WHITE HOUSE COMMISSION
COMPLEMENTARY and ALTERNATIVE MEDICINE POLICY
+ + +
Draft Interim Report
+ + +
+ + +
Tuesday, July 3, 2001
Jurys Washington Hotel
1500 New Hampshire Avenue, N.W.
P R O C E E D I N G S
DR. GORDON: We are going to get started this morning. If we could, just again, sit quietly together for a moment and relax, and be present with ourselves and with each other.
[Moment of silence observed.]
DR. GORDON: Okay, everybody. This morning and today, our task is really to try to understand some of the issues that are remaining in terms of delivery of services and reimbursement, and issues related to research, and then development of the Interim Report.
As part of that work, there is a general sense that I have heard from a number of people, both in the meetings, and informally outside the meetings, that we need to deepen our common experience of our world view of our perspective of ourselves and of our connection to CAM, especially as we move into making recommendations and creating a tone and a feeling and a perspective for the Interim Report. In line with that, Tom Chappell came up with a suggestion for working on this morning's program.
Tom, I would like to give the floor to you.
MR. CHAPPELL: Thank you, Jim.
To elaborate, there are a number of us who have wanted to do this homework and we haven't had the time. So, in a brief workshop design this morning, which we planned out with some facilitators, in small groups of six Commissioners per group, we will have a chance, in an hour, or hour and 15 minutes, to get down on paper what it is we deeply care about in the consideration of CAM products and services, or the whole orientation of CAM.
We could call these our core values. We could call this who we are, but it will, as Jim said, provide a context of our common experience as we come from different perspectives, different professions, different ways of thinking about how CAM can help the world.
So the question will be simple in the small group. It will be one question. We would ask each of the Commissioners to participate fully. There will be some prioritization, light prioritization, of your responses, and we will come back into full group and share what each of the three groups has come up with, and then turn that material over to the team and the staff for inclusion and drafting in the Final Report.
DR. GORDON: I just wanted to check and see if the Commissioners feel this is a good exercise and an important one to do, just check in with everybody and get a consensus on this, and I am seeing a lot of nodding heads. So I would like to proceed, then, with this.
As Tom says, it has been something that we have worked with some earlier, but clearly, we need to keep on working and deepening our experience of why we are here and what we are about.
So please continue, Tom.
MR. CHAPPELL: We will just go around. There will be three facilitators: Wayne, Charlotte, and myself. I will work with a group in this room, Charlotte and Wayne will be across the way in two small groups. There will be newsprint for each group, a scribe for each group, and we will simply answer the question: In considering CAM products and services, we believe deeply that.
It has to be presented as a "we believe" because you have to have a sense of our brothers and sisters in this circle, yet, owning what it is you deeply believe in, and respecting what your Commissioners also deeply believe in.
Out of this, we will get a set of values, a complexity of values that we will try to own and hold as we go forward into the strategy, the goals and everything else that we do. So this will be the grounding.
So if we could go around the room, Commissioners only, responding to the count. I will be one, you are two.
Okay. Would the ones join me?
DR. GORDON: Let's do a timetable on this, first of all.
MR. CHAPPELL: Forty-five minutes in the group. We will see you back here in --
DR. GORDON: Each group will be 45 minutes, and then come back to this room within five minutes after that, please. Then what we are going to do is, we will rearrange the schedule some, or we will shorten the schedule.
Our belief is that if we clarify some of these issues, our work, particularly in the area of -- I want to make this clear, we are going to be covering all the topics: reimbursement, delivery of services, any topics remaining from research, wellness, as well as the Interim Report. The idea is, we will be able to cut down the time, particularly, we hope, the time we spend on the Interim Report, by clarifying core values.
So that is the purpose of this. We will get to everything, and there will be time for all the work that we are doing. So 45 minutes in the group, a 5-minute break after that, and then please come back in here right after that so we can begin with the discussion of the presentations from the group, and then moving into the rest of the program.
Members of the public are welcome to sit in and observe as we have these groups. All aspects of this meeting are open, so please feel free to do that in either of the groups in the next room or to stay in this room.
[Small group discussions convened.]
DR. GORDON: Okay, we will hear from each of the groups, then if there are other comments around the table, briefly give people a chance to talk.
Do you want to talk before that, Dean, or do you want to talk after that?
DR. ORNISH: I just want to say a couple words, that, having spent most of my professional life fighting for the kind of values that I think most of us share, I found myself yesterday in this kind of curious position of being the identifier of red flags, almost like the school marm, and that is not a role I am particularly comfortable in.
I think, out of a shared desire not to make a report that is boring, but rather to make an Interim Report that is going to not get shot out of the water, to try to be skillful about it. It may be that I have just been sensitized in the seven years of dealing with Medicare, trying to get them to pay for our program, that I have a real good idea of the kinds of red flags, certainly that I have dealt with. It is out of that loving, conscious desire to try to come up with a report that really ultimately makes a difference in the lives of people.
I think we can talk about our values as we have done this morning, which I thought was incredibly useful, without pushing people's buttons. I think that is different than pushing people's buttons in the kinds of ways that we were talking about yesterday.
So I just want to make it clear that we are not, certainly Tom and I and others, are not on opposite sides. I think we have the same shared values. It is just a question of strategy.
DR. GORDON: Thank you, Dean.
Let's move, then, with each of the group leaders, in turn, talking about the experience and the beliefs.
Presentation: Small Group No. 1
MR. CHAPPELL: We believe deeply that CAM is an important and an essential part of health care; Number 2, for wellness, that it is an important and essential part for wellness; Number 3, that CAM has scientific validity and needs strengthening of evidence; Number 4, requires universal health education starting at kindergarten; Number 5, greater awareness and knowledge of CAM by medical practitioners so that they can refer appropriately.
So we need to provide greater awareness and knowledge for medical practitioners so that they can refer appropriately. That is as opposed to trying to bring medical practitioners, conventional medical practitioners, up to some degree status of CAM services.
Number 6, CAM is both transforming and re-orienting the entire health care system, that CAM brings an awareness of the uniqueness of each person. It brings a new world view to health, wellness, prevention, and that is largely through an awareness of self-care. We need to use other methods, as needed, to healing self, and that illness is, in fact, a journey that has its benefits of creating self awareness and mutual understanding.
Number 7, CAM optimizes lifestyle systems and living, all aspects of life. It brings to light all aspects of our living and our lifestyles, that optimal health encompasses all aspects of living, not just self-healing but also the disease of living. CAM offers approaches to higher, more holistic and fuller life of persons and societies.
Number 8, it offers ways to answer the question, who am I; why am I here. CAM is holistic. It is a life system within a context of living. Number 10, we Commissioners believe deeply in healing of all approaches, which includes CAM, allopathic medicine, spirituality, et al. We have a deep belief in the integration of all these different approaches. We have a deep belief in science and the scientific method. CAM is one of the many approaches to health, wellness and lifestyles, to which all aspire.
Number 13, CAM can make valuable contributions to health care, particularly the vulnerable populations. CAM is value-added, complementary, not alternative. It is an evolving, moving, dynamic model of encompassing diversity of disciplines. It has much to contribute to health care and medicine. It is inclusive of many different disciplines, all of which may and can have their respective leaders of teams. It is accountable for safety. CAM products and services are accountable for safety and efficacy.
CAM needs objective, inclusive overview of origin and evolution in the context of our culture and societal history. We need to minimize impediments to access and delivery. We need to demonstrate cost-effectiveness.
DR. GORDON: Would anyone else in the group like to say anything at this point, before we go on to the next group? These are a statement of beliefs, each articulated by different people in the group.
DR. GORDON: Okay. Let's go on to the next group.
Presentation: Small Group No. 2
DR. JONAS: We not only laid out some core values and prioritized them, we also color-coded them for easy communication.
One of the questions that came up in the middle of the conversation, but proved to be, I think, a core issue is, what are we advocates for; what do we want to see; what is this Commission really for; is it promoting something.
I think we agreed that it was promoting something, and what we decided it was promoting, it was written in red here as the overarching goal of the , which is to develop policies or recommendations for improved health of Americans by assuring the availability of safe and efficacious CAM services and products.
So the goal is not on an advocacy for any CAM services or products, it is an advocacy for improved health using safe and efficacious, as have been described and determined of these areas, these particular areas.
So that, we felt, was the overarching of what we want to see happen out of this Commission.
Now, what are the core values that go into providing that? I think we came up with really four main ones, actually seven, but four core ones. Those are in blue. The first one basically is a recognition that healing, self-healing, is the core aspect of what we want these services and products to provide and produce.
So the wording, we could play around with, but basically there is a remarkable capacity for healing that can be facilitated by addressing the underlying causes or by using services and practices that stimulate and support those healing processes. So an emphasis on healing is a core issue.
The second emphasis is holism. We think that what we really value in these types of practices is the emphasis on the whole person, the mind/body/spirit, and addressing that. You will see in some of the subsequent ones how we are addressing that.
Number three is really the issue of freedom of choice, that individuals should have freedom of choice among practitioners, products and services, provided there is accountability along with that. There has to be accountability along with that.
We debated whether we should split these up into two different areas and decided no, that they really were linked, and they should stay together.
Four was that this is a consumer-driven process and we need to pay attention to why the consumers are seeking these things, and we need to let the consumers be integrally involved in that process, and this occurs on several levels, as is outlined in the , certainly in terms of freedom of choice of particular things that they would like to have in terms of products and services, but also in terms of how the health care delivery system executes those and how research is conducted on those.
So, in other words, also on policy levels, not just on individual health care. The consumer needs to be more involved in policy decisions about the health care system and research.
The ones in green were ones that came up afterwards. They support, I think, many of these core ones, that how various services are delivered is extremely important. There should be a keen context for the provision of health care.
Those are kind of the terms that we came up with, and that incorporates things like respect, dignity, trust and core values in how health care is delivered, and an emphasis on, my term was gentleness, gentle types of intervention, but we basically translated it into less toxic and the least invasive alternatives that are safe and efficacious. End of story.
DR. GORDON: Great. Thank you, Wayne.
Any other comments from that group at this point?
DR. GORDON: Okay. Third group, please.
Presentation: Small Group No. 3
SISTER KERR: Let me know if you can hear me, because my voice may be a little softer.
Number three was the honorable group of Tieraona, Buford, Veronica, Xiaoming, Linnea. Corinne was our humble scribe. Thank you.
We spoke specifically and dominantly out of the belief and value statements. First, was that we believe the body/mind has the right and power to heal itself.
The second, is we believe health is more than the absence of disease. It is the active integration of spiritual, emotional, social, physical, and I personally included ecological self.
The third, was healing is being in right relationship with self, others, community and the cosmos.
Four, we believe people want to be cared for, to be heard, to be able to choose, have better care and access to health care services.
We believe there is no exclusive domain for healing. Healing is not the exclusive domain of complementary and alternative medicine.
We believe partnership is integral to the process of healing.
We believe all human beings have a right to feel cared for and to have access to their practitioners and modalities of choice.
We believe in the value of relationships that are marked by respectful recognition of the practitioner's skills.
We wanted to put a little footnote of particular concern, that people sometimes often use holism to cover up non-thoughtful, unsystematic health care practices.
DR. GORDON: Thank you.
