Editorial Comments

National Institutes of Health "Oregon Center for Complementary and Alternative Medicine": Value to Permanente Medical Groups and to Kaiser Foundation Health Plan and Hospitals.

In 1999, the National Center for Complementary and Alternative Medicine (NCCAM), one of the institutes and centers that make up the National Institutes of Health (NIH), approved a proposal from the Kaiser Permanente Northwest (KPNW) Center for Health Research to be one of 12 national Complementary and Alternative Medicine (CAM) research centers. This center would primarily focus on craniofacial disorders. Because of a growing interest in and use of alternative therapies by consumers to meet their health care needs, evidence of safety and efficacy was necessary to ensure the public health. In 1994, the Office of Alternative Medicine (OAM), the first NIH research and funding arm for alternative therapies, created a taxonomy to define these therapeutic practices, created research centers, and funded research projects. When OAM was expanded into NCCAM the budget grew from 19.5 million to 50 million dollars, with a projected budget for 2003 of 113.2 million. Research centers grew in number and scope. From their inception, the centers were charged with not only conducting rigorous research, but also developing the capabilities and capacity of a center, such as infrastructure support, laboratories, biometric functionality, and a critical mass of researchers, which requires attention to development of CAM investigators.

When the KPNW Center for Health Research won one of the 12 center grants they established The Oregon Center for CAM (OCCAM). The center was of interest to NIH because of its location in a metropolitan area with four CAM colleges--Oregon College of Oriental Medicine, National College of Naturopathic Medicine, Western States Chiropractic College, and the Oregon School of Massage--in addition to its association with the Kaiser Permanente (KP) medical care delivery system, the KP Dental Care Program, and the Oregon Health Sciences University School of Dentistry. The Oregon Center for CAM compounded this value by creating an executive committee composed of research and clinical representatives from all seven entities. This group's expertise would ensure importing the best scientific thinking and experience in these disciplines. This in turn would instruct the development of rigorous research in CAM approaches to prevention, treatment, and mechanisms of action in craniofacial disorders. Alex White, DDS, DrPH, as the principal investigator, brought experience as a research scientist directly from previous work at NIH. Cheryl Ritenbaugh, PhD, MPH, co-investigator and medical anthropologist, brought 20 years of clinical trials experience and multi-institutional collaborative research and training experience at the University of Arizona College of Medicine.

As an associate medical director for Northwest Permanente, I was working with the KP Regional Benefits Committee (RBC) designing member benefits in the area of alternative therapies in response to consumer and employer demand for these types of health care products and services. Because of this work and my professional interest in innovative approaches to medical care, I agreed to be a co-investigator on the grant and to sit on the OCCAM Executive Committee as the NW Permanente Medical Group representative.

To coincide with this special issue on CAM, I present a perspective on the value to the medical group, to the RBC, and to the KP health care delivery system of having an association with a CAM research center. I would like to address the following areas: why all Permanente physicians and clinicians will benefit; physician and clinician research opportunities; development of CAM services; continuing medical education opportunities for CAM; patient benefit; benefit to medical practice; and bridging between health care researchers and clinical care delivery operations.

Why All Permanente Physicians and Clinicians Will Benefit

Regardless of the region of the country in which they practice, KP physicians and clinicians have always benefited from sharing practice information. In the last ten years, this cooperation has been enhanced with the proliferation of interregional groups, national KP education and learning conferences, and the work of the Care Management Institute. It is heartening for all to know that one of only 12 CAM research centers in the country is within our program. In the next year, center researchers will begin to publish findings from their studies conducted here, which will become part of a KP evidence base to instruct clinical practice. Already CAM center researchers, physicians, and clinicians have been teaching others about their research experience and findings. Finally, grant opportunities are available for those from all regions interested in pursuing CAM research.

Research Opportunities

An essential research center activity is to develop the research interest and investigator ability of clinical practitioners. OCCAM, in addition to its three major CAM projects, developed a research fellowship program. Two KP clinicians were selected as research fellows: Charles Elder, MD, a NWP internist, and Jeff Weih, PA, LAc, an affiliated clinician in Physiatry. Dr Elder studied meditation and Ayurvedic Medicine (an ancient Hindu medical system) in "Mind Body Techniques for Temporomandibular Disorder (TMD)," and Mr Weih studied acupuncture in "Measurement of Nerve Activity and Blood Flow During Acupuncture Treatment." Other KP clinicians who have worked on, or are currently working on, research projects supported by OCCAM include: Mark Rarick, MD, oncologist, studied an ancient Japanese acupuncture system in "Jin Shin Jyutsu for Mucositis of Chemotherapy"; Joe Leben, DDS, Director of the KP TMD Clinic, a co-investigator in the Phase II TMD trials; Susan Kiley, MSW, a member of the Vohs Award-winning KPNW Multidisciplinary Chronic Pain Clinic, for "Evaluation of Healing Touch for Headache Patients in the KPNW Pain Clinic"; and myself for "Assessing Communication and Relations Skills of Traditional Chinese Medicine Practitioners with Patients." This communication study specifically focuses on using the Art of Medicine patient evaluation survey for acupuncturists working in the KP CAM network providing services to our members by referral and self-referral.

