The Bravewell Collaborative, the nation’s leading philanthropic organization supporting integrative medicine, gathered in New York City to honor Dr. Mimi Guarneri, MD, director of the Scripps Center for Integrative Medicine, with it’s third Leadership Award.
The ceremony provided an opportunity to celebrate the evolution of holistic medicine over the last 10 years, an evolution in which the Bravewell group has played an elemental role.
At a time when so much seems wrong with health care and with the world at large, the Bravewell gathering was a reminder that new, more humane systems are indeed emerging despite daunting resistance. The Collaborative’s efforts are strong evidence of what can happen when people of goodwill come together, pool their resources and their brains, and attempt to face major problems.
The Collaborative began in 2001 as a conversation between leading practitioners of holistic medicine and philanthropists who had a particular interest in fostering and guiding a shift from fragmented, procedure-oriented disease care, to a more integrative model of person-centered, prevention-oriented care.
Meaningful Steps Toward Major Changes
Spearheaded by Penny & Bill George, and Christy & John Mack, and their respective family foundations, the Collaborative drew together dozens of benefactors and patrons in what has become a major force in reshaping medicine in this country, as is evident by reviewing what the group has accomplished over the last 10 years. Key accomplishments include:
Bravewell Clinical Network: Since 2003, the Collaborative has funded research,program development and clinical care at 9 centers around the country. Combined, these centers—most at major Universities–provide comprehensive holistic care for thousands of people. They also serve as research loci, and as incubators for new models of care delivery
Consortium of Academic Health Centers in Integrative Medicine (CAHCIM): Founded in 2002 with financial support from Bravewell, the Consortium now represents 51 academic medical centers committed to reshaping medical education to include greater focus on prevention, and the core principles and practices of integrative medicine.
Bravewell Fellowship Program: The Collaborative has provided funding that enabled 75 young physicians to complete the 2-year Fellowship in Integrative Medicine at the University of Arizona. The program, headed by Dr. Andrew Weil and Dr. Victoria Maizes, has been a training ground for the next generation of leaders in integrative health care. Currently 17 Bravewell fellows are in the midst of the fellowship training, which includes extensive hands-on clinical experience as well as didactic work.
BraveNet: Based at the Duke Clinical Research Institute, BraveNet is a practice-based research network that enables the integrative healthcare community to create research collaborations on clinical as well as socioeconomic topics. The network recently completed its first study, involving more than 3,600 patients and looking at what types of patients seek services at integrative clinics and what problems these patients wish to solve. A second project, the Study on Integrative Medicine Treatment Approaches for Pain (SIMTAP) is underway.
The New Medicine Program on PBS: In the Spring of 2006, more than 500 PBS affiliate stations aired a two-hour program funded by Bravewell and exploring the emerging world of integrative medicine. The New Medicine has aired several times in the last 5 years, and has been seen by over 4.2 million people.
The Institute of Medicine Summit on Integrative Medicine & the Health of the Public: In February 2009, Bravewell collaborated with the Institute of Medicine and the National Academy of Science, to sponsor an historic, high-profile gathering of more than 700 clinicians, academicians, researchers, policy-makers, and business leaders to explore the science, practice, and pubic health impact of integrative medicine.
Held at the height of the health care reform debates, the Summit was the first time representatives of the holistic/integrative disciplines attempted to stand together as a unified field offering meaningful solutions to the nation’s health care crisis (Read HPC’s coverage of the IOM Summit).
Integrative Medicine in the Military: Last year, Bravewell representatives met with leaders in military medicine at the Pentagon to discuss how holistic/integrative therapies could be brought into the care of wounded personnel and military veterans. With a particular emphasis on pain management, the meeting resulted in a joint commitment from the Department of Defense and the Veterans Health Administration (VHA) to implement integrative pain management throughout the military medical systems. Dr. Tracey Gaudet, a founder of the Consortium of Academic Health Centers (CAHCIM), and former director of Duke Integrative Medicine, recently became the inaugural director of the VHA’s new Office of Patient-Centered Care & Cultural Transformation.