DR. GORDON: We can have some discussion. I want to say how useful, Tom, how much I appreciate your spearheading this process, and that of everybody who is participating in it.
It feels to me like what we put up on the board are really the shaping principles which will frame the Interim Report, and frame what we are doing as we move toward the Final Report, and that what we have done is to supply the impetus, the reason, in a sense, the reason why we are here, as well as the context for any specific recommendations that we are going to make. So I think it is great.
MR. CHAPPELL: I want to thank Tieraona and Charlotte and Wayne for their help with all of this, and the inspiration for it.
DR. GORDON: So, any other comments about either this process or issues that are sort of here at this point? We can come back to this, of course, as we discuss the Interim Report, but if there are issues that come up now, we can also talk about them. Any other concerns that are not articulated here that we need to discuss right now?
DR. JONAS: One of the motivations for doing this was to come up with a consensus. I mean, come up with at least the core issues, and I am just wondering if we need to do that at this point. We split up for a variety of reasons, but it really has to be from the whole group. I am wondering if there is a process for doing that, or, if we should do that at this point.
DR. ORNISH: I guess, for me, the question is, how much of this is implicit, that is, the subtext for the recommendations, and how much of it actually becomes recommendations, or is explicitly stated in the report.
I am not taking a position, I am just raising the question.
DR. GORDON: I think that is a question, and the process issue is whether we want to address that now or as we move through the report. That is the first question on the table here. We will have time as we talk about the report.
For me, much of this is the introduction and the context. Some of it is definitely going to influence some of the recommendations as well, and I think that what, exactly where, and how, is going to be subject to discussion among us all.
DR. FINS: At the risk of opening up Pandora's box here, I think this was incredibly helpful, and I thank all the people that were behind it. I think that this was essential for us to make the diagnosis before we prescribe the treatment. I feel we have written the treatment, we have written the prescription in the report here, and we haven't made the diagnosis. This is the diagnostic, and everything else should follow from this.
I think there are lots of things that are implicit here that are not explicit in the Interim Report, and I was just wondering if it would be possible for us to delay the Interim Report, which I understand is not statutorily required, and to have an opportunity to have more ownership of the Commission in the actual Interim Report, which is so important.
It is our introduction to other policymakers, and I am just wondering, what is the basis for the deadline, and is it compelling? Because I think it is more important to do it right than to do it quickly, and I think that this is the formation of the consensus.
I think most of us could sign on to most of what is on this board, but some of us would have a hard time in agreeing on the particulars and the nitty-gritty that is in the Interim Report because of balance and tone. I just put that out for your consideration.
MR. CHAPPELL: Methodologically, this is the starting point, these are your beliefs, and then your actions arise out of those beliefs. So you have got a harmonization of internal and external, and that is where the integrity comes from.
So the first thing I want to respond to in terms of method is, this is the grounding, and then all of the recommendations and actions flow out of that. These are not recommendations, these are beliefs, and they need to be presented.
Secondly, I just want to say that I have done a lot of this, and I know that there is enough trust in this group and enough similarity of content that I believe that Jim and the staff can scribe very close to some common points of interest here, and so I am not feeling that we need a heavy editing process, either today or later.
I think there is enough intuition, and if we have an editing committee that Jim wanted to appoint, I think we could come up with that product. What we need is a product, and it is called a statement of beliefs, but I don't think we need more time to do it.
DR. GROFT: Last July 14th, at that meeting, a request was made to the Commission that we have an Interim Report. I think we were nine months late getting started from when the Commission was not officially established by the Executive Order, but cast into the Appropriations bill.
At that point in time, the request was made by then-Secretary Shalala that we have an Interim Report available a year from the meeting dates, and we took that to be July 15th of this year.
I must admit there is no urgent request for this report to be submitted on that date. However, I think in all reality, if you want things to happen in this fiscal or next fiscal year with any thought of appropriations coming to any of the tasks that you identify, this cannot be delayed more than two weeks. Anything beyond that, I think we are starting to look at late August, early September.
The appropriations committees will be getting back together and they will be looking at this. We will have had time to meet with the caucuses, as we have been asked when we would be available to supply them with information about the Commission's recommendations and directions.
So I think, realistically, a delay longer than two weeks, we are starting to jeopardize whatever might be done in the next fiscal year's budget, not that it cannot be done in September, but I think people need time to look at what you are suggesting and to analyze it from their perspective, both administratively and legislatively.
DR. GORDON: One thing that occurs to me. I do not think it would be a disaster to make it somewhat later, I would agree with Steve, but not too much later. We have said we are going to have a report, and I hate for us not to do what we say we are going to do. If we say we are going to have something by July, I think one of the things that we need to stand on is our integrity. If we say we are going to do something, let's do it.
And so, that is why I think, as Steve is saying, a couple weeks' delay will not change the appropriations process, but we have said to the Secretary, we have said to Congress, we have said to Senator Harkin, we will have the report by then, and I don't like to back off that.
DR. ORNISH: What are we going to do with the extra two weeks, anyway? It is not like we are going to be meeting, so how would we use the time even if we did that?
DR. GORDON: What I would like to do, what I would like to suggest, is that we spend the time that we need now going over the report. Personally, as somebody who has participated in writing the draft and participated in this process, I feel like this process is very much informing the draft. I think the draft spent too much time looking at some of the specifics.
I think Joe's analysis is not unfair, that there wasn't enough of a diagnostic and descriptive process at the beginning. I think we can easily incorporate that, because these are the shared values that should shape what we recommend.
The idea of the process is to do as much as we can today and then get it back, to have an agreement, first of all, an agreement about tone, an agreement about context, and an agreement about recommendations, and if there are words that are buzz words, to deal with those and eliminate those, and to bring in the kind of language that we want, and then to send it back to everybody and get input.
If we find that there is substantial disagreement and concern, we can go through the whole process again and put it off. I would like to shoot for that date of the 16th.
DR. JONAS: I think since there is a date we have to have some kind of report, and there is flexibility in terms of what actually goes into that report, that the time we have is right now, and we don't have any other time. I think we need to clarify these issues. I am not sure we have had enough discussion of these issues so that we as an entire group can come up with at least a few fundamental consensus items that should go into that.
And then, I think we should go right into the report and start discussing it so that we can actually see what are we going to produce, and then we can circulate something around that we have all had at least some time to start with.
DR. GORDON: Yes, Charlotte?
SISTER KERR: I just want to say that I agree with what has been said, and I feel that the statements, the philosophical underpinning statements or vision statements are calls to attention. They are requests for listening, and they are the energetic needle put into the Congress for the listening and the focus. It is absolutely mandatory we get clear on it, that we have our process of diagnosis right before we make any prescriptions, plans or evaluations.
DR. GORDON: You're welcome.
DR. FAIR: Well, this may be accused of being a surgical approach, but I think we ought to go ahead. I mean as Steve articulated very well the reasons for doing so, I think we would damage our credibility if we didn't, and there will never be 100 percent agreement on it, no matter what we do. And I would just like to close with a comment, one of my favorites, from Sir Winston Churchill: "Action based on perfection is paralysis." I think we can't afford that.
DR. LOW DOG: Well, this is an interesting process, but if we don't conclude it, that is all it was, was an interesting process. So I think that there has not been closure yet on this, and I don't think we want to have 50 beliefs, that many of them are overlapping.
I think we need to have just a few, and we need to go through now. We can do it quickly, but I think we need to go and try to get some consensus on a few of them while we are all still here, because I think what the Interim Report must have is, it must have the core beliefs or goals of this group that feeds through the entire Interim Report, and go, then, to the report.
DR. GORDON: Okay. Other comments?
DR. GORDON: Okay, is there a general consensus that the group as a whole would like to go through these beliefs, and to select out the core beliefs that will animate the entire Interim Report and shape our deliberations? Yes? Do we have a consensus on that?
DR. JONAS: Provided we go then to the report directly, and we have a timeline for it.
DR. GORDON: Okay. Well, let me provide -- Wayne, I'm sorry?
DR. JONAS: Provided we have a timeline for the report.
DR. GORDON: Okay. Let me just say something related to that.
DR. ORNISH: Some of these are not values, some of these are actually recommendations, like requiring universal health education. I think we need to be careful about separating those.
DR. GORDON: Okay. Let me just make a point. If we are going to do what Wayne, in particular, is suggesting, and what others seem to agree to, we are not going to have time to go into some of the other issues that we have, or we may not have time.
Does everybody understand that we are not going to be able to go into the kind of detail with reimbursement, access and delivery, and wellness and self-care that we have with the other subjects, although we will address them in the context of going over the Interim Report?
I just want everybody to understand that we are making a choice, and that is a perfectly good choice, but we are making a choice.
DR. FINS: And I think it is legitimate, because people make value statements that will guide that and will make that easier downstream.
DR. GORDON: Okay. Everybody okay with this process? Tom?
MR. CHAPPELL: I just wanted to see if I have clarity about the next steps here. Are you suggesting that 18 of us deal with 30 beliefs on an open team?
There are some designs that would work. If you want prioritization, for instance, there is a tool I can offer of how we could arrive at greater prioritization.
DR. GORDON: What I first want to get is agreement that this is what we need to do, and then we can talk about the specific tools that we are using.
Is that the agreement, consensus?
DR. GORDON: Okay. So then, what we are going to be doing is we are going to go through the beliefs. I think Dean's distinction is important, the difference between beliefs and recommendations. What we want to focus on is core beliefs and values that will animate the report and will be included in the language of the report, in the introduction, and will also be part of the body of the report at appropriate places.
Then we will move into a discussion of the elements of the report in order.
MR. CHAPPELL: It is important not to discard something that looks like an action, but to restate it as a belief, because there is a belief substance in every actionable statement.
DR. GORDON: Okay. Duly noted.
DR. PIZZORNO: I have a two-process recommendation. One is, I think we should, before we do this, put on the vote here a timetable for the rest of the day so we are clear about how we are allocating time. And second, is a process that we have used for this kind of activity, is, give everybody five little stickies and you put it on the ones you think are most important, and immediately it pops out where the commonality is.
We may not have any of those little stickies, but maybe we could take a 15-minute break and staff could buy a batch and we can put them up there. Or, we could just put a mark with a pen. We can't do more than five.
DR. GORDON: Okay. Is that a process? Tom, is that --
MR. CHAPPELL: That is what I was looking at.
DR. GORDON: Okay. So I think what we should do is take -- well, Joe is suggesting doing it by balloting, but I think it may be easier to take the action. It just may work out. So you are suggesting putting five marks, each person puts five marks by the recommendation.
I think it is important, as we look at the recommendations, to remember that the process by which they were arrived at was different in the different groups.
So, for example, in the group that Wayne was chairing, there was an attempt to get consensus about specific recommendations, and in the group that Tom was chairing, clearly each recommendation represents an opinion of one person. I am not quite sure, Charlotte, was yours a consensus?
SISTER KERR: Yes.
DR. GORDON: Yes. So there are two different methods that are being used. If what we do is put those marks up, then we will take the ones that come closest to the top, and we will begin discussing them. I think what we will also find is that a number of the recommendations from different groups are very similar among the groups.
So with all of that in mind, what I would like to suggest is that we take a 15-minute break, and that in the course of that time, everybody will have a chance to put their marks up beside the numbers, and then we will come back.
