Complementary MedicineVol. 26, No. 2 EditorialInfrastructure to Spur Inclusion of Traditional, Complementary, and Integrative Medicine: The TCIM Americas Network Model Inside the Pan American Health OrganizationJohn WeeksJohn WeeksAddress correspondence to: John Weeks, johnweeks-integrator.com, Seattle, Washington 98116 E-mail Address: jweeks.jacm@gmail.comEditor-in-Chief, The Journal of Alternative and Complementary Medicine.Search for more papers by this authorPublished Online:4 Feb 2020https://doi.org/10.1089/acm.2020.29082.jjwAboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 26Issue 2Feb 2020 InformationCopyright 2020, Mary Ann Liebert, Inc., publishersTo cite this article:John Weeks.Infrastructure to Spur Inclusion of Traditional, Complementary, and Integrative Medicine: The TCIM Americas Network Model Inside the Pan American Health Organization.The Journal of Alternative and Complementary Medicine.Feb 2020.82-84.http://doi.org/10.1089/acm.2020.29082.jjwPublished in Volume: 26 Issue 2: February 4, 2020PDF download

Ethnography has long been associated with the method of participant observation, but for understandable reasons of practicality there is great interest in the idea of the ethnographic interview. Can we learn about culture through interviews? We might well ask how else we can do it. Participant observation is as much about listening as it is about seeing, and ethnographers report more of what they hear in the field than what they see. Interviewing is central to ethnography because to learn how people understand and account for their day-to-day situation, to learn what they think they are up to, we should ask them. To ask them and simply take their response at face value is naïve. But to not ask them at all is ethnographic malpractice. The main benefit of participant observation may be that it helps us to do interviewing better by allowing us to ask better questions, get better answers, and better interpret the answers we get. This benefit should not be underestimated and any ethnographer who can do participant observation, should. Organization studies, however, has many examples of excellent ethnographies which are based primarily on interview data and which did not involve a year of participant observation. I argue in this chapter that cleanly distinguishing participant observation and ethnographic interviewing is not as straightforward as it might seem, particularly when each is done well. Interview ethnography is possible, but it is not a shortcut; it is difficult and time consuming.

The Journal of Alternative and Complementary MedicineVol. 25, No. 10 EditorialFree AccessPerspectives on the American College of Lifestyle Medicine's Strategy to “End the Tyranny of the RCT”John WeeksJohn WeeksAddress correspondence to: John Weeks, johnweeks-integrator.com, Seattle, Washington 98116 E-mail Address: jweeks.jacm@gmail.comEditor-in-Chief, The Journal of Alternative and Complementary Medicine.Search for more papers by this authorPublished Online:21 Oct 2019https://doi.org/10.1089/acm.2019.29078.jjwAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail I learned via follow-up to an American College of Lifestyle Medicine (ACLM) webinar1,2 that the organization devoted to advancing multimodal lifestyle approaches to chronic conditions had a team at work developing a method to combat the damage from what their project leader has since called the “tyranny of the RCT” (randomized controlled trial).3 I invited the ACLM leaders to provide a submission to JACM's since-published Special Issue on Multimodal Approaches in Integrative Health: Whole Persons, Whole Practices, Whole Systems.4 The ACLM team contributed a piece on the misfit of the RCT with lifestyle medicine intervention in which they announced their internal collaboration to create a “Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM).”The ACLM's project and recommended directions via HEALM were recently published in BMC Medical Methodology.5 Their work, led by Yale preventive medicine, integrative medicine, and lifestyle medicine leader David Katz, MD, MPH, thus became part of the pattern of research insurgencies urging new whole systems research (WSR) models such as the one that Nadine Ijaz et al. examined in their review in the JACM special issue.6 The goal is nothing less than to elevate methods that respect the health-focused, preventively oriented, whole-person, tailored approaches such as are practiced in clinical lifestyle medicine that have, to date, effectively been suppressed by the pharmaceutically aligned disease management methods that flourish under reductivity's stern whip. Remarkably, Katz and his team choose strategically—as is shared below—to not reference the WSR opus anywhere. Katz portrays this decision as a tactical effort in a sort of game of thrones aimed at creating shared space at the top of the research pyramid.The work is important—in both substance and strategy. The ACLM team includes some of the top researchers associated with the U.S. Center for Disease Control and Prevention (CMS). It pulses with gravitas. Notably, lifestyle issues and related interventions as promoted by the ACLM are constants across a broad band of traditional, Asian, naturopathic, and integrative clinical models. I contacted key WSR researchers associated with the JACM special issue for their perspectives on HEALM. Then, I reached Katz to learn more about the team's strategy. With the remainder of this editorial, I report what I found, in the words of these experts.Nadine Ijaz, PhDIn her concise comment, University of Toronto-based researcher and certified herbalist Nadine Ijaz, PhD, the lead author on the recent JACM WSR review, references two of the integrative medicine field's most prominent WSR frameworks that predated the HEALM work.The HEALM tool represents a valuable addition to the literature on evidence evaluation—and is likely to support dissemination of quality research that focuses on prevention and health promotion rather than sickness care alone. The tool actively contributes to (and participates in) a methodological paradigm shift that centralizes more holistic, integrative approaches in health care. The authors' critiques of the classical RCT's limitations with respect to behavioral interventions strongly echo those of whole systems research pioneers. Their tangible strategy for diversifying what ‘counts’ as legitimate clinical evidence recalls the ‘evidence house’ (Jonas)7 and ‘circular model’ (Walach et al.)8 proposals of researchers in the [Traditional Complementary and Integrative Medicine] field—and should be welcomed as such. That said, significant work remains to establish evidentiary tools that contextualize ‘lifestyle’ (and other) interventions more deeply within the social, structural and ecological determinants of health. (Nadine Ijaz, personal communication via email, August 2019)Clinician-researcher Dugald Seely, ND, from the Ottawa Cancer Center and the Canadian College of Naturopathic Medicine—and a member of the JACM special issue team—begins with a comment on the ACLM's tactical choice to start the paper with a review of existing strength of evidence (SOE) tools.Dugald Seely, NDThis paper is important in two ways. First, it has collected and synthesized the evidence related to existing Strength of Evidence (SOE) tools. Second and more importantly, this work presents a new tool, the Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM), as a means of combining and evaluating evidence on lifestyle-based interventions that includes longevity as an outcome. The HEALM tool is a much needed and exciting development. Limitations to most SOE tools includes an over-reliance on the RCT as the final arbiter on causality and value for healthcare interventions. David Katz and colleagues have used a process of mapping and scoring that combines research from mechanistic basic science, observational studies for generalizability plus scale, and controlled clinical trials to assess for causality and reduction of risks of bias. The primacy of the RCT is respected in this tool, however it also allows for the inclusion and framing of the evidence through other available sources of evidence. Through this, different types of research can be holistically combined to understand the totality of evidence available and assign a score (Grades A, B or C) associated with a degree of likely certainty of effect. The HEALM tool needs to be put to the test in assessing relevant evidence, but the tool presented is meeting a gap in healthcare research evaluation head on by allowing for and indeed welcoming the plurality of evidence available. (Dugald Seely, personal communication via email, August 2019)Particularly notable for the purposes of this discussion is the reference to the SOE review. The HEALM team did not choose to begin its argument with the prima fasci evidence that lifestyle medicine represents a practice paradigm that does not fit the reductive model. Nor do they begin by reiterating characteristics that define the whole systems practice paradigm—though most are congruent with the lifestyle medicine clinical model (e.g., multimodality, health-focused, individualized, mind-and-body). The team that referenced none of the WSR opus also chose to keep at arm's length any consonance with the WSR. Instead, as Seely notes, the ACLM team first report the results of a systematic scoping review that sets context from within the framework of the SOE dialogue. Then, they rest the case for their differences on a separate trio of concerns relative to evaluating lifestyle medicine interventions on which the SOE review came up nearly empty: Criteria to evaluate exposure-outcome relationships examined over years/decades/lifetimesCriteria to evaluate behaviors/exposures used in lifestyle medicine that may not allow for randomization or blinding (e.g., smoking, long-term dietary patterns, etc.)Guidance to synthesize findings from diverse study designs, except to prioritize RCTs over observational studies.5One witnesses the bowing to the RCT, yet also the emergence of a model that, remarkably, evokes the broader culture context in which this medical-cultural power-struggle is engaged: diversity, on the one hand, and dominance of one perspective on the other. The HEALM team recommends a “systematically weighted approach” involving multiple research models that “(increase) the weight and thereby validity of evidence specially applied to lifestyle interventions.” Seely celebrates HEALM's elevation of a more holistic and inclusive view of evidence.Scott Mist, PhD, MSAOM, LAcOregon Health Sciences University Assistant Professor, acupuncturist and JACM statistics editor Scott Mist, PhD, MSAOM, LAc weighed in on ACLM's SOE work with a few brief comments that challenge the RCTs primacy.One of the things that I have been interested in for a while is re-assessing the hierarchy of evidence. There has been a number of really good studies9,10 showing that large case studies—observational type research—correctly predict the outcomes of randomized clinical studies.A counterpoint argument to these papers