Bravewell Leadership Awards: Established in 2003, the Bravewell awards honor physicians that have taken leadership roles in advancing integrative medicine. The award provides the recipient with a gift of $100,000 intended to support further development of his or her work.
The first recipient was Dr. Ralph Snyderman, former Chancellor for Health Affairs at Duke. The second, in 2005, was Dr. Brian Berman, Director of the University of Maryland’s Center for Integrative Medicine. In 2007, Bravewell honored six integrative pioneers: Drs. Larry Dossey, James Gordon, Jon Kabat-Zinn, Dean Ornish, Rachel Naomi Remen, and Andrew Weil.
Bravewell co-founder, Christy Mack, presented the 2011 Leadership Award to Dr. Erminia “Mimi” Guarneri, founding director of the Scripps Center for Integrative Medicine.
“Dr. Mimi Guarneri is a true leader in integrative medicine,” said Mrs. Mack. “In addition to caring for patients, throughout the years she has worked hard to help other doctors and nurses gain proficiency in integrative medicine by putting on national educational conferences for caregivers, by directly mentoring other practitioners in her center, and by serving various associations in the field.”
“She stepped up to the plate for Bravewell over and over again, serving — without any financial reimbursement — as the head of the Bravewell Clinical Network for more than 9 years, on the planning committee and as faculty for the IOM’s Summit on Integrative Medicine and the Health of the Public, and by speaking at special briefings on integrative medicine that Bravewell helped organize on Capitol Hill and at the Pentagon.”
Curing the “Occulostenotic Reflex”
“We need to think about integrative medicine as an economic strategy,” said Dr. Guarneri in a press conference prior to receiving the Bravewell Leadership Award. “Ninety percent of cardiovascular disease is preventable! We do 1.3 million angioplasties every year, and 500,000 bypass surgeries. If we prevented just 10% of these, we would save $10 billion per year.”
Dr. Guarneri speaks from experience: she began her career as an interventional cardiologist, performing the very procedures she is hoping will become less frequent as the nation’s health care systems—and its public–embrace a more integrative approach.
As much as she’s working to help patients reverse heart disease, she’s also hoping to cure cardiologists of what she termed the “Oculostenotic Reflex,” a deeply ingrained impulse to “see a lesion and immediately try to fix it, whether or not it is even stenotic, and whether or not stenting will make any difference in preventing MI or death.”
“In the 1990s, all I was concerned about was, ‘How do I mechanically fix this diseased coronary artery?’ The reality is, we can repair arteries and restore blood flow to the heart within 20 minutes. It’s truly a modern miracle! But, it doesn’t address the issue of why this person with a prior bypass is showing up on my operating table needing an angioplasty.”
Citing new data on the country’s 2010 drug utilization, recently published by the IMS Institute for Healthcare Informatics (http://www.imshealth.com), Dr. Guarneri noted that last year, the country spent $13.6 billion on statin therapies alone.
Despite the nation’s exorbitant expenditures on surgical interventions and drugs, 2,200 Americans die from CVD each day, and coronary disease still causes 1 in 6 deaths. “Statins do not cure CVD.”
Psychotic, Depressed, Dyspeptic
The IMS data indicate that Americans spent $308 billion on pharmaceuticals last year; collectively, we consume 47% of all pharmaceuticals produced on the planet. Judging by the drug categories with the biggest total expenditures, one can conclude that, “the US is psychotic, depressed, has hyperlipidemia and heartburn!” Dr. Guarneri joked.
But it’s really not a joke. It’s a frightening reality, one that’s economically unsustainable. Like many clinicians involved with Bravewell, Dr. Guarneri believes that a fundamental shift from disease-based interventions to wellness-focused care has tremendous potential to save lives and save money.