MS. CHANG: Just a process question. Are we clear on what the mark represents? Is it, those are the things that we are now going to discuss for what purpose? Are we discussing them as recommendations, or as what?
DR. GORDON: Let me just make clear that what we are going to be discussing are core beliefs and values.
Is that correct, everybody, at this point? William?
These are core beliefs and values. These are not recommendations.
DR. ORNISH: I am a little uncomfortable. I just want to raise this as a question, and you all can shoot it down.
There are two different approaches here. One is that we get clear about what our core values are, so that we can then use that as a context, as I mentioned earlier, for our recommendations. The other is, is the intention of this, what we are about to do, to decide which of these core values that are actually to go in the Interim Report?
I just want to raise the awareness that there is a risk of doing that. There is, on the one hand, an opportunity to do that, but there is also a risk that if you have core values that are very different from other people's core values and they end up in the Interim Report, then they become red flags for people.
We may say, well, that is just too bad; that is just the way it is and we don't care, but I think we need to go into that with our eyes open and make a real choice about that.
DR. LOW DOG: I think the point, though, is that we are trying to do consensus, and there is a very diverse group of people here. As long as they are true to themselves about what they believe, because if we don't have consensus, it won't go in.
So I think everybody just needs to be real true to themselves and put up there what they can live with. When we come to consensus, I think if we can all agree, then I think that there are not going to be big land mines.
DR. ORNISH: But that is where I am trying to make a different point, which is that we can all agree on something and it can still be a land mine. That's all. I think that that is okay as long as we are clear about that, but just because we agree on something doesn't mean that it is not going to push people's buttons.
MR. CHAPPELL: I think the cost of perhaps disenfranchising a couple of core beliefs that don't make a hit list can be avoided by our agreeing that we are not going to have 30 beliefs. We want to have this list around eight to 10 beliefs, and there are lots of common threads in here.
So I think if we were to go for more than five, I am thinking seven, we will be less disenfranchising.
DR. PIZZORNO: All right, seven.
DR. GORDON: Any other comments on this?
MR. CHAPPELL: Seven is a CAM number. I mean, it is spiritual, it is traditional.
DR. GORDON: I know. This is exciting.
What I would like to do is to give us the chance to see what the leaders are in these beliefs, and then we can talk about them. My sense is that they are going to be incorporated in different ways, that ones for which there is full and enthusiastic consensus will be stated very much up front as core beliefs. Others may influence some of the tone and some of the recommendations.
We will have an opportunity to discuss possible land mines, and we will have an opportunity to discuss exactly how many numbers, land mines, or fireworks, gold mines. Thank you.
Joe? Go ahead. We have a couple more comments.
DR. PIZZORNO: One more small detail, just to make it easier. If we stick some crosses, just put a line down. If you see four, put a cross; make it real easy for people to count afterwards.
DR. GORDON: Effie?
DR. CHOW: I am concerned about the repetitions, the duplications. There are a lot of things there. If you select five, does that mean all the others go out, or will there be a process where you take the rest and kind of integrate it?
DR. GORDON: What we will attempt to do, what all of us will attempt to do collectively, is to take a look and see what we have done, once we have done it, and then we will try to integrate. We may not have the exact wording of each statement, but we will have the basic principle there. If there are a couple, or three or four, that are very similar, we will try to work them together. Okay?
So I think we need to see how it falls out before we move any further. So let's take a 15-minute break and do this process.
Discussion Session IV: Core Beliefs
DR. GORDON: Okay. Before we begin the discussion of the tally, what I have done is, I have tried to group some of the responses that are similar with one another. So we will go through the ones that have the most assent from the group, but before we begin, Linnea wanted to read a poem that will help us get centered. It was a poem she was going to read before she led her session on access and delivery, but it is a good time to read it now, too.
MS. LARSON: I thought that this would enable us somehow to get focused, and it is from a book of poems by a poet named David Whyte, and the book is titled "The House of Belonging," and the poem's title is called "Working Together."
"We shape ourself to fit this world, and by the world are shaped again, the visible and the invisible working together in common cause to produce the miraculous. I am thinking of the way the intangible air casts its speed 'round a shaped wing, easily holds our weight. So may we in this life trust to those elements we have yet to see or imagine, and look for the true shape of our own self by forming it well to the great intangibles around us."
DR. GORDON: Thank you very much. Very apropos.
What I have tried to do here is to tally the marks, and then to group according to similarities. What is interesting is that there are a number of similarities.
Does anyone know where Wayne is? It would be good to have him here.
COMMISSIONER: He is on the phone.
SISTER KERR: I will go get him.
DR. GORDON: Why don't you get him.
The first statement, which is a kind of restatement of the mandate for the Commission, is this one here and is the one with the single most number of marks besides it: "The Commission is for the improved health of Americans by ensuring the availability of safe and efficacious CAM services and products." So this is the one to which there is the most general assent.
Second, is this one here: "Individuals should have freedom of choice among practitioners with accountability." This one is not directly stated anywhere else, but it is echoed in some of the others here. For example: We believe in healing, of all approaches; CAM is has been evolving and moving to dynamic models; a diversity of disciplines; We need to minimize impediments to access and delivery.
So all of these have some relationship to this one here. Let me repeat that one: "Individuals should have freedom of choice among practitioners with accountability." Then there are a variety of others that come under this.
DR. FINS: I think it is really important that we don't editorialize and spin it. I mean, I can see differences. I think people who voted for that may not endorse that.
DR. GORDON: Understood. Understood. I am just saying that there are others that have been put up that may be similar, although this is the primary one. Okay?
SISTER KERR: Just also to say, the second part of the one that has a lot of -- is similar to that one.
DR. GORDON: I'm sorry. This is the same one. Thank you, Charlotte. This is the same one as Number 1, really.
SISTER KERR: Number 2.
DR. GORDON: Number 2, sorry. This one here: "All human beings have a right to be cared for and to have access to their practitioners and modalities of choice." What we are looking for is a general feeling.
Would you agree that that is pretty much the same as Number 2?
SISTER KERR: Yes.
DR. GORDON: What we are looking for is the general feeling. Joe, I appreciate what you said, but I am trying to give a sense that these may have something to do with that, but they may not be as clearly marked up.
Number 3: "The body has a remarkable capacity for healing that can be facilitated by addressing underlying causes of illness and suffering."
This one here: "The body and mind have the right and power to heal themselves." This one is Number 4. Maybe it's Number 3 in terms of the tally.
DR. LOW DOG: Oh, I see. I wanted to clear how you are going through it.
DR. GORDON: What I'm trying to do is, and it may be one or two more, but these are definitely the ones that are the leaders. This one is health is: "Health is more than the absence of disease, it is the active integration of spiritual, emotional, social, physical and ecological selves." That is Number 4.
"CAM is holistic, a life system within a context of living." That may be a slightly different way of stating it. And over here: "Emphasis of care of the whole person, mind, body and spirit." In fact, I think you are right, this one is actually Number 3 in terms of tallies, since we put them together, rather than Number 4.
Number 5: "It is consumer-driven health care, and consumers need to be involved at all aspects, from personal to policy levels of health care."
Number 6: "Has scientific validity and needs strengthening of evidence."
MR. CHAPPELL: In the group, it was presented as a belief, that there is a lot of scientific validity, but we need to have better substantiation through more evidence.
DR. JONAS: Is that a belief and a commitment to science, then, as a process for identifying safe and efficacious?
MR. CHAPPELL: Yes, and that shows up in some other statements about our commitment to science and the scientific method.
DR. GORDON: Let's speak one at a time into the mike so we can get the discussion down.
Wayne, you asked a question?
DR. JONAS: Well, there is a difference between saying we believe there is science to support CAM, than from what I think I hear you saying, which is that we believe that science is an important process for clarifying what is safe and efficacious in complementary medicine.
In other words, there is a commitment, a belief to science and the scientific process.
MR. CHAPPELL: Totally. So said in our group.
DR. FINS: I mean, that raises just a process question, whether or not if that is something that other people would have endorsed and they didn't see up there in a clear way. I was sort of surprised that concern for the scientific method and scientific validation only got five, eight votes, or whatever votes, because I think that if I do my own head count, there are more people who believe in that, but Wayne might not have voted for that, for example.
DR. JONAS: Actually, no. I am also surprised that that is lower.
DR. FINS: I mean, can we just ask --
MR. CHAPPELL: Well, that particular point is fractionated. It shows up in more than one, so if you pool the ones on that subject, you will get a bigger number.
DR. FINS: I think this is an important enough point for the people in conventional medicine that I would just like to posit some language, maybe, that, Wayne, you just offered.
You want to just restate that, and maybe we can just take a hand count to see if people see that as more belief?
MR. DeVRIES: Let me throw out, for example, what I did. I agreed with that statement, however, I thought this statement right here, that this group made as an overall, said the same thing, that it was a broader statement. I thought it was an outstanding statement, and that is why I went there. I didn't give a vote to that, because I believe that really replaced it, and then some.
DR. FINS: I voted for that as well because I think it is very encompassing and it is a broad thematic. But again, because I think we want to avoid land mines and we want to have a balanced sounding report, I would like to offer to the Commission Wayne's language, if you could recast it, and then just take a hand vote, just to say that it is one of the major beliefs. We are asking for six votes.
I know it changes the rules a little bit, but I think it is something that got embedded --
DR. GORDON: Well, I think each of these is what our core principles and values are, and we are not going to put them in a hierarchy of the report, but I think your request is an absolutely legitimate one.
Joe's concern is to get us on record as a commission stating the importance of scientific investigation.
DR. LOW DOG: Right, because I think for me, when I saw CAM has scientific validity, I couldn't sign on to that because some of them really do not. So it limited me from choosing that, though I believe very strongly in the role of science here.
DR. FINS: Did you just offer that?
DR. JONAS: We may not put all our five in a particular hierarchy, this is more important than this, but we are going to have a cut-off at some point. We are not going to do 30, and I certainly think that commitment to science and the scientific process should be on our list, definitely. We should have that explicit as one of the core issues that we are committed to and just state it that way.
DR. GORDON: Wayne, do you want to state it?
DR. JONAS: Yes. That we are committed to science and the scientific process as a method for identifying safe and efficacious CAM therapies.
DR. FINS: All in favor?
[Show of hands.]
DR. FINS: Anybody opposed?
DR. FINS: No.
DR. JONAS: Well, we are committed to science and the scientific process for the identification and development -- is that the adjective -- of safe and efficacious CAM therapies, yes, and services and products. Okay, services and products.
DR. PIZZORNO: I think we should include terms like "effective and appropriate." I think the reason for that is because, I know within much of the CAM community there is an anti-science perspective, a belief that science kind of takes the magic out of the healing, and I think we should be very clear that we don't agree with that. Science is an appropriate way of advancing these modalities and therapies.
DR. FINS: You want to just read it so Michele can just get the definitive words?
DR. JONAS: Well, I just said we are committed to science and the scientific process for identifying and developing safe and efficacious, and you can add "appropriate" if you want, although I think that is a little more complicated than actual science.
DR. GORDON: Well, "appropriate" may come before the "science," appropriate use of scientific methods.
DR. JONAS: Science and scientific process for identification and development of appropriate CAM products and services.