came from the editor of BMJ11—but I thought that it was a weak argument—mainly saying that there are few good observational studies. There are caveats about the size, just like any other type of study, but I think that the field should be rethinking the role of observational studies and the primacy of RCTs. (Scott Mist, personal communication via email, August 2019)Mist underscores the importance of looking beyond the RCT in suggesting methods that may make it share the throne.Jennifer Rioux, PhD, AD, C-IAYT, AYT, RH (AHG), CCA-IIIThe second author with Ijaz on the WSR review is Ayurvedic practitioner and WSR researcher Jennifer Rioux, PhD. In a short essay included next in full, Rioux—who also offered original research and commentary for that issue—celebrates HEALM while challenging its limits. In particularly, she questions its obeisance to an era in medicine, and medical research, dominated by the RCT. She challenges the HEALM team pointedly: “We may ask ourselves if the hierarchy-of-evidence-project plays a role in replicating colonial structures that serve to prove the supremacy of biomedicine and its attendant research methods, rather than to improve patient care overall.”Developing innovative frameworks to evaluate evidence in studies of ‘lifetime cumulative effects of specific health behaviors' is critical work. The HEALM tool highlights the suitability of research design for the question and supports a balance between evidence quantity and quality in varying combinations. The authors contend that it is useful to hybridize and tailor the evidence hierarchy to the specifics of lifestyle medicine, however their assertions repeatedly reify the supremacy of the RCT, while downgrading forms of evidence that are often more appropriate for studying traditional, complementary and integrative medicine (TCIM), as well as lifestyle medicine.The term ‘hierarchies of evidence’ is problematic in holistic medical paradigms where understanding diagnosis and treatment may rely on arranging evidence laterally, allowing a primacy of evidence types to emerge as dependent on population, condition, nature of treatment, and outcomes of concern. There is increased understanding in lifestyle medicine that individualizing treatment and shifting treatment priorities over time are correlated with better outcomes. The shifting and emergent nature of evidentiary balance deserves attention, alongside hybridizing and tailoring the hierarchy.I applaud the encouragement of diversified evidence sources and ‘an amalgamation of complementary evidence.’ However, the rating schemes they discuss continue to rely on privileging not just RCTs, but statistical measures like p-values for establishing ‘certainty about treatment effects,’ when it is widely understood that these can be manipulated in the direction of significance. We may ask ourselves if the hierarchy-of-evidence-project plays a role in replicating colonial structures that serve to prove the supremacy of biomedicine and its attendant research methods, rather than to improve patient care overall. This approach excludes evidential constructs that can be more democratically applied across medical paradigms, thus inhibiting interprofessional dialogue within lifestyle medicine.The authors invoke non-RCT evidence as providing context for understanding causality while simultaneously acknowledging ethical and practical limitations of RCTs in lifestyle medicine. They state that even ethnographic studies can contribute evidence, then swiftly change tack, reminding us ‘but these are subject to bias.’ They focus on clarifying causal effects but do not acknowledge the specific, irreplaceable ways that qualitative research illuminates context and process, thereby facilitating a meaningful, patient-centered understanding of causality. Where is the patient's voice in the hierarchy?Discussion of the vast resources necessary to amass ‘higher’ levels of evidence is absent. Scale and complexity of TCIM research, in concert with lifestyle medicine, are naturally disadvantaged through resource deficiency. Limited resources necessitate a greater emphasis on observational studies and small-scale, no control, pre-/post-measures, leading to potentially higher risk of bias (ROB) (conventionally understood). An incurious discussion of RCT primacy replicates a research infrastructure that perpetuates consolidation of resources in the biomedical research community. Weighting and synthesizing evidence is valuable and would be enhanced by further unpacking a continued reliance on quantitative hierarchies, RCT supremacy, and unexamined ROB conventions. Without a rigorous exploration of these foundational assumptions, the HEALM tool replicates the social and political order of privilege in research communities. (Jennifer Rioux, personal communication, September 2019)It is clear from points made earlier that Rioux's argument does not end with the imbalance in power struggles between research communities. Rather she turns attention to the ways that she believes such imbalances express themselves in deficiencies in patient care—particularly in lifestyle-related chronic conditions.Reflections from HEALM's KatzIn an article reported elsewhere,3 I engaged ACLM leader Katz on their strategic approach with HEALM. He confirms that the HEALM work is transparently political as a step to remove the RCTs barrier to the advancement of the lifestyle medicine clinical model. The target audience is a key stakeholder: nutritional epidemiologists for which they presented an advisory team of impeccable endorsers. They consciously chose to draw narrow boundaries for their engagement. They chose not to stray into the integrative and WSR dialogue, despite the rich resonances. While in the interview Katz did not hesitate to join a growing league of others11 decrying what he calls the “tyranny of the RCT,” any such hair-pulling is not found in the paper. ACLM's interest as Katz shares was not in pointing out differences, or calling out shortcomings, but in advancing the field to which ACLM is dedicated: “If you want to wage war, you take up the sword, If you want to make peace you genuflect a little bit. We didn't wish to look for any non-existent provocation.” Yet in response to a question as to how radical the proposal is, the pressures at the seams of this subservience stretch the threads.The most popular method for measuring strength of evidence is GRADE13 and it depends almost entirely on RCTs. In reality, there is a tyranny of the RCT—the idea that if we don't know something via the RCT we don't know it. But in lifestyle medicine, we are interested in lifelong effects that RCTs can't measure, and in interventions where the placebo may be unethical. Given the growing tyranny of the RCT, [HEALM] is pretty revolutionary …We were looking to be narrow as possible in the way we framed this for this to have maximum value. We wanted it to be as conventional as possible. We want it to capture the attention of nutritional epidemiologists. The more radical the proposal, the move conventional the case you want to make. We wanted our citations to be from researchers and journals the people we wanted to influence knew. We stuck close to our narrow proposal to do the systematic review then develop and propose the HEALM model. [Our work with HEALM] is a classic case of if you can't beat them, join them—then beat them by joining them …[With HEALM we are] looking to broaden people's minds. There is a widespread debate in the peer-reviewed literature and the research community more generally about the nature of evidence for nutrition and other lifestyle interventions. An answer is never better than the question that is asked. There is not only a tyranny of the RCT, there is a tyranny of evidence-based medicine. Evidence-based medicine (EBM) ignores the fact that whoever has the money has the evidence. Pharma has the money. It is true that the evidence of absence is not the absence of evidence. (Interview with David Katz, excerpt from a published interview.)3These selected representatives of the WSR and integrative health community herald HEALM's value and express interest in its potential contributions, while, in the main, urging a less compliant line on the RCTs overbearing if not tyrannical position. The ACLM strategically chose to keep the integrative barbarians outside of the gates. Better, for them they judged, tactically, to stay focused on what they portrayed as more narrow lifestyle medicine issues. As politics, this was a move to gain a new respectful place for research on lifestyle medicine on the research throne. It is an internal play for power inside of the court of the RCT king.Tyranny, down through history, is typically associated with bloodshed. Katz, in the interview, points to the gross financial inequities that tilt even the RCT playing field toward pharma—aside from any recommendation of other research methods as HEALM urges. Rioux associates the imbalance with a sociopolitical structure known to produce population-level murderous outcomes: colonialism. It is beyond this column to examine whether the mayhem in the mainstream biomedical industry—put at just more than 250,000 deaths each year by Hopkins researchers14—can be causally associated with that industry's symbiotic relationship with the purportedly tyrannical RCT. (The questions are interesting. What for instance is the count if one considers the deaths and morbidity associated with millions of people who are directed toward pharma interventions rather than the best sort of multimodal, lifestyle medical interventions?)I join the WSR researchers who offer perspectives here in wishing for the best for the HEALM initiative while simultaneously wondering whether the present power imbalance can be tipped via such tiptoeing around the advocates and defenders of the primacy of the RCT, regardless of its misfit with lifestyle medicine and other whole systems approaches. Perhaps research should be commenced that provides an evidentiary case that will foment pitched rhetorical battle to put an end to the morbidity and mortality that come from the RCTs role in delaying optimal care, and the failure to properly diagnose and treat. Might such research support a movement of resources toward more equitable and diverse models? In the era of chronic diseases and lifestyle-related ill health, is the continued supplication to the RCT a major public health problem?AcknowledgmentsThe author is grateful to Nadine Ijaz, Scott Mist, Dugald Seely, and Jennifer Rioux for their thoughtful responses to the query regarding HEALM, and to David Katz for his direct responses on the strategic nature of the HEALM initiative.References1. Frates B. “How to Effectively Incorporate Lifestyle Medicine in the Academic Setting”. Webinar, American College of Lifestyle Medicine. Recording available only to members. Online document at: https://www.lifestylemedicine.org/webinars, accessed September 24, 2019. Google Scholar2. Weeks J. Harvard's Beth Frates: Applying Prochaska's Change Model to Advance Lifestyle Medicine in Institutions. Today's Practitioner. 