Having the assistance and advice of research experts so close at hand is extremely valuable for supporting physicians who are new at clinical research and at writing grant proposals. This assistance is necessary to ensure that their work formulating critical clinical questions and study design goes forward.

Development of CAM Services

Having an associated research center can be highly beneficial for people designing and developing clinical services. One new program is an example. Several years ago, John Scott, MD, a Colorado Permanente physician, developed the Cooperative Health Care Clinic concept, in which several patients with similar medical conditions gathered to have a group visit with their doctor and a multidisciplinary team. In the NW, Dr Elder adapted this model to meet patients' needs for information and guidance in the area of CAM. In part because Dr Elder had developed credibility as a serious researcher of CAM through his fellowship with OCCAM, and because of demand for services by patients and physician colleagues alike, his pilot group clinic was recently expanded to better serve the region. Patient satisfaction with the clinic and with the supplemental information and treatment he offered demonstrated their need for alternatives to traditional medical care when there wasn't a conventional alternative.

When an innovative clinical physician has experimental data, based on rigorous research design and methodology, and has presented that data at a peer-reviewed national conference, that physician has a credible place to start when discussing new alternatives with physician peers. It is no longer opinion or personal anecdote. This increases the legitimacy of the innovative effort and infuses the innovator with energy to work the research question harder and longer. Concomitantly, the visibility and credibility of the CAM research center is enhanced.

As a result of my personal involvement on the OCCAM Executive Committee, and as an OCCAM researcher, I improved my understanding of both CAM practitioners and their therapies, which in turn informed my evaluation of and decisions about CAM benefits design and implementation for KP members. Specifically, the improved working relationship built with Complementary Health Plans (CHP)--KPNW's contracted CAM network--through collaboration on study design, has improved my understanding of the quality of care that CHP and its practitioners are committed to deliver to our members. The KP Art of Medicine survey tool, used for several years across the Permanente Medical Groups, is now being used by acupuncturists at CHP. What will be the effect of this feedback for these practitioners? Our planned follow-up project will study its use in evaluation of patient and practitioner satisfaction for chiropractors, naturopaths, and massage therapists. To supplement this anticipated perspective, having an opportunity to bring the voice of KPNW physicians and KPNW patients to the executive committee's discussion of CAM has been another benefit for the medical group.

As an initial response to consumer interest and demand for CAM, NWP formed an Alternative Medicine Journal Club (AMJC) to create a network of interested physicians and health care practitioners at KP, and to provide a discussion forum for both clinical and patient questions, and to review recent CAM literature. With the establishment of OCCAM the journal club was infused with CAM practitioners from the colleges and investigators in the study projects. Instead of a forum of uninformed clinicians seeking understanding from each other and from interpretation of the CAM literature, a new level of interaction and understanding occurred when this diverse group of people sat together with a common interest and talked about what they knew, didn't know, and wondered about.

The Oregon College of Oriental Medicine (OCOM) is developing a doctoral program (one of the first in the country). Because of OCOM discussions with NWP physicians in the multidisciplinary chronic pain clinic, the College plans to have clinical preceptor rotations on medical services to enhance the integration of western medicine into the practice of traditional Chinese medicine. This association will enhance the education of NWP physicians, the integration of acupuncture into the pain clinic, and the use of NIH evidence-based indications for acupuncture in medical practice.

Continuing Medical Education Opportunities for CAM

Physicians who desire more knowledge about complementary and alternative medicine practices have benefited from the expertise now available from the CAM colleges in Portland through the Oregon Center of CAM. At KP Continuing Medical Educational conferences, researchers and practitioners presented information, discussed case studies and research findings, answered questions raised by KP clinicians, and demonstrated techniques in experiential workshops. OCCAM cosponsored this most recent conference as an opportunity for the research center to inform clinicians about the center and its research projects and to create an evidence base for CAM.

In addition, clinician requests for educational preceptorships with CAM practitioners have become available because the CAM colleges participate in the research center planning and clinical studies, and there is a shared commitment to provide opportunities for interested clinicians.

The Permanente Journal (TPJ) has featured several articles on CAM topics. Through my work at OCCAM I became aware of other systems of health care and healing. I saw the importance of an article submitted by Louis Montour, MD, a Colorado Permanente family physician, who wrote about the Native American "Medicine Wheel" as a model for understanding patients with chronic pain, and explaining treatments and activities patients can use to restore balance in their lives.¹ In addition, exploring the healing practice of shamans--ancient medicine men who are our professional ancestors--I wrote about the similarities of shamanic healing to the physician-patient interaction and physician treatment of medical conditions. This editorial was titled, "Healing Physicians, Physicians Healing,"² OCCAM researchers have submitted a grant proposal to study shamanic healing of TMD pain. Other CAM articles published by TPJ include: "Complementary and Alternative Medicine Comes to KP"³ by Lydia Segal, MD, a Mid-Atlantic Permanente physician, who authors an update in this current issue; "Use of and Interest in Complementary and Alternative Therapies Among Clinicians and Adult Members of the Kaiser Permanente Northern California Region: Results of a 1996 Survey"⁴ by Nancy Gordon, PhD, ScD, a Division of Research Investigator, and David Sobel, MD, a Northern California Permanente physician; and "The Herbal Medicine Pharmacy" ⁵ by Phillip Tuso, MD, a Southern California Permanente physician, who authors an update in this issue.