DR. FINS: Yes, because that means that science is appropriate when it is convenient, when it fits an advocacy position. That is not what we mean to say right here.
DR. JONAS: Yes. I think identifying appropriateness is a much different process. It uses science, but science itself is primarily for identification and development, and finding and developing safe and effective services and products, and whether appropriate or not, is more complicated than that.
DR. GORDON: [Inaudible] -- requires universal education starting in kindergarten. The other is a greater awareness and knowledge of CAM by medical practitioners so they refer appropriately. Where are we with that?
DR. JONAS: I don't see those as core values. I see those as ways of applying some of what we have just talked about, so those may go into the actual recommendations, and they are actually in the recommendations.
DR. GORDON: Well, let's talk about these, and then I have one other point I want to raise.
MR. CHAPPELL: Has the point of education been made yet in any of our other core values?
DR. GORDON: No.
MR. CHAPPELL: So we don't want to discard this because it sounds like an action. We want to rewrite it so it is a core value on education.
DR. GORDON: Well, I think it is there implicitly. We might want to rewrite it in terms of we place a value on education and self-awareness, something like that.
MR. DeVRIES: If you changed consumer-driven health care, personal and policy, and in parentheses said research, education and delivery, would that get you there? It is on the third sheet from the left, second one, consumer-driven health care, personal and policy, research, education and delivery.
MR. CHAPPELL: George, the difference for me
MR. DeVRIES: Just a broad area that says consumer-driven health care, consumer-driven health care, personal and policy, so it is not just policy, it is personal and policy, and then in the context of research, education and delivery. Just a thought.
DR. GORDON: It may be important to emphasize education as a separate item, because it is a kind of balancing of treatment and teaching. It represents a different way of thinking about health care and is very much a part of CAM. It says we are not just treating people, whether it is in the context of the office or in the context of the school, or the context of a public library methods or self-awareness.
DR. FINS: I just want to go on the record that the Latin root for doctor comes from teacher. So there was something to it in conventional medicine before it became a CAM thing. I think the notion of having a collaboration with paients is important.
DR. GORDON: Okay, let's all talk one at a time so that everybody can hear.
Well, there may be one thing you want to remind people of, that this is part of the healing tradition, and that we are re-emphasizing it, and it is re-emerging once again in CAM.
Now, there is one other issue, some of the aspects that were mentioned here that I have subsumed under Number 3, where four people marked this one having to do with emphasizing the uniqueness of each person, and I am wondering if that is something that we want to either include in what we have done, or make it a separate category. Perhaps we might make it part of Number 4, integration of body/mind/soul, and we might add "and the uniqueness of each person."
DR. FINS: I would say that that sounds right, the definition of health. So it is not a CAM definition, again; it is more than that.
DR. GORDON: Exactly.
Go ahead, Joe.
DR. PIZZORNO: If we ever have to do things here that are only uniquely CAM, there are shared values across health disciplines, and we should have that.
DR. GORDON: Anything else on what Michele just raised, of uniqueness? Is that a value, is that a belief that each person is unique and has to be approached as a unique individual?
Yes? Nodding heads? Okay, great.
DR. CHOW: I just want to point out, I think that is really important because that is how the practitioners deal with each person, and also, that relates to research, and that you can't do one and it goes across the board for everybody. So I think that is important, whether you include it into that number.
You suggested putting it into that number up there, the first one?
DR. GORDON: Either we can put it into that number, or make it separate.
DR. CHOW: I would make it separate.
DR. GORDON: Separate.
DR. CHOW: Because it is such an important issue.
DR. GORDON: Other comments about that?
So what we have is, I think, about eight different statements about shared belief and values which we understand.
Joe, I don't think an attempt is going to be made to say that it is only ours, but these are values that we have. In fact, I would like to make a statement that these are, in some sense -- the language is not quite right -- these are the enduring values of health care and healing, sort of the deepest, most enduring values of health care and healing in many different systems. So we are part of something; we are not apart from. Okay.
So we can either move ahead with looking at the Interim Report at this point, understanding that these eight are shaping values for what we are doing, and understanding that we will integrate these into the introduction and the overview as well, and then take up the body of the report, and see what we want to do with the report and how we want to have these values introduced into the body, and also, just how we want to look at everything that is in the report, and see if it makes sense to us. Or, we can spend more time discussing these. So there is a choice point right here.
DR. FINS: There is another big theme, which, again, might have been buried in all this, which I think I did hear a consensus on in the past, and that is the issue of integration, that if patients move from the CAM world to the conventional world, and back and forth, and it is a single patient, we need to have an integrated approach in order to ensure safety and efficacy, collaboration, referrals, the entire panoply thing.
So I don't think any of these statements capture the importance of the integrated versus the world approaches.
DR. GORDON: Joe, I think that is right. I think what we need is some kind of discussion about the wording because some people like integration, some people prefer collaboration.
DR. FINS: I am not wedded to the wording, but the idea of collaboration is something that I think we have to endorse. Otherwise, everything else we have aspired to won't be along operational lines.
DR. GORDON: Tom?
MR. CHAPPELL: Bill used some interesting language in our group about following the consumer here, and so providing collaborative services is better than force-fitting this different methodology. So I do agree with you that this needs to be addressed as one of our core values, and I prefer the notion of collaboration to better serve our consumer.
DR. GORDON: Other comments on this? Because I think this is -- especially if there are any differences or any concerns about this issue of collaboration, integration, we should get them out on the table now and it will make our looking at the Interim Report easier.
Anything, Joe? Do you have anything? Are you okay? Yes, Tom.
MR. CHAPPELL: Again, our group, building on collaboration was more complementary, the notion of value added, but perhaps that is -- I guess I will stay with what is on the board.
DR. GORDON: Veronica?
DR. GUTIERREZ: I would like to go back a second to education. I think part of that was addressed under the issue of a partnership between the provider and the consumer, and part of that relationship or partnership of healing is education. So I wanted to factor in that partnership perspective.
DR. GORDON: Does that feel comfortable to everybody? All right.
Are we satisfied with these as stated? And can we move ahead to the Interim Report, or do we want to have more discussion? Okay. Go ahead, Joe.
DR. FINS: I mean, I think this discussion hopefully will be time-saving downstream, so I apologize for it, and I appreciate your indulgence in giving me more opportunity here.
In that first thing that we all agreed
DR. GORDON: Fine, but just understanding we need to get to the nitty-gritty of the Interim Report as well.
DR. FINS: Not to nitpick with the language, but other people will. I agree wholeheartedly with the sentiment of statement Number 1 in red, from Wayne's group. The question is when we say "assuring the availability," could that be construed as an entitlement which raises all kinds of problems about other entitlements, and I am just wondering if "assuring" is the right word.
DR. GORDON: Tom?
MR. CHAPPELL: "Helping to."
DR. GORDON: "Helping."
DR. FINS: Can we leave that to Jim to wordsmith it?
DR. GORDON: Okay.
DR. FINS: Is that like a red flag in anybody else's landscape, a land mine? It begs the entitlement question. It is implicit.
DR. GORDON: Go ahead.
DR. CHOW: I like the word "assuring" because following that, you are talking only about safe and efficacious CAM, not all kinds of different things. So I would go with "assuring." That is more action, just like Tom was saying. What was it you don't like, "encouraging"?
DR. GORDON: George, please.
DR. BERNIER: Can you tell us where we are in terms of numbers of guiding principles?
DR. GORDON: We are at nine.
DR. FINS: Can we say "ensuring"? Because what we are talking about here is not an entitlement, but whatever is out there, whoever pays for it, it is safe and it is efficacious. Not that we are supplying or giving.
DR. GORDON: "Ensuring"? Okay. Anything else on this?
MR. CHAPPELL: I think we are doing very well. Nine or 10 of these is max. We are really at a good number, and I want to resist any effort to try to come up with any overarching statement for them all because that is not where it is at. It is the particularity here of each of these nine that we are making a commitment to, and these are the gains and values that we have to incorporate now in the choices that we make going forward.
DR. FINS: Like you planned it all along, Jim.
DR. CHOW: I would like to know what the difference is to Joe, the "ensuring" versus "assuring."
DR. PIZZORNO: I think we should move on. Let's leave this wordsmithing to the staff. We have given a large input, and we could argue three or four different words there. I don't think we are going to change it.
DR. FINS: Just so the instruction to Jim would be so that it doesn't infer an entitlement that is not intended.
DR. GORDON: Okay. Are people content to move on?
DR. JONAS: I mean, these are all over the map, still. It would be nice to have them condensed on a single piece of paper. Is it possible to have that available, say, for this afternoon as we go into the thing, and we can have them on a single -- wonderful. I don't want a summary of all the major points of yesterday and today. I only want these 10 reworded so that we can look at them, and maybe we will do a little wordsmithing on them. I think that would not be a bad idea.
DR. GORDON: I think there are two things. What Jim was saying, Wayne, is that he is also going to give us the points from yesterday because they may be helpful to us in looking at the report. So I appreciate him doing that. It is a different issue.
DR. JONAS: It is, and I would like these up on the wall. I mean, if we are going to say, all right, here is what we are going to start with, then I suggest that we take all these down, raise the 10 that we have, put them up on a couple sheets or whatever it takes, and have those there as we go into our discussion.
DR. GORDON: Fair enough. Everybody okay with that, with having the 10, Number 10 up there?
DR. GORDON: Okay, good. So the revised order is to move directly into the Interim Report at this point, rather than take the more detailed look at reimbursement and access, and delivery and wellness. I just want to check in with people, and to deal with access, delivery and wellness in the context of dealing with the Interim Report, unless we have extra time, in which case we can go back to them and look at them in more detail. That is where we are right now.
I just want to make sure that everybody is content with that, including the people who are leading, facilitating the discussions, Tom and Linnea particularly.
One of the things that Tom mentioned -- and I don't know if you feel this way, Linnea, too -- are, there a couple of issues that you would like to raise for us. Or, do you want to wait until we come to that section of the report before you raise the issues? Linnea?
I am asking that because they spent a lot of time thinking through all of the issues related to these topics, and there may be some things that would be very valuable for us to consider at this point.
MS. LARSON: Yes. I did want to emphasize the conspicuous absence of recommendations under the category of uninsured and underinsured. So I would really like us to be mindful of that, and to actually offer up some solid recommendations. I have a few, but I really want us to focus on that area.
DR. GORDON: Thank you. Tom? You have anything you want to say at this point?
MR. CHAPPELL: The self-care/wellness pieces in your book, not the Final Report, but in the book. There is a menu of many considerations, and they fall under five different categories that are expressed in the report, on page 20 of the report.
So I think if we just ask the writers to be directed at lines 9 through 17 of the report, that circumscribes the issues that need to be addressed.
DR. GORDON: Lines 9 through 17?
MR. CHAPPELL: On page 20 of the report.
DR. GORDON: Of the report, okay.
MR. CHAPPELL: Specifically teaching, promoting and encouraging CAM approaches to wellness, self-care.
DR. GORDON: Okay.
MR. CHAPPELL: Be mentioned in all levels of the educational system, integrating CAM, assuring all conventional health professionals have some training, integrating CAM into the workplace, health activities. Very important insight, and exploring ways to integrate CAM into the national health and wellness initiative of the entire population.