2018. Online document at: https://todayspractitioner.com/john-weeks/harvards-beth-frates-md-applying-prochaskas-change-model-to-advance-lifestyle-medicine-in-institutions/#.XYpZbmZ7kh7, accessed September 24, 2019. Google Scholar3. Weeks J. HEALM: The David Katz' and lifestyle medicine strategy to get randomized controlled trials to share research's iron throne. Online document at: www.johnweeks-integrator.com/uncategorized/healm-the-david-katz-and-lifestyle-medicine-strategy-to-get-randomized-controlled-trials-to-share-researchs-iron-throne/, accessed on October 5, 2019. Google Scholar4. Boon H, Herman P, Mist S, Reece BF, Rioux J, Ritenbaugh C, Seely D, Standish L, Taylor S, Wayne PM, Weeks J, Witt C (Eds.). Special Focus Issue On Multimodal Approaches In Integrative Health: Whole Persons, Whole Practices, Whole Systems [Special issue]. J Altern Complement Med 2019;25. Google Scholar5. Katz DL, Karlsen MC, Chung M, et al. Hierarchies of evidence applied to lifestyle medicine (HEALM): Introduction of a strength-of-evidence approach based on a methodological systematic review. BMC Med Res Methodol 2019;19:179. Crossref, Medline, Google Scholar6. Ijaz N, Rioux J, Elder C, Weeks J. Whole systems research methods in health care: A scoping review. J Altern Complement Med 2019;25:S21–S50. Link, Google Scholar7. Jonas WB. The evidence house: How to build an inclusive base for complementary medicine. West J Med 2001;175:79–80. Crossref, Medline, Google Scholar8. Walach H, Falkenberg T, Fønnebø V, et al. Circular instead of hierarchical: Methodological principles for the evaluation of complex interventions. BMC Med Res Methodol 2006;6:29. Crossref, Medline, Google Scholar9. Benson K, Hartz AJ. A comparison of observational and randomized controlled trials. N Engl J Med 2000;342:1878–1886. Crossref, Medline, Google Scholar10. Concato J, Shah N, Horwitz RI. Randomized, controlled trials, observational studies and the hierarchy of research designs. N Engl J Med 2000;342:1887–1892. Crossref, Medline, Google Scholar11. Barton S. Which clinical studies provide the best evidence: The best RCT still trumps the best observational study. BMJ 2000;321:255–256. Crossref, Medline, Google Scholar12. Interventional News. A call to arms against “the tyranny of the randomised controlled trial.” 2019. Online document at: https://interventionalnews.com/tyranny-randomised-controlled-trial, accessed September 24, 2019. Google Scholar13. GRADE Working Group. Grading quality of evidence and strength of recommendations BMJ 2004;328:1490. Crossref, Medline, Google Scholar14. Makary MA, Daniel M. Medical error—The third leading cause of death in the US. BMJ 2016;353:i2139. Crossref, Medline, Google ScholarFiguresReferencesRelatedDetailsCited byUsing a Survey to Characterize Rehabilitation Professionals' Perceptions and Use of Complementary, Integrative, and Alternative Medicine Sonya Kim, Carmen Capo-Lugo, William R. Reed, Ariana Vora, Reza Ehsanian, Shilpa Krishnan, Xiaolei Hu, Mary Lou Galantino, Marianne H. Mortera, Aaron Beattie, Nicole Sasson, Brian R. Theodore, Matt Erb, and Patricia Heyn30 July 2020 | The Journal of Alternative and Complementary Medicine, Vol. 26, No. 8 Volume 25Issue 10Oct 2019 InformationCopyright 2019, Mary Ann Liebert, Inc., publishersTo cite this article:John Weeks.Perspectives on the American College of Lifestyle Medicine's Strategy to “End the Tyranny of the RCT”.The Journal of Alternative and Complementary Medicine.Oct 2019.975-978.http://doi.org/10.1089/acm.2019.29078.jjwPublished in Volume: 25 Issue 10: October 21, 2019PDF download

Healthcare reforms have long been advocated as a cure to the increasing healthcare expenditures in advanced economies. Nevertheless, it has not been established whether a market solution via private financing, rather than public financing, curb aggregate healthcare expenditures. To our knowledge, this paper is the first that quantifies the impact of reforms that significantly increases (decreases) the private (public) share of healthcare financing on total healthcare expenditures relative to income in 20 OECD countries. Our reform measure is based on structural break testing of the private share of total expenditures, and verification using evidence of policy reforms. To quantify the effect of these reforms we apply Propensity Score Matching and Inverse Probability Weighted regression analysis. Over a 5-year evaluation period the reforms lead to an accumulated cost saving 0.45 percentage points of GDP. The yearly effects of the reforms are largest in the first years in the post-reform period and decreases in size as a function of time since the reform. Our findings suggest that the investigated healthcare reforms have a relatively short-lived effect on aggregate health spending relative to GDP. The findings are robust to various sensitivity tests.

The most efficient way to locate information published in a journal article is through a periodical index. A scholarly international journal for research in African social sciences and humanities with contributions in English and French; includes an excellent book review section. A British journal concentrating primarily on the Neolithic through Iron Age periods of Western Europe although coverage has been expanded to include Asia, Africa, and the Americas, A regular Notes and News section includes information on dating, mapping, and other techniques, as well as brief excavation and survey reports. The journal builds a broad interdisciplinary knowledge base for the study of all aspects of humankind by selecting topics which are "broad in terms of time, available data and methodology."

The Journal of Alternative and Complementary MedicineVol. 25, No. 2 EditorialsThe Early Movement for Research Evidence in Modern Naturopathy: Fighting Above Its Weight ClassJohn WeeksJohn WeeksAddress correspondence to: John Weeks, johnweeks-integrator.com, Seattle, WA 98116 E-mail Address: jweeks.jacm@gmail.comEditor-in-Chief, The Journal of Alternative and Complementary Medicine.Search for more papers by this authorPublished Online:20 Feb 2019https://doi.org/10.1089/acm.2019.29064.jjwAboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 25Issue 2Feb 2019 InformationCopyright 2019, Mary Ann Liebert, Inc., publishersTo cite this article:John Weeks.The Early Movement for Research Evidence in Modern Naturopathy: Fighting Above Its Weight Class.The Journal of Alternative and Complementary Medicine.Feb 2019.125-128.http://doi.org/10.1089/acm.2019.29064.jjwPublished in Volume: 25 Issue 2: February 20, 2019PDF download

The Journal of Alternative and Complementary MedicineVol. 25, No. 7 EditorialsFree AccessReversing the Fields: Do Group-Delivered Services Belong Closer to the Center of a Transformed Health Care System?John WeeksJohn WeeksAddress correspondence to: John Weeks, johnweeks-integrator.com, Seattle, WA 98116 E-mail Address: jweeks.jacm@gmail.comEditor-in-Chief, The Journal of Alternative and Complementary Medicine.Search for more papers by this authorPublished Online:16 Jul 2019https://doi.org/10.1089/acm.2019.29070.jjwAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Adherents of the field broadly known today as integrative health and medicine have for four decades sought a “paradigm shift” from a reductive to a holistic philosophy. Paradigm shift is a misleadingly quiet descriptor for such a disruptive goal. Terms and phrases used by leaders of the dominant school of biomedicine in the past half decade begin to capture the necessary drama. A cochair of the Global Forum on Innovation in Health Professional Education at the U.S. National Academy of Sciences urged “blowing up the boxes” of the curriculum shaping present medical education.1 These comments followed a reflection of the other cochair that medicine “needs a transformation, and transformational change requires death … and rebirth.”2Realistic assessment of the challenges from a paradigm shift toward a health approach are echoed at the top of health care policy and delivery in similarly disarming, or welcome, language—depending on one's perspective. A former administrator of the U.S. Center for Medicare and Medicaid Services who cofounded the value-based medicine driving Institute for Healthcare Improvement urged a global gathering of hospital leaders toward a “salutogenic” focus. This, he argued, would require taking steps “more radical than we have yet imagined.”3 A chair of the American Hospital Association who was similarly reflecting on redirecting the mission of his member organizations from disease management to “creating health” admitted being stumped: “I don't think anyone yet knows the recipe.”This context frames the theme of this JACM Special Focus Issue on Innovation in Group-Delivered Services. A move to use of group medical visits from one-on-one care can be seen simply as an added seasoning to adorn the regular practice of medicine. Yet even here paradigm issues press in on all sides. Commitment to quality use of group medical visits breaks large and small boxes. Clinical educators need to teach new skills that include collaborating closely with other disciplines and working with teams. Practitioners must educate patients to the value of group, apply new skills while leaving the comfort and control of a one-on-one treatment room for a group environment in which their choices are observed and may be challenged by increasingly Internet-empowered audiences. Challenges to administrators posed by groups range from space, check in, staffing, and phone protocols to scheduling and the barriers to appropriate payment.Each of these becomes a broader systemic concern if one imagines that group-delivered services merit consideration not as seasoning but as staples in a transformed system where the focus shifts from masking or suppressing symptoms and managing disease to creating health or salutogenesis. Might fundamentally shifting substantial treatment—particularly of those with chronic conditions—toward group-delivered methods be essential ingredients of the recipe to reach what the radical reformers at the U.S. Veteran's Administration call the future state of “whole health”?4In medicine's “C-suites” (CEO, CMO, CFO), evidence available today for group-delivered integrative services would embroil them immediately in the most pivotal and revolutionary question: Is their business—nominally not-for-profit although it may be—fundamentally about the production and volume focus of a medical industry or the value and health focus of an organization that merits the title of health care system? Cost savings from three of the best researched of integrative health practices—each delivered through group visits—show remarkable diminution of the need for the services that are the medical industry's current staples: Multiweek group-delivered programs created by Dean Ornish and others to reverse heart disease found per capita savings—through foregone cardiovascular services—at $17,687 per participant over a 3-year period.5Multiweek group-delivered multimodal mindfulness-based stress reduction programs developed by John Kabat-Zinn produced cost