“We have the tools. We know that for every dollar we spend on, say, the Ornish lifestyle based programs for CVD, we save $6. We have the research. We need to apply it.” Last year, Dr. Guarneri co-authored a review paper entitled The Efficacy and Cost-Effectiveness of Integrative Medicine, documenting the actual real-world outcomes and savings from application of integrative principles and practices in treatment of heart disease, stroke, cancer, diabetes and depression.
Scripps: Where Tech Meets Touch
The Scripps Center for Integrative Medicine, which Dr. Guarneri has helmed since its inception, is often cited as an ideal model of modern integrative medicine, a clinic that provides equal measures of high-tech and high-touch. The center provides state of the art cardiovascular imaging and conventional CV risk workup, as well as intensive lifestyle interventions, yoga and mindfulness programs, nutrition-based therapies, and an array of holistic treatment options. There’s even an on site formulary devoted exclusively to nutraceuticals, botanical medicines, homeopathic products, and other non-pharmaceutical therapies that have been carefully vetted by the Scripps team.
Despite it’s apparent success, the development of the Scripps center was far from easy, and Dr. Guarneri said it continues to face challenges.
“I naively believed that if we created the best integrative medicine center within our five hospital centers, that integrative medicine would move laterally through the system. I learned that creating an isolated system is not the way to go. It needs to be a whole cultural transformation. It needs to come from the top, and be propagated through the whole system through education on all fronts,” she said during a panel discussion moderated by CBS Evening News Medical Correspondent, Dr. Jonathan LaPook.
In addition to her clinical and administrative roles, Dr. Guarneri has been a leader at the forefront of integrative medical education. She was recently elected President of the American Board of Integrative and Holistic Medicine.
One of the keys for propagating the waves of change throughout medical culture is to build connections between practitioners in different disciplines and to foster personal interdisciplinary relationships. “You need to get the different camps into the same room,” Dr. Guarneri said, reflecting on her experiences at Scripps. “You need to take away that sense of threat from some unknown someone in another building.”
That’s no easy task, given the diversity of methods and modalities, as well as the broad range of health care professionals that fall under the rubric of “Integrative Medicine.” It is compounded by the fact that most of the money in health care still flows in torrents into the disease care systems, while barely a trickle runs into the preventive medicine sector. Many of the centers that Bravewell funds still face daunting fiscal challenges despite the philanthropic support.
With a few exceptions, the for-profit insurance plans as well as the federal programs have been reluctant to cover comprehensive integrative care of the sort that Bravewell’s contingency would like to see.
The Collaborative’s work thus far has been focused, for the most part, on the institutional level, where many advocates believe they can find the greatest leverage for change. A recurring question at the press conference was whether the progress that Bravewell is making at the academic centers and in the Department of Defense will ever percolate down into the “trenches” of solo, small-group, and community-based primary care.
While acknowledging that much of American medicine seems stuck in the “pre-integrative” era, Bravewell’s leadership is hopeful that the changes happening at the institutional level will propagate outward from the academic centers and into the communities. Many believe sheer economic pressure will force the changes.
For her part, Dr. Guarneri believes the necessary changes are as much perceptual and philosophical as they are fiscal and clinical. At some point, on the golden road to the modern tertiary care center, practitioners and the public alike became entirely fixated on the “How” of medicine, and forgot about the “Why.”
“We stopped asking the “Why” questions, and we need to start asking them again. “Why am I diabetic?” “Why do I have heart disease?” “Why am I constantly getting sick?” Those questions—if asked earnestly–will inevitably lead to the issue of lifestyle.
“We know that 70%-90% of all disease risk is related to lifestyle and environmental factors. Genetics is only a small part of it. Macro and micronutrition, spiritual and social balance, physical activity, sleep and restoration, environmental protection, emotional and mental balance….these are the key factors. This is where the leverage is, because all of these things are modifiable. They are what influences gene expression.”