So from my part of the report, it is to keep the focus on those five questions.
DR. GORDON: Great, okay. We will come back to those. Those are the recommendations that have been made in the draft, so we will be coming back to those.
Now, the process of going through a report, in a group of 20 is not an easy one. I think what we need to do is to focus, or at least, what I would like to do, and throw it out as a suggestion, and I am obviously open to modifying it, is that we focus on the general areas of concern that we feel ought to be in the different sections, that we get a sense of what the tone is or is not, how you would like the tone to be, that we address any specifics that either need to be emphasized or that are absent, or that should not be in the report, and that we focus, especially, on the recommendations that we come up with at the end.
I think that if we try to go over every word, we are going to drive ourselves crazy in the context of 20 people doing it. We can do it where it really seems important, and I am not sure about that. I am just raising that as a possibility, and I would like to now open it to discussion about how to go through the report.
My thought was to go through it section by section, and to hear people's issues, comments, concerns about content, tone, specificity, and what is left out as well what is there.
SISTER KERR: My comment is not so much on process, but in light of what we just did -- for example, what arises for me, speaking of the page, was it 20, you were on? Twenty, beginning at line 9. For example, we have a lot of statements throughout our study, a report that is integrating CAM approaches into training and education in CAM approaches.
As you know, one of my concerns has always been that we would say that this is talking about modalities being added onto a system, and what arises now for me that may be appropriate in language here is, for example, something like integrating the principles and practices of CAM, speaking of the 10 as principles. They may or may not be principles.
Do you understand what my point is? What do we actually mean, if we say "integrate CAM approaches"? We want to teach everybody about acupressure, shiatsu massage, or we want to teach them that people are dah-dah-dah-dah-dah, which we just listed?
DR. GORDON: Okay. Let me back up for a second and tell you that what we are talking about now is a general principle, in a sense, about the way we are going to approach all the issues in the report, and that is great, that is a good way to begin.
Before we go into that discussion, I want to get a sense, which I think whoever passed it, probably Michele, said. Who is leaving early?
MR. CHAPPELL: I am.
DR. GORDON: What time are you leaving?
MR. CHAPPELL: At 1:30.
DR. GORDON: 1:30, okay. What time are you leaving, George?
DR. BERNIER: 3:45.
DR. GORDON: 3:45, 4:00, okay.
So with the exception of Tom, we have everybody here through 3:30 or so.
So my concern about you, Tom, is that we make sure that we do our best to make sure you are here for the discussion on wellness, since that was the area that you were particularly concerned with. So we may need to shift the order of looking at the report a little bit to accommodate you. I would like to do that. If that is okay.
Is that okay with everybody, that we make sure we do that? And then, before everybody else leaves, we will have finished the discussion about the Interim Report. At approximately 3:30 we will be having public comment, okay? So that is the timetable. We will take a break at 12:00, 12:10 for lunch for 50 minutes. A 50-minute lunch.
Discussion Session V: Draft Interim Report
So let's begin. We will come back to you, Charlotte.
Charlotte raised the issue that perhaps it sounds, in the report, too often like we are talking just about techniques, that we ought to be talking about and referring back to principles, these 10.
SISTER KERR: Principles and practices.
DR. GORDON: Principles and practices.
Yes, Tom and Joe.
MR. CHAPPELL: Yes. I think it is very important we maintain the word "beliefs," not "principles," because that is what we said we were doing, and principles and beliefs are different enough that it changes it.
DR. GORDON: Do you want to say how it is different and how it changes it?
MR. CHAPPELL: Well, a principle is something that is going to help guide joint, or guide action, it is kind of a guideline. And beliefs are a common baseline of agreement and understanding, and so I don't want to confuse substance with process. So it will work very well if we do drop in the word "beliefs," as Charlotte is suggesting, into some of the language here.
But I also wanted to comment on your question about process. For me it is really important that I have trust in you and the staff to do the writing and editing. I can't come here and negotiate and wordsmith. I don't have time for that, but I absolutely trust you and the staff to gain the sense of things and to put a draft together to the best of your ability. And I think that is the common principle we need to have in moving forward here.
DR. GORDON: Thank you, Tom. In light of that, Tom, what should we be focusing on in these discussions?
MR. CHAPPELL: How we can help you as the drafters, and being sure that you are gaining from us what we want for edits and changes. We just dump it into your basket.
DR. GORDON: Okay. Charlotte, you had something you wanted to say, and then Joe, and then Linnea.
SISTER KERR: I don't have a conclusion. I wish I had a dictionary and my Latin is not very clear, but I want to request of those who deal with this word "belief" and "principle" that we really look at exactly what we are saying.
I have a feeling "belief" to me feels like it may be one of these yellow flashing light things that some of my colleagues keep referring to, and I really want to know what the root of "principle" is myself.
DR. GORDON: Joe?
DR. FINS: I am responding to Charlotte's example, not the specific, but I think it is a very rich question, I think it is very interesting. I think it should have a home in the Final Report. I am not sure it is what we need to do in the Interim Report because this is very short, and I think what you just raised is a much more complicated question.
It would help, I think, to get clarity about what we really want to put in here. I think a little vaguer, a little less fully address these kinds of issues would I think be probably more appropriate for this juncture. And I think we can learn a sort of process lesson from this process in ramping up for the Final Report in a way that allows us to contribute and write and not to wordsmith, but just to be more collegial about how that document gets produced.
DR. GORDON: I have Linnea, Effie, and Tieraona.
MS. LARSON: This is a comment to Tom in terms of the process of the writing of the Interim Report. I would actually like the Commissioners to have the opportunity to make comments prior to the release and the printing, to use those comments, for the staff to be able to use those comments, not just simply say okay, now in 10 days you are going to write it.
I want to have all of the Commissioners who are able to, to say yes, I have read through this draft and I am going to make my comments in the next 10 hours or 12 hours. So it is processed.
DR. GORDON: The plan that we currently have is to take everything -- let me just clarify this -- to take what comes out of this meeting, the 10 principles, the 10 beliefs, to take the recommendations, the critiques, the concerns about which there is general consensus, and I want to emphasize that, and to represent those in a draft that will be prepared within six days, will be out to every Commissioner with three days, then to give back critiques as detailed as anybody wants on it.
If you want to have phone calls, that is fine, too, whatever, but the idea is we are going to try to represent what comes out of the whole Commission, and then give it back to everybody with several days for comments, and then produce the report. Now, if we go on and send it back yet again, it is going to prolong it.
So, Linnea, does that answer it?
MS. LARSON: Yes. I wasn't interested in prolonging anything. I was simply interested in the collaborative effort with clearness of our beliefs that happen in here, and in clarity of the written word. That is what I was interested in.
DR. GORDON: Terrific. Yes. That sounds great. That is the intention all across the board.
DR. CHOW: Whether we use the words "principles," "belief," or "conceptual framework" or whatever, this has come from the Commission for this process. But what about the belief and the principle or conceptual framework from the people, you know, that we have heard of? Is there any attempt to extract from that the concepts?
DR. GORDON: I think the question you are raising is a really important one, and it is a question that we have had just in creating this draft, and that is, are we speaking as Commissioners who have heard others and are integrating what we have heard; are we relaying what people have said; or, are we speaking on our own.
For me -- and we all need to figure it out together -- my sense is that, ultimately, we are speaking as Commissioners who are representing what we have heard. I think one of the errors we make sometimes in the report isn't entirely resolved, because sometimes we just refer back to what people have said, and we haven't taken ownership.
Maybe it is this process of this meeting that enables us to take ownership of what we have heard, because, ultimately, we are responsible, and of course, we are responsive and responsible to the people who testified to us and to the American people.
So it is an interesting balance. I think that is one of the issues we have to discuss and come to an agreement about here.
DR. CHOW: That is exactly the point of my question, and the thing is, it can come from the Commissioners themselves and the body of people that we have heard. I don't see it either/or.
DR. GORDON: Tieraona?
DR. LOW DOG: Yes. I just want to add to that. I think it is not only what we have heard, but what we have not heard, because I think we need to be very, very clear that we did not get a full spectrum of people here that we listened to, that represent all of America.
DR. GORDON: Tieraona, before you move on, do you want to say something about that? Because I think that is an important point.
DR. LOW DOG: I think we heard a lot of the believers. I think we heard a lot of the advocates. I think we heard from a lot of people who are invested in this moving forward who have strong beliefs, and that is not good or bad. I am not saying that. I am not placing a judgment on it. I am just very clear that if you say that 40 percent of the public uses CAM products and CAM services, it means 60 percent do not.
Many of the people who are not interested in CAM also do not take the time to come to hearings like this and make their opinions known, because it is not something that is that important to them. So we have heard from a group of people that advocate and are believers.
So I just want to be clear on that, that there have been groups we haven't heard from, and we have had letters from some of the more skeptical crowd, some who were not able to attend at the time frame that we gave them, who raise important issues that we must not neglect, so that we are truly not just advocates, but that we are looking at this from a balanced perspective, which wasn't even what I was going to say.
DR. GORDON: I think this is a really important thing.
DR. LOW DOG: That wasn't my point.
DR. GORDON: I think we might as well focus on it a little bit now. Is that something you just want to deal with in the context of going through the report, or is there some kind of general statement or tone that not hearing from those people implies, some principle that you would like to articulate?
Joe, go ahead, if you want to.
DR. FINS: If I could just give an example, which is in the second paragraph of the document, that we are citing that 42 percent of the population of the United States uses a CAM therapy and product. We know where that data came from, and clearly it should be cited, but the other issue is, does that represent accurately the prevalence of this movement, because if someone took a multivitamin, they got counted, or if they had a massage, they got counted.
So in a sense, that is a convenient paper to use to promote an advocacy position. So I think it is the best paper, the best data we currently have, but it is being spun in a way that suggests that it is more prevalent.
The Bob Blendon paper that we circulated about the issue of supplements, the reason I asked that it was distributed was because it suggested that consumers, the rank-and-file Americans in an epidemiologic study, have a desire for more regulation in whatever form it takes of the supplement world.
You would not have known that by listening to the selected group of people who came here, and I appreciate their desire to express their opinion, but what we heard here was not necessarily representative of what most Americans think.
Now, we can debate the science of Blendon's study, and we can debate Eisenberg's methodology, and that is a fair discussion, but I think it needs to be acknowledged, exactly as Tieraona has said, that the advocates came out in a way that people who are opposed or didn't care, didn't. That doesn't take away our obligation to be fiduciaries and stewards for safety and efficacy.
DR. GORDON: Other comments on this general issue? Then, Tieraona, we will come back. I don't want to lose this. We will come back to your comment.
Effie and Wayne.
DR. CHOW: That was my point, that I think it should be stated that we did have some adverse opinions expressed. We did invite them, but we could state that in the overall concept exactly what Tieraona was saying.
What my question really meant to bring out is that we have, and then we have not. That is talking about into the future, what we need to do more of.
DR. JONAS: Yes, I agree. I think this should be stated, actually, up front, this is what we heard from, and this is what we did not hear from. What we heard, the advocacy that we heard, largely, the advocacy that we heard and the detractors that we heard, we are taking in the context of looking at whether this is something that is going to contribute to the overall health of Americans. So we are contextualizing this, and this is the way we are managing it.