savings of $724 per participant relative to usual care.6Multiweek group-delivered multimodal relaxation-focused programs developed by Herbert Benson and others were associated, in a retrospective examination of 4452 participants, with 43% lower use on average of pharmaceuticals, emergency room visits, hospital visits, and physician visits than in controls.7If one questions whether the use of group-delivered medical services meets the threshold of box-breaking and radical, picture how unsettling the 43% reduction may be in the hospital C-suite where success is measured in revenues created from services that the group services are associated with radically reducing. One might wonder too at the response in the C-suite to a “Policy Recommendation” at the end of the study. The authors suggested that for the entire population such well-researched mind–body group-delivered behavior change programs “should perhaps be instituted as a form of preventative care similar to vaccinations or driver education.” What might the impact be of such a public health innovation delivered through groups?If one allows common sense and such present evidence to cut through the bondage of the normal cultural economics of one-on-one care, a case statement for pushing research, education, and practice toward expansive use of groups ripples down before one like a red carpet.Most of our challenges—in health and medical economics—are with chronic conditions.Creating health in people with virtually all such conditions requires central engagement with lifestyle changes—the behavioral determinants of health.Face-to-face teaching and even video or web-based exchange of information about such conditions and how to make changes is most efficiently delivered in a group environment.Adults learn better in interactive group environments than one on one.Engaging active practices to positively influence one's behavioral determinants—such as meditation, mindfulness, cooking kitchens, yoga, t'ai chi, and Zumba—is fostered with and through groups.Group environments limit disabling influences of transference in one-on-one expert-to-patient environments. As group acupuncture proponent Michael Smith, MD, once opined: “If you want to empower patients, put more patients than providers in the room.”8Evidence that social isolation is a significant contributor to chronic pain conditions suggests that the therapeutic medium of groups be part of the message of change.9To the extent that community centers can be the locus for change on social determinant that impact health, the use of these for group activities fosters connections to support such campaigns.The appeal to the evidence-informed essential common sense in most of this list is acquiring a growing base of research support. Leaders of a functional medicine-focused integrative group program at the Cleveland Clinic report that their model is more rapidly shifting patient-centered outcomes scores than a team-based functional medicine model that is itself outperforming regular primary care.10 Some of the evidence is being offered up in this journal. A remarkable experience of a cancer center with acupuncture reported by Gentile and Yaguda found that switching from one-on-one treatment to group both increased income and access. The systematic review by Pariky et al. provides a look at key components.A mentor in my personal journey toward considering the potential of groups was Eileen Stuart-Shor, PhD, RN who worked in the 1980s and 1990s with Herbert Benson and others in a pioneering multiweek group-based programs that were shown to reverse the course of heart disease.11 She described what became a familiar experience as she increasingly created opportunities to present their positive outcomes in conventional cardiology forums. In the summative tale, a fellow panelist would share outcomes from a new pharmaceutical agent that, while positive, showed less change than the group-delivered program she was reporting. Stuart-Shor observed repeatedly that regardless of the positive differential in favor of her group-delivered medical intervention, attendees flocked to the other presenter asking for more information. Optimal use of group-delivered medical services is box-breaking and radical (personal communication, 1999).The transformative change toward group medical visits from one-to-one services is an equal opportunity challenge to conventional, complementary, and integrative practitioners. Despite the alignment of integrative, naturopathic, and functional medicine mission and values with this delivery method, professionals across all fields are products of health care educational systems that value and even glorify the sanctity of the one-to-one practitioner–patient relationship. Is it time to elevate the sanctity of the special value of the group as Geller explores in this issue—in medical treatment?In recent years, promotion of group-delivered services at the Institute for Functional Medicine12 and by Integrative Medicine for the Underserved13—a partner organization for this issue—appear to be leveraging change. A recent interview series on group-delivered services from James Maskell14 that highlight the work at the Cleveland Clinic and of multiple authors in this issue includes evidence of change—if not yet of a tide fully turning to affirmatively explore all the potential to human health from innovation in, and implementation of, group-delivered services.The good news for such an awakening is that subsets of health care leaders across multiple domains are increasingly aware that we need to be looking beyond present horizons for solutions that are more radical than are typically considered. The goal of this special focus issue was to help locate some contributions. JACM will continue to be interested in research on innovations in group-delivered services. The truism in paradigm shifts is that one cannot get out of a mess by reapplying the same tools that got one into it. Group-delivered medical services can be potent agents of change that hit a lot of the right notes.References1. Scrimshaw S. Global forum on innovation in health professional education. Meeting welcome. Online document at: www.iom.edu/Activities/Global/InnovationHealthProfEducation/2015-APR-23/Day%201/Welcome%20and%20Session%20I/1-Welcome-Video.aspx, accessed May 13, 2015. Google Scholar2. Cox M. Opening Comments [Closed Planning Session]. Global Forum on Innovation in Health Professional Education. Washington, DC, April 22, 2015. [Google Scholar]. Google Scholar3. Berwick D. “H4: The Nature of Transformation.” Plenary presentation, Institute for Healthcare Improvement. December 13, 2013. Online document at: www.ihi.org/resources/Pages/AudioandVideo/Don-Berwick-Forum-Keynotes.aspx, accessed June 20, 2019. Google Scholar4. Gaudet T, Kligler B. Whole health in the whole system of the veterans administration: How will we know we have reached this future state? J Altern Complement Med 2019;25(S1):S7–S11. Link, Google Scholar5. Highmark Blue Cross Blue Shield. Dean Ornish program for reversing heart disease cost effectiveness summary. Online document at: https://www.ornish.com/wp-content/uploads/Highmark-cost-analysis-2.pdf, accessed June 20, 2019. Google Scholar6. Herman PM, Anderson ML, Sherman KJ, et al. Cost-effectiveness of mindfulness-based stress reduction versus cognitive behavioral therapy or usual care among adults with chronic low back pain. Spine 2017;42:1511–1520. Crossref, Medline, Google Scholar7. Stahl JE, Dossett ML, LaJoie AS, et al. Relaxation response and resiliency training and its effect on healthcare resource utilization. PLoS One 2015;10:e0140212. Crossref, Medline, Google Scholar8. Smith M. Presentation on National Acupuncture Detoxification Association, Healthier Communities Best Practices Forum: East Meets West. Healthcare Forum, American Hospital Association, Honolulu, HI, November, 1999. Google Scholar9. Mackey S. Learning health systems for optimized care and real-world research discovery. University of Washington School of Medicine, Department of Anesthesiology and Pain Medicine. June 5, 2019. Online document at: https://depts.washington.edu/anesth/administration/calendar/?trumbaEmbed=view%3Devent%26eventid%3D129698621, accessed June 20, 2019. Google Scholar10. Hyman M. Real world: integrative, functional and naturopathic clinical pilots in the era of value-based care. Panel presentation, Integrative Health Symposium. New York City, NY, February 22, 2019. Online document at: https://www.ihsymposium.com/session/real-world-integrative-functional-and-naturopathic-clinical-pilots-in-the-era-of-value-based-care, accessed June 20, 2019. Google Scholar11. Leserman J, Stuart EM, Mamish MEet al.. Nonpharmacologic intervention for hypertension: Long-term follow-up. J Cardiopulm Rehabil Prev 1989;9:8 Crossref, Google Scholar12. Institute for Functional Medicine. Ins and outs of the group visit model. Online document at: https://functionalmedicinecoaching.org/ins-and-outs-group-visit-model, accessed June 20, 2019. Google Scholar13. Lastad AT. Integrative Medical Group Visits at Community Health Centers. Hosted in the Toolkit webpage of Integrative Medicine for the Underserved. Online document at: https://im4us.org/toolkit/integrative-group-medical-visits-at-community-health-centers, accessed June 20, 2019. Google Scholar14. Group Visits Series, James Maskell host. Evolution of medicine-functional forum podcast. Online document at: https://functionalforum.com/category/podcast, accessed June 20, 2019. Google ScholarFiguresReferencesRelatedDetails Volume 25Issue 7Jul 2019 InformationCopyright 2019, Mary Ann Liebert, Inc., publishersTo cite this article:John Weeks.Reversing the Fields: Do Group-Delivered Services Belong Closer to the Center of a Transformed Health Care System?.The Journal of Alternative and Complementary Medicine.Jul 2019.666-668.http://doi.org/10.1089/acm.2019.29070.jjwPublished in Volume: 25 Issue 7: July 16, 2019PDF download

The objective of our study is to report our experience of treatment of a patient with endometrioma who was diagnosed with blood deficiency and blood stasis.A 36-years-old Korean woman diagnosed with endometrioma of the right ovary complained of pelvic pain around the menstrual periods, vaginal discharge, and swelling and itching of the pudenda. The patient was administered the modified Gyejibokryeong-hwan (GBH) and the Bogol-gongjin-dan (BGD) for 6 months.After treatment, the size of the endometrioma in the right ovary was reduced to 17 × 11 × 10 mm from 25 × 21 × 17 mm before treatment. The level of CA 125 decreased from 47.2 U/ml at baseline to 34.3 U/ml after treatment. The level of CA 125 after treatment was within normal range. After treatment, the pelvic pain around the menstrual periods (VAS 7→1), vaginal discharge (VAS 4→1), and swelling and itching of the pudenda (VAS 5→2) decreased from the baseline values.Herbal medicine is a potential alternative therapy for patients with endometrioma of the ovary. Further studies, including case-control studies and RCTs based on an international standard and higher methodological quality, are needed.