Patient Benefit

Ultimately, the most important benefit of OCCAM clinical studies is for KP patients. Patients who seek treatment for chronic pain often require a multidisciplinary approach utilizing multiple interventions simultaneously or in parallel. These patients become frustrated when conventional medical treatments fail to bring desired relief, and there are no other options for them. Across the country, they seek alternative therapies. TMD patients are one such subgroup. They are commonly referred to the TMD Clinic, directed by Dr Joe Leben. Here they may enter one of two OCCAM Phase II trials, and then be randomized to either usual care or one of four CAM therapies. In the literature and in my conversations with Permanente physicians, some patients do improve with alternative therapies that wouldn't have if the alternatives weren't available. It is never clear just what the patient needs for improvement; patients are different, have different belief systems, different experiences, and come from different cultures. For example, Asian patients may view oriental medicine as their traditional medicine, and find comfort and benefit from this approach. As well, patients routinely express that by participating in a research study they feel good about making a contribution to improve health care for future patients.

Benefit to Clinical Practice

Physicians have expressed that they too look for alternatives and supplements to conventional western medical treatment for their patients, especially for chronic conditions, some of which are difficult to treat, such as fibromyalgia, headaches, irritable bowel syndrome, low back pain, dysmenorrhea, and chronic fatigue syndrome. Physicians can now refer these patients--or those seeking information, exercise, lifestyle changes, or herbal supplements--to Dr Elder's CAM group clinic. The collaborative work between CAM practitioners and physicians can be viewed as foundational preparation for future creation of an integrated medicine clinic. This clinic will likely grow out of our multidisciplinary pain clinic. Several other physicians and clinicians with an interest in CAM are encouraged by having a CAM research center in our system. In conjunction with this, my participation in the research center has aided my development of other physician leaders in innovative clinical areas. Having a center developing investigational projects allows examination, comparison, and reevaluation of traditional medical care. This invigorates clinical practice.

Bridging Research and Clinical Practice

Researchers at the KPNW Center for Health Research, who have historically focused on population-based health care studies, have for several years looked for opportunities to work with physicians in clinical research addressing health care issues in the care delivery system. A new group of KPNW physician and research leaders meet together in a group called the "Bridge Advisory Committee" to learn from each other's perspective and to encourage and support collaboration between research and clinical practice. Their focus is to conduct rigorous research on the most important clinical issues facing primary and specialty care physicians. OCCAM has exemplified how traditional medical researchers and practitioners from four alternative health disciplines can design and carry out research in the clinical setting, benefiting both groups and patients. The Bridge Group's work is an expression of that model.

Because medical anthropologist, Nancy Vuckovic, PhD, collaborated with me as co-investigator on my OCCAM developmental study evaluating communication between acupuncturists and patients, she was introduced to, and then became a member of, the KP Interregional Clinician-Patient Communication Leadership Group. This bridging activity brought Dr Vuckovic's professional research and anthropologic perspective to this clinical group, and she found value in participating in and learning from the clinical application of our communications research.

Conclusion

Having a CAM research center associated with a Permanente Medical Group and the Kaiser Foundation Health Plan and Hospitals has positively impacted several areas: research opportunities, development of CAM services, continuing medical education opportunities for CAM, clinical practice, patient care, and bridging research and clinical practice. Rigorous research, especially multidisciplinary, multihealth system collaboration has created the foundation for a high-quality evidence base for CAM in clinical practice. This continues the integration of conventional medicine and the best of complementary and alternative medicine for the benefit of patients. Implementing research findings improves the delivery of health care to meet patients needs, and to produce patient, practitioner, and physician satisfaction and improved health.

References:

1. Montour LT. The medicine wheel: understanding "problem" patients in primary care. Perm J 2000 Winter;4(1):34-9.
2. Janisse T. Healing physicians: physicians healing. Perm J 2000 Spring;4(2):3-7.
3. Segal LS. Complementary and alternative medicine comes to KP. Perm J 1998 Spring;2(2):33-7.
4. Gordon NP, Sobel DS. Use of and interest in complementary and alternative therapies among clinicians and adult members of the Kaiser Permanente Northern California region: Results of a 1996 survey. Perm J 1999 Summer;3(2):44-55.
5. Tuso PJ. The herbal medicine pharmacy: what Kaiser Permanente providers need to know. Perm J 1999 Winter;3(1):33-7.

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