I think this should be up front, that that is how we have received this information.
DR. GORDON: Thank you.
DR. CHOW: Can I make one more? The studies, I respect them and all, but I think David himself admits that it is from a particular population, and I know Francis Brisbane brought out the whole cultural aspect, that people were practicing and weren't identifying that it was CAM that they were practicing, or the different cultures. I think we can all identify with that.
DR. GORDON: Tieraona?
DR. LOW DOG: Yes. I don't really like the citing of this, and one, we do need to reference it, it needs to be clearly referenced in the report, but it has real problems for those of us who acknowledge CAM. I think that there is a tremendous prevalence.
However, I don't think most of us consider going to Weight Watchers going to a CAM practitioner. That is not what we consider to be CAM, and that is what is in this study. I have a lot of people who use a Centrum vitamin every day, but they do not consider themselves to be following CAM.
Further, the problem with the study, which Eisenberg does admit, is that it did not include non-English-speaking people. It didn't hit lots of different people. So I think that it is an interesting thing, but when you then conclude that more visits were made to these CAM practitioners, I feel we have misled a little bit, chiropractors, massage therapists, that we are sort of leading you into believing that these people all went to see practitioners of what we are defining as complementary and alternative medicine. That study clearly includes people that none of us in this room would consider CAM practitioners.
DR. GORDON: Wayne?
DR. JONAS: Maybe what I heard you say is the definition, because all of this really hinges around the definition which overlaps many conventional areas, in other conventional areas. So maybe we do need to have some type of a definition, which we worked on a little bit before. I am not sure exactly what happened to it, but perhaps that needs to be somewhere in the up-front.
MR. SWYERS: I would avoid that in an Interim Report.
DR. JONAS: We need to describe what we are talking about, I think, a definition or a description.
DR. GORDON: Since we are focusing on this now, I think what would serve everyone best is if we could get a sense in this meeting, as quickly as possible, of what kind of data you would like to use, we would like to use -- not you, we would like to use, and how we would like to deal with the definitional issue, if at all, or descriptive issue right up front. So if we can focus on that, that will help to frame the report.
DR. JONAS: I mean simple way, again to get back to our core principles, is to recognize or acknowledge that there is a lot of ambiguity about the definition of complementary and alternative medicine, and this leads to confusion over what is going to be useful and not useful, what actually is in these categories, not in these categories. And so the question is, because of that ambiguity, is what -- let's see, what am I trying to say here?
I am saying because of the ambiguity, this makes it difficult. This is one of the challenges in terms of trying to discern what in these areas will truly improve the health care of the American public. In other words, the definition itself is a challenge to our first principle is what I am saying.
DR. GORDON: We can say the definition is a challenge. Where do we go beyond that? Where would you like to go, where would anyone like to go?
DR. JONAS: And then you come up with just your pragmatic description, if you will, of these are the things, these are the areas we have decided to deal with because of what has been presented to us, but this is not the entire field.
DR. GORDON: Okay. And which areas would you include? When you say these are the areas.
DR. JONAS: The ones in the report.
DR. GORDON: Now are you talking about the ones in this introductory part of the Interim Report? Or somewhere else?
DR. JONAS: I am talking in the report in general. We don't have to summarize the categories that we are going to be dealing with in the introduction. I am not saying that. I am saying that we should make it clear that the whole issue of the definition of what is CAM and what is not CAM is ambiguous, and this in itself makes it difficult to know how to approach and to decide on what is useful and what is not useful for improving the health of the American public, period.
So what we heard was a number of advocates about particular aspects of health care that have this loose affiliation with complementary and alternative medicine. And so we are beginning to deal with some of those categories in the report, end of introduction, and just go into the report. We don't have to define those and describe those actually in the introduction.
DR. GORDON: Okay. Tom?
MR. CHAPPELL: I would like to offer the idea that CAM is a 1992 word that was necessary then, and I think it is already outdated. I think today in the most positive way of speaking about this movement, along with conventional medicine, it is complementary medicine. And I think the word alternative is a real problem for us at this stage because so much we have heard in the hearings is that we need collaboration, we gain from learning from one another. The different orientation of complementary medicine is value-added, and complementary medicine doesn't presume that it circumscribes the rest of the health issues. I know that is a problem for Joe.
So complementary says what it is for me, and not alternative.
DR. GORDON: I think these are deep waters and we need to keep moving into them.
Effie and Tieraona and Joe.
DR. CHOW: I think we need a statement of how we are presenting the whole package, the definition we are using on CAM, whether we want to state that is nebulous or whether we want to say that we operate on the Office of Alternative Medicine which is in CCA and they say that outside of Western medical science is complementary alternative medicine.
The term complementary medicine is better than complementary alternative medicine. I would like to see it complementary health care, something to do with health, because when you put medicine in it, it is still pushing things into medicine, and we are really talking about overall health, particularly in view of what we just discussed as our mission statement, et cetera. So complementary health care or something similar, away from medicine.
DR. GORDON: Tieraona.
DR. LOW DOG: I would agree that we need to define the CAM community because we refer to it repeatedly throughout. I agree with Wayne that we need to acknowledge the difficulty with the language itself and this very sort of fragmented group of people that we heard from. I think we need to be real clear about that up front.
I myself don't have an issue with medicine. I think that it is shortsighted to think that medicine is just to treat disease. I think medicine has always been about public health, about prevention, about disease treatment, and for many native people medicine actually is this very, very, very, very, very, very big term that means much greater than anything we have even been speaking here.
So I am not attached to the word medicine at all. I want to be careful to do away with alternative at this point, only because I am not sure it is necessary to do it, and that sometimes this is used as a true alternative, it is not used as a complement to Western medicine. Some people use massage for their back pain instead of non-steroidals. They are not complementing anything, they are using it as a true alternative.
So I think there is a reason why we have adopted both complementary and alternative, neither of which is perfect, but I think both represent the spectrums of what this is.
The other thing about medicine is truly some of these modalities treat illness. They are not just about prevention. Many of them have value actually in treating disease and treating illness. I don't want us to be shortsighted or limited. Many of these will show in the future, as we learn more, that they are effective at treating different disease states as well as prevention.
So I think we want to be expansive in our vision, and we don't want to be limiting in our vision as we move forward.
DR. GORDON: Joe.
DR. FINS: I think one way of perhaps handling it is to have -- and Michele offered this, and I am just going to modify it -- to say that definition of what CAM is and what it is not was an element that is under discussion and will be addressed in the Final Report. Not to define it here.
But also I would add that this discussion has regulatory implications about where you draw the line for things like licensure and the like. So I don't think we necessarily have to define it here. I think it is in the executive order, so that is language that we sort of inherited, so we are obliged to go with it, it is the name of our commission, after all. And I think that the kind of rich discussion that we have just had should naturally find its way in a first or second chapter of the Final Report. But it doesn't need to be addressed here. Simply flagging it as an issue that has important conceptual, regulatory and clinical impressions, but not get into it right in this report.
DR. GORDON: Tieraona?
DR. LOW DOG: I am not sure what the time is, but we have till like 3:00 or 3:00. There are 25 pages in this report. We have discussed how we are going to do the process here. I actually think we do need to sort of go through the pages. I don't think we need to go through word for word, we shouldn't be wordsmithing unless we have got a real problem with a particular word. But I do think we need to go through the pages. We need to go through the pages one by one, and we need to know if we have closure on a page. But I think that we should probably get that started when we can.
DR. GORDON: Well, we are on the first page right now. That commitment is there.
Go ahead, Joe.
DR. PIZZORNO: I have a concern about what our commitment is. One of the risks of a consensus process is to give veto to a minority, and so I think we need to have some ground rules as to how we do this, because we are not going to agree with everything. We can't let a single individual or couple stop something also.
DR. GORDON: Is everybody agreed on that? That we are looking for a consensus process, we are not looking for unanimity, and that there may be --
DR. FINS: Suppose as a preamble we say something like it is the sense of the Commission, and that these issues will be fleshed out. So it takes the onus of a dissent off the table at this point, but it leaves it in play for some future date.
DR. GORDON: Great.
DR. JONAS: And it is the sense of the Commission there was not unanimity on all the issues, and the full richness of the discussion will be fleshed out in the Final Report.
DR. GORDON: Tom?
MR. CHAPPELL: I am having a little trouble with that, based on the advice we received yesterday about showing that you are a very diverse group and that you come with a report that has consensus, and that in having consensus, you have more power and effectiveness in the way you communicate, and that also we not present minority reports.
Those were the recommendations we received yesterday.
SISTER KERR: I agree that that was the recommendation. I disagree with the recommendation. But I do agree in Joe's point that in the Final Report we do have to have space for a dissenting voice. I am not suggesting it, I am just saying leave space.
DR. FINS: I want to just be clear, we are not there yet, but I want to say at this point, I think, to say it is the sense of the Commission, and positions will be elaborated in the Final Report is a way to allow us to reach a kind of consensus and have people sign on to the document as a whole, and not have a deal-breaker on page 14 or whatever.
DR. GORDON: I don't think you and Tom are saying anything very different, actually. It seemed very similar to me.
Go ahead, George.
MR. DeVRIES: I think it is a little premature, at this point, to say majority rules, and if somebody disagrees with something, that they can't somehow express that separately, or there can't be a process that happens over the next couple weeks to reach consensus on that where we truly have unanimity among all of us.
So I think it is premature to say majority rules, at this point. I think what I would like to really say is that I think we need to leave room for the process to work itself through. I think we have a chair who is going to work to bring consensus to the process. We have a staff who is going to work to make sure the language is such that it gets maximum agreement from the group. I think it is premature on that basis.
Does that make sense?
DR. GORDON: That was also the feeling I had from what Joe was recommending, that we are really trying to come to a common sense of where we are in this. I think we also have to leave a little latitude, because this really is the beginning. The whole purpose of the Interim Report is where we agree. I mean, that is really the strength here, is where we agree, understanding that there are areas that we have not fleshed out, there are areas we have not worked out, there are areas of disagreement.
I don't think a couple of weeks is going to be enough to deal with some of those, George.
I think we really need, some of the areas that we have talked about, that we really need to both have more information and that we need to do some studying between now and October, and that we need to have significant time in October to focus on exactly those areas that are the hard places for us.
So what I would like for us to do, insofar as we can, is to come to areas of agreement now, and understanding, and with the understanding which will make explicit, but -- I don't want to keep repeating it ad nauseam in the Interim Report -- that the Final Report is going to be a much more articulated view of some of the complexities of the issues that we are not addressing here.
DR. FINS: I think it is so important for, Tom always says let's think in 10-year blocks, and for the long-term historical context, fleshing out some of these ideas, the dissent, the controversy, the areas where we can't get agreement, may be the most important thing that we contribute in a historical sense, maybe not for a legislative session, but downstream.
So I think there is a richness to that that we shouldn't excise from our deliberations.
DR. JONAS: I would like to make a suggestion, actually, in terms of the format of the introduction, and actually, the format of the first two and a half pages, which I see is the introduction. That is that we begin with the definitions that we have been given. We have been given some, non-Western medicine, et cetera, and we have gone over those.
We acknowledge in the definition the ambiguity of the whole process and some of the challenges and difficulties that this presents for getting to the goals of the Commission.