The Journal of Alternative and Complementary MedicineVol. 25, No. S1 EditorialOpen AccessValues Align for Researching Whole Systems: A Reflective Overview of the Special IssueJohn Weeks, Heather Boon, and Cheryl RitenbaughJohn WeeksAddress correspondence to: John Weeks, johnweeks-integrator.com, Seattle, WA 98116 E-mail Address: jweeks.jacm@gmail.comEditor-in-Chief, The Journal of Alternative and Complementary Medicine.Search for more papers by this author, Heather BoonLeslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.Search for more papers by this author, and Cheryl RitenbaughDepartment of Family and Community Medicine, University of Arizona, Tucson, AZ.Search for more papers by this authorPublished Online:21 Mar 2019https://doi.org/10.1089/acm.2019.29066.jjwAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail “In the broader context of the call of Berwick and others toward a multiyear march of the medical industry to become a true health care system, it is possible that the whole system research conversation of 20 years ago was the right conversation, ahead of its time. Perhaps that conversation's time of latency is over. What is certain is that we need to be putting new thinking and new research resources behind new kinds of questions if we are to effectively assess the outcomes of this new/old approach to health.” (Gaudet)—Tracy Gaudet, MD and Ben Kligler, MD, MPHOffice of Patient Centered Care and Cultural Transformation, Veterans Health AdministrationContext: Convergence of ValuesWe engaged this special issue project to foster what we believe is a useful convergence. On one hand, members of our team (Table 1) have worked for many years to develop and apply research methods that suit the characteristics of traditional and integrative health practices. These typically have complex features: multimodal, individualized, patient-centered, lifestyle oriented, whole person, health-focused, and oriented toward effectiveness. Together, they seemed to have about as much opportunity to be appropriately measured through the historic gold standard of randomized controlled trials as a camel has of passing through the eye of a needle. We perceived that we needed new methods. We grouped these as “whole systems research” (WSR).1,2Table 1. Special Issue Editorial TeamHeather Boon, BScPhm, PhDUniversity of TorontoPatricia Herman, ND, PhDRAND CorporationJianping Liu, PhDBeijing University of Chinese MedicinePresident, ISCMRScott Mist, PhD, MAOM, MS, MA, LAcOregon Health & Science UniversityBarb Findlay Reece, RNPast VP, Samueli InstituteJennifer Rioux, PhD, AD, C-IAYTIntegral Ayurveda and Yoga TherapyCheryl Ritenbaugh, PhD, MPHUniversity of ArizonaDugald Seely, NDOntario Integrative Cancer CenterLeanna Standish, PhD, ND, LAcBastyr UniversityStephanie Taylor, PhDVeterans AdministrationPeter Wayne, PhDHarvard/Brigham and Women'sJohn WeeksJACM; The Integrator BlogClaudia Witt, MD, MBAUniversity of ZurichIn 2001, a North American group of scientists met to examine options.3 We did not foresee that solutions would come quickly. Two years later in 2003, we formed an international organization of researchers in traditional, complementary, alternative, and integrative medicine. The goal of the organization, ISCMR—a supporting partner for this special issue—is to “foster the development and dissemination of new knowledge regarding whole person healing and whole systems healthcare research.”4 The background section of the review led by Ijaz in this issue describes in more detail the biomedical research context and our past and present challenges. For instance, table 1 in that article describes the “Characteristics of Clinical Whole Systems Paradigms for 13 distinct fields.” (Ijaz) From these origins, the WSR movement made contributions to the broader research community. Notable was that of MacPherson,5 Witt, Berman, and others in furthering pragmatic trial designs.6 Yet a hoped-for movement for “whole systems research” that matched what we originally perceived as a need to move medicine toward whole systems solutions to health care delivery—for expensive chronic conditions, in particular, and for problem solving in general—has not, to date, emerged inside biomedical circles.Yet concurrently in this time period, we are observing remarkable familiar-sounding changes in the dominant biomedical research and delivery paradigm that reflect what were our original priorities. Many of the values that we were seeking to explore have begun to be identified and highlighted in the mainstream of biomedicine. In the United States, turning in this direction may be traced to the 1999 National Academy of Medicine study “To Err is Human.”7 That report split the best-in-the-world image that cloaked the corpus of U.S. medicine, revealing the 100,000 lives lost to usual care—now exceeding 250,000 by some estimates—making it the U.S.'s third most powerful cause of death.8 For many, this nightmarish awakening provoked calls for transformative change.9Efforts to undo the causes of these losses began promoting a shift from focusing on “volume” to a focus on “value.”10 The former administrator for the U.S. Center for Medicare and Medicaid Services, Donald Berwick, called for a shift from disease management to a “health creating” paradigm.11 A proposed shift in mission at a Harvard Medical School captures the realignment from “alleviating human suffering caused by disease” to “improve health and wellness for everyone.”12 The U.S. Veterans Administration (VA) began seeking to implement such a whole system change, establishing an Office of Patient-Centered Care and Health System Transformation—which is featured in an article and a commentary in this issue—and commencing a system-wide campaign toward a “whole health” model (Taylor, Gaudet).The dominant school of medicine's tactics for fostering this newly focused value-based care included resonant considerations and directions: interprofessionalism, patient centeredness, cultural sensitivity, behavioral and social determinants of health, personalized care, stress reduction, and outcomes of well-being and resilience (Table 2). Backing these was the growing realization that suppression of disease is not creation of health.13,14 These aims birthed new methods for examination: patient-reported outcomes, pragmatic trials, and implementation research, to name a few. The invited commentary led by Elder in this issue explores the convergence of these with the original WSR aims, through reference to the WSR exemplars in the Ijaz review.Table 2. Convergence of Interests: Whole Systems Research and Value-Based MedicineWhole system research Challenging clinical characteristicsValue-based medicine Key considerationsTeam careInterprofessionalismPatient centeredPatient centeredIndividualized/tailoredPersonalizedLifestyle (diet, exercise, stress, self-care)Behavioral determinantsHealth and wellnessResilience and well-beingMultimodal (mind–body–spirit)Chronic disease modelsEffectivenessOutcomesIn this convergent context, we issued our call for articles.15 We intentionally cast a wide net for what we chose to call the Special Issue on Multimodal Approaches in Integrative Health: Whole Persons, Whole Practices, Whole Systems. The submissions fell neatly into two distinct groups. One was a set of research articles from researchers at not-for-profit, state, and national entities focusing on methods to transform treatment toward multimodal team-based integrative whole system models. The focus of virtually all of these was on treatment of pain. The second is a group of new exemplars of multimodal and whole systems analyses to which we invited the Ijaz-led analysis of 41 historic WSR exemplars, Whole Systems Research in Health Care: A Scoping Review.Transforming Systems of Pain Treatment Toward Integrative HealthThe crisis in chronic pain treatment in the United States and beyond, due to almost sole reliance on pharmaceutical approaches that became visible in recent years as “the opioid crisis,” runs concurrent with the submission of most of these articles. Governmental agencies, hospitals, and other medical delivery organizations alike are seeking to implement approaches to pain treatment that better integrate nonpharmacologic practices and practitioners. Multiple guidelines and policy documents urge this multimodal interprofessional direction.16–18 In some cases, as will be seen, organizations have engaged the issues with striking whole systems strategies.The invited commentary from Gaudet and Kligler—quoted at the top of this article—describes the plans of the U.S. Veterans Health Administration to transform the agency to a “whole health” model. Pain, opioids, and post-traumatic stress disorders (PTSDs) of returning soldiers drive the efforts, led by these two integrative health and medicine veterans, to reframe the mission of this government-funded single-payer entity. In the invited commentary “Whole Health in the Whole System of the Veterans Administration: How Will We Know We Have Reached This Future State?” the two leaders describe their strategy. They share atypical research questions and measures to clarify whether the VA is reaching the desired “future state” of creating whole health. The VA's transformational road has its distinctive hurdles and illuminations. In “What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration,” Taylor et al. share nine key factors facilitating implementation of complementary and integrative health approaches in that nation's largest health care systems, together with seven areas where challenges are routinely arising.Moving from that nationwide entity to the U.S. state of Oregon, lawmakers there faced their own crisis from overreliance on pharmaceuticals. They passed a law to push treatment of back and neck pain toward a multimodal system that includes nonpharmacologic treatments by acupuncturists, chiropractors, yoga practitioners, massage therapists, mind–body practitioners, and others. The target is an underserved population for whom health care is paid by the government, like that at the VA. In “Whole Systems Within Whole Systems: The Oregon Health Plan's Expansion of Services for Back and Neck Pain,” Eaves et al. employ a “whole systems framework” to explore the implementation of the new guidelines. (Eaves) Theirs was a “multilevel framework designed to consider the multiple actors and level of influence that [Oregon Health Plan] administrators and our research team expected would influence implementation before beginning our evaluation.” Using survey data and interviews, the article's implementation-orientation identified the high level of complexity encountered when changes are sought that impact so many aspects of the organization of health care.An underserved population for whom services are typically also government funded is the subject of the article led by Hursak entitled “Design, Implementation, and Evaluation of an Integrative Pain Management Program in a Primary Care Safety-Net Clinic.” Although part of the state of California's public health system, the context is in contrast with the Oregon article in that here the researchers explore the implementation of a multipractitioner integrative model in a single clinic. The method is a group-based service model through which clinicians and administrators lead those they serve to other services. It could inform development, for instance, of individual Oregon clinics seeking to elevate their nonpharmacologic offerings.A common denominator across these three articles is that the initiative to change treatment is for populations with high trauma: veterans returning from war, and underserved and economically stretched individuals and families who use state-funded services. Is it possible that the multimodal whole person whole systems methods are particularly valuable—as compared with single-agent pharmaceutical methods—for populations that are complicated by trauma and poverty?This theme of serving a population with high levels of historic trauma continues in Drost's work in a government-run clinic in a Canadian province in which team members sought to follow the guidelines of that nation's Truth and Reconciliation Commission by incorporating indigenous healing practices in provincial health care. In “Developing the Alliances to Expand Traditional Indigenous Healing Practices Within Alberta Health Services,” the focus is on the inclusion of the traditional use of sweat lodges into a single health care center. Yet the author engaged the project to illuminate strategies for others seeking these and other culturally appropriate ways to serve indigenous people throughout the jurisdiction.A key factor for success among the nine in the VA study was “demonstrating evidence of [complementary and integrative health] effectiveness.” (Taylor) In “Employing Evidence in Evaluating Complementary Therapies: Finding from an Ethnography of Integrative Pain Management at a Large Urban Pediatric Hospital,” Roth and others engaged a series of interviews with representatives of multiple stakeholders to better understand how evidence has meaning in the effort to create changes toward complementary and integrative approaches. Their five themes demonstrate how this seemingly static concept takes multiple forms in shaping the interest and action of key parties. Access to quality electronic health data to inform the shift toward multidisciplinary integrative pain treatment is the subject of a brief commentary from Ye and others entitled “Improving Usability of Electronic Health Records for Whole Systems Integrative Medicine Practitioners.”In private not-for-profit health care institutions, sustainability is frequently an issue. In “Implementing an Integrative Survivorship Program at a Comprehensive Cancer Center: A Multimodal Approach to Life After Cancer,” Glaser et al. take a narrative approach to describe how this program was developed and grew to eventually include integrative modalities such as healing touch, yoga, oncology massage, and, through partnerships with community practitioners, acupuncture. A team led by Hansen at an academic medical center in the central United States shares their success for a nurse and health coaching-oriented strategy in “A Replicable and Sustainable Whole Person Care Model for Chronic Pain.” The model similarly grew organically based on available resources—in this case nurses trained in health coaching who are at the program's center. These distinctive characteristics suggest that the replicability and sustainability may not be precisely in the provider mix but rather in the process choices of making the most of the human resources and relationships in a given site, and the practice of solidifying the model in a step-by-step way. This set of articles taken together provides guidance as to both the consistencies and variations to be found among challenges and solutions in this arena.Exemplars of Multimodal and Whole Person TreatmentsThis body of pain-related efforts to transform whole systems of treatment at multiple clinic, hospital, state, and national levels already described arrived as a surprise. What we knew we wished to draw were the latest clinical exemplars examined through WSR and multimodal research methods. A part of the mission to anchor this work was to reflect on the opus of WSR over the past two decades and examine it systematically, particularly with reference to whether any of the methods in these exemplars might have utility for research colleagues in biomedicine who find themselves confronted with the complexities of measuring interventions that meet the interprofessional, patient-centered, and other outcomes of the emerging value-based era.In “Whole Systems Research in Health Care: A Scoping Review,” Ijaz and a team, supported by many of the members of the Special Issue Editorial Team, identified a set of 41 historical clinical research exemplars. These reflect treatment in 13 traditional, complementary, and integrative medicine disciplines. The aim was to map “the range and methodological characteristics of WSR studies.” (Ijaz)The invited project, supported, in part, through funds for the special issue, includes multiple charts that can guide newcomers as well as WSR veterans through the choices and exemplars. The goal was to explore methods rather than effectiveness. One chart explores the design, interventions, and outcomes of each study. Another examines the research strategies in each. Eighteen use randomized methods—although only a few were controlled—and another 14 depend on statistical (4) or pragmatic (10) allocation designs. Although the gold standard of a single-agent randomized placebo-controlled trial could not by definition be met in these studies, it is notable that these WSR scientists were typically able to apply research methods developed in the biomedical framework—including more recent methods in the value-based era such as pragmatic trials.The development of a complex whole system intervention by Seely and a Canadian team documented in “Intervention Development Process for a Pragmatic Randomized Controlled Trial: The Thoracic Peri-Operative Integrative Surgical Care Evaluation Trial” is already an exemplar in how to herd the famously individually minded cats of integrative practice—in this case naturopathic doctors—to define the “intervention palette with core and optional components.” Although the work began with multiple systematic reviews, the demonstrated genius may be in the 32 member “Intervention Development Committee” on which 14 medical doctors from 5 specialties and multiple research scientists worked shoulder-to-shoulder with the naturopathic clinicians and researchers to set the intentionally malleable clinical guidelines. Selection assignment was based on a systematic analysis of five factors ranging from “practical usage” and “safety” to “holism across goals,” “feasibility and scalability,” and “evidence for effectiveness.” In this case, the process appears also to be part of the outcome. Naturopathic doctors are seeking to create relationships with medical colleagues and would appear to have done so in the process of the research itself.Rioux and Howerter took a different tack in their plunge into a WSR method that they reported as “Outcomes from a Whole-Systems Ayurvedic Medicine and Yoga Therapy Treatment for Obesity Pilot Study.” Here the model is one of the first in the WSR field to honor both the biomedical and Ayurvedic models throughout design and implementation. Study design involved dual diagnosis (biomedical and Ayurvedic) at baseline as well as individualized treatments including diets based in Ayurvedic food classifications (creamy, astringent, etc.) and Yoga tailored to dosha imbalance, body habitus, and abilities. Perhaps the most novel component of the design was measurement of both biomedical and Ayurvedic outcomes.The other two exemplars each reports outcomes of multimodal interventions directly or indirectly pain related. In “Evaluation of an Integrative PTSD Treatment Program,” Hilton et al. used a mixed-methods approach to evaluate “Back on Track,” an intensive outpatient “whole systems approach for the treatment of combat-related stress reactions and PTSD in active duty service members.” Quantitative data were evaluated on 585 soldiers who underwent the “psychoeducational group therapy format with a holistic approach for treating combat stress, increasing resiliency, and assisting with reintegration” through content “in bio-psycho-social-spiritual domains, including didactic lectures on mindfulness and the relaxation response and daily sessions of yoga nidra and meditation.” (Hilton) The authors discuss how the value found surpasses the results of either “gold standard cognitive behavioral therapy” or individual complementary medicine treatments. (Hilton) The holistic combination seems to be linked to the effect.Side-Bar 1. Comparing Apples with Catastrophes: Whole Costs Needed to Assess Whole System MethodsThe marquee results in the integrative team cost analysis by Wayne et al. will not please the integrative health advocate who assumes that integrative services are cost effective. In that Boston, Massachusetts-based medical delivery center fueled by a mix of private and government insurance methods, the total adjusted annual chronic low back pain-related costs per patient were nearly 70% greater than similarly insured people with usual care. Yet at the same time, the authors noted “trends towards decreased direct expenditures and medication usage over time.” They urged further research with, among other changes, “longer observational periods [that] explore multiple metrics of cost-effectiveness.” Their multimodal team-based approach potentially met neither the time nor cost dimensions of an optimal “whole system” framework.Consider the same team intervention inside the Veterans Administration's “whole health” campaign as described by Gaudet and Kligler. The VA's lifetime relationship with the veteran and his or her family creates interest in a longer “observation period” than, for example, the annual insurance policy bazaar that defines an insurer's commitment to a patient in the U.S. private insurance system. The VA's single-payer environment also incentivizes interest in considering all the costs that might be associated with the veteran's care. These include such expensive human and financial challenges as addiction, family disruption, in-patient treatment, and homelessness. These are associated with pharmacologic measures for pain management. They are not associated with the nominally more expensive care from an integrative team of acupuncturists, chiropractors, integrative medical doctors, and others found by Wayne and his team. Considered in this context, their limited framework suggests they were comparing apples to catastrophes.The multiple submissions to this Special Issue on Multimodal Approaches in Integrative Health that focus on the care for populations with high levels of trauma—returning soldiers, indigenous people, and those who are economically disadvantaged—underscore a related insight. Reductive narrow lens approaches to pain and treatment in general may more readily fit the needs of advantaged people. But when the complexities attached to trauma are part of the picture, human-connected treatment that engages the whole person—which may be comparatively cost-intensive in the limited frame of the intervention—could prove to be both the most effective and cost-effective, under full cost accounting (Side-Bar 2). Increasing funding of research directed at applying better methods for measuring such complex outcomes will be needed.