We then give the context and background within health care, which I didn't see here, in terms of the trends and the forces that are currently going on in health care that have nothing to do with CAM but are part of this entire movement: aging; chronic disease; costs; side effects; disparities in health care; the health principles and prevention; emphasis on prevention, just put a context around those. We have heard from a number of those throughout. So that is the background section.
Then we need to have a section saying that this is an important thing for the American public, and we can talk about whatever percentage of use you want to talk about. I mean, I would use Eisenberg. I mean, it is there. There are problems with it, et cetera, but I would at least say this is an important area for the American public, and that complementary medicine may be important also because it may provide opportunities to address some of these larger health care issues that we have just outlined in the background.
Then we go to our operating assumptions that we just described here. These are the assumptions, whether we call them beliefs, principles, or whatever, these are the assumptions off of which we operate, and then go into the general description of what the Commission has been doing, and that type of thing. That, in a format, provides us a solid introduction, grounds it in the health care delivery system and says this is an important part of that.
DR. GORDON: I would like to talk about Wayne's outline of the introductory section, but if there are other comments before that.
Tieraona, did you want to say something?
DR. LOW DOG: Yes. I would sort of echo that. I think there needs to be more of a contextual framework of leading into why this movement is here, why it is happening, put it in some sort of historical and social context, what is the driving force behind it.
I would rework a little bit of this article because there is going to be an article coming out in one of the journals that is basically all about how misleading these Eisenberg studies have been. I don't want us being set up for that. I think you could use it as a stepping-off place to say, even here, in these studies we find conflict, or we find ambiguity, over the terms. I mean, I think you could use it as support.
I would fluff this with some statistics, though, too, when you are talking about, particularly, those with cancer, using a lead-in sentence, "Surveys have shown that up to 60, 70 percent of women with breast cancer are using." I would fluff those up a little bit, and then use it as lead-in so it gives a little bit more of a richness to text.
So I would agree, more contextual, historical, social framework, and then buff it up a little bit with your data and references.
DR. GORDON: Joe?
DR. FINS: May I can make a suggestion that I think what Wayne suggested is absolutely correct. I have been arguing for this historical, sociologic context. I don't think we have had testimony that allows us to write that yet, but I think we should say here that we will address that in the Final Report.
DR. GORDON: No --
DR. FINS: Well, what is the basis of the -- DR. GORDON: I think the basis is that some of us have been spending 30 years in this movement and have studied the movement extensively, and we do have a sense of the history and where it comes from. We talked with various people and read all the literature, read all the sociology, read all the history.
DR. FINS: The difference is between autobiography and biography.
DR. GORDON: Understood. I think that we are not dealing with either one here. What we are dealing with is an assessment of the terrain that is out there, and I think you have to take a look at it, Joe. I don't think this is going to be autobiographical. This is much more a question of, where does this come from historically, where does it come from sociologically, where does it come from in terms of the needs of people with chronic illness, for example, which is the issue that Wayne raised.
It is pretty clear we are not so much talking about the sociology of the movement, we are talking about the demography, if you will, of the people who have been seeking out these treatments.
DR. FINS: If it is simply the demographics, I have no objection, but if it is an interpretation of the larger meaning and why we are here as a commission, that, I think, is interpretative, and I think any of us who are already around this table are really precluded, in a way, from offering an interpretation, because as historians, you can't write a history of your own time. So we need to have a little academic detachment.
SISTER KERR: Joe, I just remind you of what you have offered both days to me, a reminder of a process that we will get something down of context, but it may not be there until the Final Report. Though I would second what Wayne said, and also for myself, I would like for us to have a moment and invite our writers to see, also, what is inspirational about this moment in history, and see some language in there.
Again, we will work on that as we go along. This is a call from the people, and I want to be sure that is in there in some way.
DR. GORDON: Joe, that is really what I am talking about, is that the reason there is a Commission is because so many people out there are using these therapies. They want to know more about them. They want to have more access to them. That is pretty clearly the reason why we exist.
Are you comfortable with that?
DR. FINS: There are levels of complexity about why we exist. That is one of them.
DR. GORDON: Right.
DR. JONAS: Yes. I mean, it would be nice to have a full background of the health trends and how those relate to these areas. I mean, there are multiple other reasons, I think, also, including globalization and the information age. Rising health care costs are making people say, gee, you know, how can we afford it? So there are multiple things.
DR. GORDON: Wayne, what I am thinking is that all of those, very briefly stated, are a part of the background. I mean, obviously anything that anyone says is some kind of interpretation of the facts, but there seems to be enough agreement across observers.
DR. FINS: Let me just make my last appeal, and I will never bring this up again. Let's try to get a historian or some scholar outside the movement who has taken this on, and try to get him or her to give us an academic presentation, maybe to start us off in October as a plenary, to help us contextualize this and jump-start the writing of the Final Report.
MS. LARSON: Let's get Bill Moyers to give us a few tips.
DR. FINS: Or somebody, you know.
DR. GORDON: Yes. I agree it is a good idea. We actually did that with the health professions. We had the guy from New Jersey who came and did give us a sense of the history of the development. So we want to pay attention to it. We will pay attention to it.
A decision that we have made -- and Joe and I were having this conversation earlier -- a decision, at least a kind of consensus that developed in the comments that Commissioners made, is that people would really rather not have more presentations, but would rather have, if we are going to get material, written material that we can look at ahead of time.
So I want to come back to this, after this discussion is over, because one of the other items on our agenda is, we have already mentioned some of the areas that we want to look at again in October. This is clearly another of those areas.
I want to make sure that we agree that we are not going to have more testimony. If we want to have more testimony, we have to understand the time-consuming nature of that. We can do that.
DR. FINS: How about if we commissioned a paper?
DR. GORDON: That's fine. That is certainly something we can do. What I am saying is, I agree that we need to have that information. The question that we can talk about, we don't have to take up time in the session but that we can talk about, is whether or not we want to have more people come and testify, or whether we simply want to work with written materials.
Jim, do you want to say something?
MR. SWYERS: Yes. Just to address Wayne and Tieraona, and Joe's comments, we have already started writing the first section of the report.
DR. GORDON: The Final Report.
MR. SWYERS: The Final Report, and Wayne's outline pretty much mirrors what we are doing. There will be a lot more richness and information in those sections. We started doing that, but for us to try to abstract the report before it is finished is hard to do.
DR. JONAS: To me, there needs to be some kind of contextualization in the report also, whether it is a simple trend and discussion of the demographics and the issues. The factors that have led us to this point, I think, need to be in here.
MR. SWYERS: We have done some of that. We can pull some of that information out and put it in this.
DR. JONAS: It doesn't have to be the whole thing, but it would be nice to have some.
MR. SWYERS: It is just going to be sort of a surface discussion.
DR. GORDON: Okay. So we can take a look at that and maybe either pull some out, but there is agreement that we need some background. Is that correct?
If I seem repetitive at times, it is because I want to really make sure that we do have a general agreement about what needs to be in the report, and the more we can get clear about what needs to be in there in this meeting, the easier the rest of the process is going to be for everybody.
MS. LARSON: I would like to move very quickly, that we are decided on that, and that we can get through to Tom's area, wellness, because we have half an hour before we are going to break.
But what Wayne outlined and what Jim has said, yes, we are already doing this. Then the specifications of the contextualization, I think, are really important, but I think that we can continue to beat a dead horse right now.
DR. GORDON: Is there anything you want to say about that before we stop beating that horse?
MS. LARSON: I have, maybe, two sentences, but I think I will table them for another time.
SISTER KERR: Can I take your two sentences? Thanks.
I just want to say that for me it is tremendously important that the Interim Report have this context. I know we just said it. To me, it is symbolic that if we do not do it and just move into these recommendations, it is not emphasizing what we understand is the spirit and the call from the people to do this, and it sets the stage for the listening. I truly believe that. Thank you.
DR. GORDON: Okay. Tieraona?
DR. LOW DOG: Yes. I echo that.
Could we just focus so that we are not in danger of scope creep throughout this day? Could you please define again for us, real clearly, what is the actual, in just a couple sentences, intent of this report, and who is the audience, and who are we aiming it for, so that we are very clear on that throughout the deliberations.
DR. GORDON: Sure. The intent of the report, and Steve will correct me if I stray, is to provide an update to the Secretary, and through the Secretary of Health and Human Services, to the President and to the Congress, about our activities so far. That is sentence one.
It is also to provide an update on our activities, to make some specific recommendations about which there is general consensus, which may be used to help shape legislative and/or administrative initiatives, and to give some sense of where we are headed with the Final Report, but that is really subsumed. I see that as emerging out of what we have been doing so far.
So that is the basic intent.
Would you agree, Steve?
DR. GROFT: Yes, I think that really summarizes it. One additional fact or direction is that we have to give the public some information about where we are going, and give them the opportunity to comment on what our feelings, our beliefs are, and the direction of the report. That is part of it.
DR. GORDON: The primary audience is Secretary of Health and Human Services, the President and the Congress, and through them -- and this is what Steve is emphasizing -- to the public, to give us feedback about the report, to tell us where we are on target as far as they are concerned, where we are not, what else we need to be looking at, what concerns we have or have not addressed, and how they feel about how we are proceeding.
DR. GROFT: I think, as Tom mentioned, CAM started back in 1991-92, with the introduction of that terminology. The same with this Commission, where the introduction of the concept of the Commission was probably 1998. So we are three years down the road, and to say, are we, as we see it, going on the right track, or does the public feel that we should be going on another track, or picking up additional information that we haven't considered at this point in time, I think that is important also.
DR. GORDON: Okay. Any other questions about that? About the intent and the audience?
DR. GORDON: Okay.
SISTER KERR: Is there any addendum to that, where you said that this report is to speak where we have consensus? If I were the public listening, I may go, well, for gosh sakes, why aren't they talking about that and that? Is there any way to clarify that for the public reading?
DR. GORDON: Clarify what? I'm sorry.
SISTER KERR: These are only the points of consensus.
DR. GORDON: Yes. We can certainly make that clear. I think that is a very good point. We will make it clear.
Does that make sense? I think that what we need to do is to make clear exactly what we are doing and not doing in this report.
DR. LOW DOG: That is not what we said just a little while ago, though, because now we are saying that this report is clearly where we have consensus, and earlier we were saying that we may have ambiguity, we may not have unanimity.
DR. GORDON: We have consensus that we have ambiguity. No, I am not just playing with words, what I am saying is that we will say where we are. If we have ambiguity about certain areas, or if certain areas are unresolved, I think it is important to say that, that we understand that.
The point is that the consensus is about all of these issues. Consensus doesn't necessarily mean that we are in agreement about the particulars. It means that we are in agreement about where we are with the particulars.
DR. FINS: I think the best way to address this is with text. I mean, I think it depends on where we are, and I think we should go to the Tom thing so we can take advantage of his leadership on this.
DR. GORDON: Okay. The Tom thing.
DR. GORDON: Do you think that is an appropriate title in the report? We will call it "The Tom Thing." Is that okay with everybody? Can we move on to the Tom thing?
No, seriously, can we move on to the section on wellness at this point. So we will move right ahead?