—J.W., H.B., and C.R.While also multimodal, the context, content, and delivery are significantly different in the contribution from Wayne et al. entitled “Cost-effectiveness of a team-based integrative medicine approach to the treatment of back pain.” The multidisciplinary treatment at a large tertiary care hospital and its associated clinics included treatment from an interprofessionally trained team that delivered “chiropractic, acupuncture, psychiatry, physician-administered integrative medicine consultations, and multiple mind–body and movement-based therapies.” (Wayne) The findings were mixed with questions regarding changes over a longer term that beg questions (Side-Bar 1) about the extent to which the payment model, delivery context, and the application of whole system accounting will ultimately be the determining factors regarding the clinical and cost value to be gained from these whole person multimodal interventions.Reflections on the ProjectThe value in exploring this convergence of the integrative clinical concerns that WSR seeks to address and the directions in the value-based era are suggested by two invited commentaries. As multimodal approaches have risen in value for major chronic disease, a subset of physicians have formed an international organization focused on “lifestyle medicine.” In “The Need for a Whole Systems Approach to Evidence Evaluation: An Update from the American College of Lifestyle Medicine,” Katz and Karlsen announce the challenging work underway from this group to clarify appropriate methods “in which the entire model of care is deemed the ‘active ingredient’ [and thus] require assessment of the entire model of care versus other models.” (Katz) Their proposed Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM) project, in development, promises to be an interesting addition to the WSR methodology oeuvre.That is a coming attraction. For the present moment, an invited commentary from Elder et al. sought to share highlights from the body of WSR methods and exemplars that might be the most useful to researchers who are also grappling with how to measure the more complex and individualized interventions of the value-based era. In “Convergent Points for Conventional Medicine and Whole Systems Research: A User's Guide,” the team extracts from the Ijaz review of 41 WSR trials those examples that might prove of most utility across “four potentially cross-talking themes—complex behaviorally-focused interventions, patient centered outcomes, team-based care, and resilience and well-being.” (Elder)The response to the call for articles was striking in both categories of responses. Despite significant efforts to reach communities of researchers who are applying WSR methods, the yield was quite limited, despite the fact that special issues that declare for WSR are rare. Assuming the light response was not a marketing failure, one wonders, ironically, if at just this convergent moment when whole systems thinking is on the rise, if the energy in the movement for WSR is on the decline. In private conversations and published statements, adherents share challenges in securing funding.19 An organized effort to convince the largest funding entity for complementary and integrative health to prioritize “researching the way we practice” in multimodal integrative clinical has produced limited response.20 Can it be that former WSR researchers have become pragmatic trialists—a direction that their ranks arguably fostered? Or are they seeking to approximate capturing the whole through mixed methods research? How comfortable can researchers, payers, and policymakers, for that matter, be with trials that may knit together patient-reported outcomes, biomedical, and cost data as Seely does in the trial included in the Ijaz review?21Side-Bar 2: Advance the Dialogue: An Invitation for Commentaries on the Special IssueWe hope that the perspectives and findings in this editorial and commentaries, the Ijaz scoping review, and the original research articles in this Special Issue on Multimodal Approaches in Integrative Health: Whole Persons, Whole Practices, Whole Systems prove stimulating. To expand and advance the dialogue on the multiple themes—whether related to a method or conclusion in a single article, the state of the whole systems research movement, measures needed to reach the “future state” of whole health, or strategies to support implementation research in these areas—we invite your commentary of up to 500 words on a topic of your choice that ties back to content here. Please submit them to JACM by April 30, 2019, with a cover note identifying them as responsive to this call. We will work with the Special Issue Editorial Team to select articles for publication.—C.R., H.B., and J.W.At the same time, we were struck by the series of articles that focus on something that could not be anticipated in the more polarized era 20 years ago: namely, the transformation of whole systems of care toward including nonpharmacologic practices and practitioners in an integrative health model. These new models for delivery of health urge a new application of research methods that fit a new paradigm of care (Side-Bar 2). Gaudet and Kligler ask through what measures and methods the Veterans Health Administration can know that the largest health care system in the United States has reached the “future state” of “whole health.” The transformation of care in multiple centers, hospitals, and under new national, state, and provincial regulations—examined in the other articles—is microcosms of reframing of what researchers need to be asking.The farmer, poet, and author Wendell Berry has written of the importance of maintaining wilderness at the borders of farmlands for the sake of biological diversity for the health of the land and, by extension, the planet.22 The emerging appreciation of whole systems thinking in health care, whether related to the microbiome or to the social determinants of health, suggests that tilling the soil of WSR methods, by whatever names, merits not dismissal, but investment.AcknowledgmentsThis special issue was supported by a grant from the Lotte & John Hecht Memorial Foundation. It was engaged with the fiscal partnership of Bastyr University, Bothell, WA, offering programs in areas including naturopathy, acupuncture, and Oriental medicine, nutrition, herbal medicine, Ayurvedic medicine, psychology, and midwifery. We also thank ISCMR, a global organization that networks researchers in traditional, complementary, alternative, and integrative health and medicine for their partnership in promoting this issue.References1. Ritenbaugh C, Verhoef M, Fleishman S, et al. Whole systems research: A discipline for studying complementary and alternative medicine. Altern Ther Health Med 2003;9:32–36. Medline, Google Scholar2. Verhoef M, Lewith G, Ritenbaugh C, et al. Complementary and alternative medicine whole systems research: Beyond identification of inadequacies of the RCT. Complementary Ther Med 2005;13:206–212. Crossref, Medline, Google Scholar3. Tzu Chi Institute for Complementary Medicine. Tzu Chi Institute for Complementary Medicine Conference: Art and Science of Healing II. Vancouver, BC, October 19–21, 2001. Google Scholar4. About ISCMR. Webpage, ISCMR-Researchers in Traditional, Complementary, Alternative and Integrative Medicine and Health. Online document at: https://www.iscmr.org/content/about-iscmr, accessed February 17, 2019. Google Scholar5. Macpherson H. Pragmatic clinical trials. Complement Ther Med 2004;12:136–140. Crossref, Medline, Google Scholar6. Witt CM, Withers SR, Grant S, et al. What can comparative effectiveness research contribute to integrative health in international perspective? J Altern Complement Med 2014;20:874–880. Google Scholar7. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Institute of Medicine (US) Committee on Quality of Health Care in America. Washington, DC: National Academies Press (US), 2000. Google Scholar8. Makary MA, Daniel M. Medical error—the 3rd leading cause of death in the US. BMJ 2016;353:i2139. Crossref, Medline, Google Scholar9. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: Setting a goal and a deadline for improving health care quality. JAMA 2006;295:324–327. Crossref, Medline, Google Scholar10. NEJM Catalyst. What is Value-Based Health Care. New Marketplace. N Engl J Med. Online document at: https://catalyst.nejm.org/what-is-value-based-healthcare, accessed February 17, 2019. Google Scholar11. Weeks J. Hooking up: Don Berwick, integrative medicine and his call for a radical shift to ‘health creation. ’ Huffington Post. 2014. Online document at: www.huffingtonpost.com/john-weeks/don-berwick-integrative-m_b_4781105.html, accessed February 17, 2019. Google Scholar12. Weeks J. Paradigm Shift? Harvard Medical School Considering Mission Reframe from Sickness Model to Health. Today's Practitioner. 2018. Online document at: https://todayspractitioner.com/john-weeks/paradigm-shift-harvard-medical-school-considering-mission-reframe-from-sickness-model-to-health/#.XGsQKrh7mM8, accessed February 17, 2019. Google Scholar13. Weinstock M. Toward a healthier tomorrow. Hospital and Health Networks Web site. 2013. www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Magazine/2013/Dec/1213HHN_Coverstory, accessed April 14, 2014. Google Scholar14. Stempniak M. The patient experience: Taking it to the next level. Hospital and Health Networks Web site. 2013. Online document at: www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Magazine/2013/Apr/0413HHN_FEA_PatientexperienceGate, accessed April 14, 2014. Google Scholar15. Weeks J. Multimodal approaches in integrative health: Whole persons, whole practices, whole systems—an invitation to submit. J Altern Complement Med 2018;24:193–195. Link, Google Scholar16. Joint Commission. Clarification on the Pain Management Standard. Clarification to Standard PC.01.02.07. Online document at: https://www.jointcommission.org/assets/1/18/Clarification_of_the_Pain_Management__Standard.pdf, accessed February 17, 2019. Google Scholar17. Oaseem A, Wilt TJ, McLean RM, et al. Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline. American College of Physicians. Annals of Internal Medicine. Clinical Guidelines. 2017. Online document at: https://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice, accessed February 27, 2019. Google Scholar18. Phillips JK, Ford MA, Bonnie RJ, eds; National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington (DC): National Academies Press (US), 2017. Google Scholar19. Ritenbaugh R, Aickin A, Bradley R, et al. Whole systems research becomes real: New results and next steps. J Altern Complement Med 2010;16:131–137. Link, Google Scholar20. Menard M, Weeks J, Anderson B, et al. Consensus recommendations to NCCIH from research faculty in a transdisciplinary academic consortium for complementary and integrative health and medicine. J Altern Complement Med 2015;21:386–394. Link, Google Scholar21. Herman PM, Szczurko O, Cooley K, et al. 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Google ScholarFiguresReferencesRelatedDetailsCited byNaturopathic Management of Acute Pediatric Respiratory Infections: A Modified Delphi Study Leslie Solomonian, Jamine Blesoff, Luciano Garofalo, Sandra Lucas, Andrea Picardo, Anna Garber, Mariah Wilson, and Matthew Leach24 February 2023 | Journal of Integrative and Complementary Medicine, Vol. 0, No. 0Nondual Awareness and the Whole Person21 May 2020 | Global Advances in Health and Medicine, Vol. 9Pathfinding, Progress and Partnerships: Commentary on the JACM Whole Systems Research Special Issue Michael Epstein15 August 2019 | The Journal of Alternative and Complementary Medicine, Vol. 25, No. 8 Volume 25Issue S1Mar 2019 InformationCopyright 2019, Mary Ann Liebert, Inc., publishersTo cite this article:John Weeks, Heather Boon, and Cheryl Ritenbaugh.Values Align for Researching Whole Systems: A Reflective Overview of the Special Issue.The Journal of Alternative and Complementary Medicine.Mar 2019.S1-S6.http://doi.org/10.1089/acm.2019.29066.jjwcreative commons licensePublished in Volume: 25 Issue S1: March 21, 2019PDF download

The Journal of Alternative and Complementary MedicineVol. 24, No. 11 EditorialFree AccessFundamental Misclassification, Worse Media, and Failure to Communicate: How “Complementary Medicine” Was Incorrectly Linked to Early DeathJohn WeeksJohn WeeksAddress correspondence to: John Weeks, johnweeks-integrator.com, Seattle, WA 98116 E-mail Address: jweeks.jacm@gmail.comEditor-in-Chief, The Journal of Alternative and Complementary Medicine.Search for more papers by this authorPublished Online:13 Nov 2018https://doi.org/10.1089/acm.2018.29056.jjwAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail “Arose is a rose is a rose is a rose.”1 American poet and author Gertrude Stein famously penned this line 105 years ago. The phrase is used to signify that things are what they are. By this same light, if cancer patients should choose to not listen to their oncologist and instead delay or disregard that advice, then the path they are choosing is an “alternative” to the recommendations of the conventional oncology provider. It is not a complement. When it comes to cancer care, alternative medicine is alternative medicine is alternative medicine.A rose, to the authors of a recent widely reported article in JAMA Oncology,2 is apparently a begonia. The results caused the New York Times to warn readers, in a subheading, that “people who used herbs, acupuncture and other complementary treatments tended to die earlier than those who didn't.”3 At issue, as Society for Integrative Oncology (SIO) leaders have remarked in interviews following the wave of media, is a classic “misclassification error.”4 As will be seen, the repeated confusion of “alternative” for “complementary” led to the faulty conclusion that complementary therapies kill. The authors state as much. When they removed those who denied or delayed treatment (a.k.a. chose “alternative” courses), the evidence of the association between “complementary therapy” use and diminished length of life “goes away.”In a separate study, the authors had already usefully found death rates higher among cancer patients who choose alternatives.5 Yet, with this follow-up examination, death associated with the choice of complementary treatments was unleashed into the public domain, corrupting the decision processes of untold multitudes who grope to find the best paths through a cancer diagnosis and treatment process. I interviewed and wrote on this topic elsewhere when the story and resulting media broke in July 2018. This column offers reflections on what was, at the very least, a disservice to the human beings and those who care for them when they are considering their plan after a cancer diagnosis, and what might be done.Misclassification ErrorsThe misclassification by the Yale research team led by Skyler Johnson and James Yu was not merely to call alternative medicine users complementary medicine (CM) users. The misclassification was also on the other side of the ledger: the controls. Surveys have shown that 48%–88% of people with cancer try some complementary treatment.6 Johnson and Yu acknowledge this. They also note that most people do not communicate with their oncologists about their choices. These failures to communicate most certainly meant that a high percentage of those in the control group were using complementary therapies that were unreported.On my request, JACM Statistics Editor Scott Mist examined the article. The apparent gravitas of the Johnson and Yu results comes with their sharing that their research was based on mining data on 1,901,815 patients in the U.S. National Cancer Registry. But they identified only 258 patients who met the study's criteria for “complementary medicine” use. How could this be? With the known high use of complementary practices, Mist concluded that “there should have been between 836,799 and 1,673,597 CM users. They found less than 0.01%. That should have stopped the study right there. There is no way that less than 1/100th of the population is representative of the population of CM users.”4 To summarize: the most influential information in the findings of what Johnson and Yu classified as “complementary medicine” users were actually using these therapies as “alternative medicine.” And logic dictates that a high percentage of the so-called controls were certainly CM users. To corrupt the metaphor a bit, neither the rose nor the begonia were what they were declared to be.Lack of Patient-Centered Cancer CareWhat lay behind these errors? A garbage-in-garbage-out problem lets Johnson and Yu partially off the hook. They relied on a database that was neither built for, nor captured, the information they were evaluating. Two studies from researchers at the Mayo Clinic in the recent JACM Special Issue on Integrative Oncology underscore how poorly patient choices of complementary therapies are represented in doctor notes and electronic records. The titles alone capture the chasms: “Absent and Discordant Electronic Health Record Documentation of CAM in Cancer Care”7 and “Contending Worldviews in the Clinical Encounter: An Empirical Study of Complementary and Alternative Medicine Deliberations in Contemporary Medical Oncology.”8One wonders, do these dismal records of present oncologist–patient dialogue on complementary or alternative treatment suggest that most oncologists can distinguish between “complementary” and “alternative” and get it right in their notes? Not only were these oncologists not communicating with their patient about their extraclinical choices, when they were they could quite likely have been documenting the nuances between alternative and complementary wrong. The misclassification plaguing the Johnson and Yu article may have begun here, in the beginning, in the creation of suspect data on which the entire study and its conclusions rest.Lack of Interprofessional CollegialityWhere the Yale team is not off the hook, especially in the emerging interprofessional era, is in their failure to respect the integrative oncology field enough to bring someone with expertise onto their team. Anyone with familiarity with the evolving field of integrative oncology would have immediately recognized the problems their method would encounter and then the problems in the article. Unfortunately, the Yale team did not deem it necessary to include an expert in the field they proceeded to publicly damn. Did the editors of JAMA Oncology seek out a peer with actual expertise before publishing a message they must have known would spread like wildfire in the media? SIO president Lynda Balneaves underscores the sad lack of collegiality: “Honestly, this has disappointed me. It's too bad that the authors didn't just connect with researchers knowledgeable in integrative oncology before doing this work. There are a lot of us out there.”9 The evidence of a burgeoning field with respect and endorsement in conventional oncology circles is readily at hand.10,11Call for Retraction?The decision to publish this research was a very big deal—a sort of life and death judgment on the field, especially with the way “complementary medicine” played in resulting headlines. Multiple individuals, institutions, and organizations—including the SIO—sent critical letters to JAMA Oncology.4 As of this writing, none of their letters have been published. To my knowledge, none called for retraction. Balneaves believes that even the “major misclassification bias” does not hit the threshold to call for retraction. She strategically prefers that JAMA Oncology open a dialogue on integrative oncology that could prove broadly educational for the field. Yet the criticisms of the Johnson and Yu study sound multiple notes that stimulate retraction. “Honest error” is one reason.12 Nor would it be a stretch to consider the process “compromised peer review” given the apparent lack of experts in the subject matter being part of the process.13 Johnson and Yu have been made aware of their mistakes, opening another potential reason for retraction noted in the same study—in 38% of incidences the retraction was not required by the editors but was “issued by the authors.” At this writing, the nonretracted article has 190,259 views.One wonders, in this era in which the boundaries of the scientific academy are peppered to porousness by media and social media, whether justification for retraction might simply come through applying medicine's first concern: primum non-nocere. Given the value that researchers have confirmed in complementary therapies for people undergoing often brutal oncologic practices, failure to retract likely not only causes harm but also sustains it into perpetuity for anyone who uses the Internet. The complementary medicine in cancer care kills message is there for the clicking.JAMA Oncology cannot recall the misinformation the article has spewed into a public hungry for assistance in making informed decisions about complementary and alternative therapies during cancer treatment. But it can begin a new era of collaboration by retracting the article—or at least making a splash of publishing the critiques and inviting dialogue with the integrative oncology community.References1 Wikipedia. Rose is a rose is a rose is a rose. Online document at: https://en.wikipedia.org/wiki/Rose_is_a_rose_is_a_rose_is_a_rose, accessed August 15, 2018. Google Scholar2 Johnson SB, Park HS, Gross CP, Yu JB. 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Online document at: www.johnweeks-integrator.com/uncategorized/interview-sio-president-lynda-balneaves-on-the-jama-oncology-paper-linking-complementary-care-with-early-death, accessed October 3, 2018. Google Scholar10 Lyman GH, Greenlee H, Bohlke K, et al. Integrative therapies during and after breast cancer treatment: ASCO Endorsement of the SIO Clinical Practice Guideline. J Am Soc Clin Oncol 2018;36:2647–2655. Crossref, Medline, Google Scholar11 Mao JJ. Advancing the global impact of integrative oncology. JNCI Monogr 2017;2017:lgx001. Crossref, Google Scholar12 Van Noorden R. The reasons for retraction. News Blog. Nature.com. Online document at: http://blogs.nature.com/news/2011/10/the_reasons_for_retraction.html, accessed October 3, 2018. Google Scholar13 Moylan E, Kowalczuk M. Why articles are retracted: A retrospective cross-sectional study of retraction notices at BioMed Central. BMJ Open 2016;6:012047. Crossref, Google ScholarFiguresReferencesRelatedDetails Volume 24Issue 11Nov 2018 InformationCopyright 2018, Mary Ann Liebert, Inc., publishersTo cite this article:John Weeks.Fundamental Misclassification, Worse Media, and Failure to Communicate: How “Complementary Medicine” Was Incorrectly Linked to Early Death.The Journal of Alternative and Complementary Medicine.Nov 2018.1029-1031.http://doi.org/10.1089/acm.2018.29056.jjwPublished in Volume: 24 Issue 11: November 13, 2018Online Ahead of Print:October 30, 2018PDF download