As we are turning to that page, Joe Kaczmarczyk left me a note, that Professor Orzak, who presented the testimony on the evolution of professions, is developing a more expanded version of his testimony, which will be available to us. Joe mentioned that we can ask him, if we want, to supply other sociological and historical information.
So that may be one way for us to go.
MR. CHAPPELL: Are you ready for my thing?
DR. GORDON: Yes.
MR. CHAPPELL: Could you turn to page 19, and turn off any other mikes, please?
Discussion Session VI: Wellness, Self-Care and Prevention
MR. CHAPPELL: On page 19, lines 7 through 29, there is a good contextualization of the evolution of wellness, self-care and prevention as a way of taking care of yourself.
I want to direct the Commission's attention to the next page, page 20, lines 9 through 17, and in directing you to these lines, I don't have anything to process that was otherwise in our booklets here of a menu of suggestions because they will just have to stand as a menu of suggestions that fall within the guidelines of these five categories in 9 through 17.
The first category is addressing education. The second category is really talking about education, again, and then the third within the health care professions, more education, and then four is the workplace, and five is sort of national initiatives for the entire population.
So this circumscribes the suggestions that have been coming forward in the hearing process, and I think the report appropriately targets these areas of attention and need and development.
So, first of all, teaching, promoting and encouraging CAM approaches to wellness, self-care and prevention at all levels of the educational system.
Is there consensus that we should be striving to bring education of CAM services, products, at all levels of education?
DR. GORDON: I just want to make a point of process. What Tom is doing is not addressing up front the text, and you are not addressing it because you are satisfied with it --
MR. CHAPPELL: Yes.
DR. GORDON: -- or you have no particular concerns about it. So do you want to address the text if anybody else has any concerns afterwards, and go to the recommendations first? Or would you rather address the text first?
MR. CHAPPELL: I will come back to it, if you would like me to.
DR. GORDON: Is that all right, or do you want him to address it first?
MR. CHAPPELL: I would like to be focused.
DR. GORDON: Okay.
MR. CHAPPELL: At this point I would like to be focused on these five areas.
DR. GORDON: Okay. Is that fine with everybody? I would like to let people who have taken the lead in these areas take the lead in the discussion, and then if we want to go back and go over it a different way, we will do that later. Okay? Is that all right?
SISTER KERR: Where does it fit in if you have comments on language? Now or later?
DR. GORDON: What Tom is asking is that we look at the recommendations now and that we come back to the previous text, though we can obviously deal with the language of the recommendations, but that we deal with the text that leads up to the recommendations after we have dealt with the recommendations.
DR. FINS: I think that the way it is textualized, the recommendations, is problematic, and so I think it is sort of hard to dissect that out. Let me just give you an example of what I am thinking about. On page 19, you know, in lines 17 to 20 or so, there occurs what will call CAM creep, where CAM becomes prevention and not a subset of prevention.
I think we really need to avoid CAM creep because I think it decreases the credibility of CRAM -- CAM.
DR. GORDON: You mean canned CLAM.
DR. GORDON: I hear you, Joe.
DR. FINS: Let me just finish. I think explicit mention here of , for example, and the excellent efforts of the United States Public Health Service in promoting prevention and health education and those kinds of things, that this is in conjunction, that CAM does not replace prevention, but is an integral part of these wellness strategies.
Then we go to the following page, where you have your five recommendations, and the way it is written now, it sounds sort of like we are proselytizing for CAM, when in fact we are now advocating an approach to prevention which includes CAM.
I don't know if I am clear, because I am tired, but that is --
MR. CHAPPELL: That is okay. I am trying to help us avoid a CAM of worms here and get us right to the recommendations to see whether or not we have any consensus.
SISTER KERR: Where are the recommendations? I am on page 20.
DR. GORDON: Page 20. Charlotte, are you looking at the one with the numbers on the side of the page?
SISTER KERR: Yes.
DR. GORDON: It's line 9 through 17 there. There are five recommendations.
MR. CHAPPELL: I would just ask if I could be the facilitator of this section, please. I have been asked to do something, and I would like to be given a chance to do it.
So for everyone's benefit, what I would like to do is to take you first to the recommendations in lines 9 through 17, after whether or not we actually have agreement, so that the reporters can know our wishes. And then we will go back to see if we need to clean up any of the other language, the precepts to that.
DR. LOW DOG: May I respond to that? I have problems with the recommendations, because they are too vague for me. And it goes back to our ambiguity of what CAM is.
MR. CHAPPELL: I was going to take them one by one.
DR. LOW DOG: Well, with all of them, but where we say CAM approaches to wellness, self-care and prevention at all levels, integrating CAM approaches into programs of health education for children in elementary schools, what exactly does that mean that you are teaching my second-grader? I mean I am interested in prevention and I am interested in self-care, but that is way too vague for me because CAM is huge. I have no idea what that means.
MR. CHAPPELL: So you are really asking whether we have a curriculum in mind, how would the curriculum be developed. So this is not specific enough.
DR. BERNIER: Again, I want to stay focused where you have us, Tom, on the recommendations. But I agree in the sense of the vagueness, but I wonder if it is vague because in the previous text we don't say, you know, in this context wellness means good nutrition, exercise, not smoking, doing the things of self-care to take care of yourself, and that this has been shown to reduce chronic illness and other disease.
By specifically saying this is what it is, then you put into a context later when you are basically making recommendations.
MR. CHAPPELL: Okay. Thank you, George. Tieraona?
DR. LOW DOG: My response to that is that throughout my medical training, exercise, lifestyle management, smoking cessation, a month at the wellness center, all of those things, and almost all of the research that has been done and paid for by that has actually been in conventional medicine. The Public Health Department, OSHA, job training safety, all of this is in and under the Public Health Department and in preventive medicine.
So I am not clear when we say CAM approaches. You are going to have to define what is different or unique or distinct. If you are saying exercise, lifestyle, nutrition, be clear what you are saying. But to say CAM approaches, you have lost me there because that is what public health officials have been fighting for forever. And the work that has been done in that is in conventional medicine.
DR. GORDON: Are there other comments about this recommendation? Effie?
DR. CHOW: I think there is so much question on this and ambiguity because again we don't have the definition of CAM. I go back to my work. And back here on 19 it begins to describe what CAM approach is, line 24 to 9 of the next page. But whether that is specific enough for the discussion to then take a look at what CAM approach means in the recommendations.
So in a way taking the recommendations without kind of going through their principles, again --
MR. CHAPPELL: Yes. I am happy to take your direction on this and turn now to 19 and start at the beginning and just see whether or not we are absorbing all of the precepts that go into the recommendations. So why don't we take those paragraph by paragraph.
So I am at line 8 now on page 19. I just ask you to bring your comment at this point on the three paragraphs there, through line 19, if you could. Joe?
DR. FINS: Yes, I would just again go back to the notion of trying to contextualize this. You used the phrase before in our small group like CAM is value-added. And so I would say here that CAM is that sentiment, and we don't need to wordsmith it, but it is value-added to all the primary and secondary prevention efforts and wellness efforts that Tieraona and I have spoken about, that are part of the mainstream medicine, which would have to get us on lines 19 and 20, taking up this language.
I think it is patently untrue that prevention activities frequently take place outside the conventional health care system. It may take place outside the health care system, but it also takes place within, and some of the things that you are saying are truly preventive may not be efficacious.
I mean, you know, we know pap smears are good prevention, but we are not sure about some of the other modalities which are cited in lines 26, 27, 28, as proven to be preventive.
So I think we have to acknowledge the preventive services that are in place, that are efficacious, and then say that the people we heard from, consumers, also want these other modalities for additional enhancement of wellness and strategies for well-being and prevention.
MR. CHAPPELL: Jim?
DR. GORDON: You are making a distinction between those activities in prevention for which there is good evidence and others for which there may not be good evidence, but people are using?
DR. FINS: There are two points. One is that most prevention is happening within the mainstream, mammography, pap smears, smoking cessation, cholesterol lowering, exercise, et cetera, in the context of things that you might see in the United States in the Healthy People 2010 sort of thematic.
The second point is that those modalities have proven intervention characteristics, and we talked about yesterday some are better, some are worse. Quiacs are less good than pap smears, for example, in preventing colon cancer versus cervical cancer. We have that information.
Some of the things that are down here that are not as proven yet, it doesn't mean that they won't work, but they are just not proven. So there are two points that I am trying to make.
The more important one is to contextualize this section against all the other efforts that have been led by the United States Public Health Department.
DR. GORDON: Yes. No, that point I understand, and I think we are clear on that one. That is a very good point.
The second one, I think, is an important point, too, and the question is how to work with that point. And I think you are pointing to some kind of ambiguity in the language that we may be focusing on some things which are much more in the mainstream, and then we are focusing on others that are CAM, and we are kind of lumping them, or at least they seem in the text to be lumped together a bit.
MS. LARSON: My only point was to mention that what you were saying is it is disease prevention. That is a different thing versus wellness promotion, and this is what we must make a distinction in. That is what we are trying to get to here.
DR. GORDON: Does everybody understand that? So your pap smear would be disease prevention.
DR. WARREN: Pap smear is not prevention.
MS. LARSON: It is detection.
MR. CHAPPELL: Just a moment, everybody. We will just go in some order here, and we will give some people a chance to speak that haven't had one. Don and Julia, and then Tieraona.
DR. WARREN: Well, what I don't understand here, you are calling a pap smear prevention. Pap smear is detection, it is a screening. It doesn't prevent anything. It picks up disease, dysfunction, just like a dental X-ray picks up dental decay. It doesn't prevent it.
MR. CHAPPELL: I agree.
DR. GORDON: I'm sorry, we are going to listen to these other people now.
DR. WARREN: So I like what he has got here. I like what is on this page. It describes it. It is disease screening. That is exactly what he has listed it as, and that is what it is. It is not prevention. Mammogram is a screening, it is not a prevention. In fact, it may be a causative factor in some studies. So I think what we have got here is the right thing.
DR. GORDON: Julia?
MS. SCOTT: I was going to say pretty much the same thing, except I see it as secondary. The things that you are talking about are secondary prevention, but I think the emphasis or the distinction here is a system that is geared more to the detecting of diseases, whereas, I think many of us believe CAM is an addition in wellness.
DR. LOW DOG: I think all of these are important. I think that what I want to caution us against is using divisive types of language and not acknowledging the tremendous efforts that have been done in conventional medicine towards public health, wearing seat belts, bicycle helmets. My god, the big initiatives that have been done on that. That is not disease-oriented, that is to prevent you from dying in a car accident. It is prevention, pure and simple.
Now, where we are talking about this with meditation and biofeedback and stress management, things that promote wellness and health, that is very different in some ways, but there is overlap. I think all we have done is, one, I think we need to rework some of those sentences there to honor all the work that has been done, but then to say, we find that there is potentially some very exciting techniques or whatever -- somebody smarter than me with words -- there is some very exciting stuff in CAM, and then mention them: meditation; biofeedback; imagery; tai chi, that may serve to promote wellness and improve health.
I think we just need to be careful with our language, and I think there are some exciting areas here that can improve health.
MR. CHAPPELL: If I am getting the sense of the comments, it is that we want to be as inclusive as possible here about what has gone on before and what has been added to, what has been contributed to.
DR. LOW DOG: And be inspirational. It is exciting work. What is out there that can help us.
MR. CHAPPELL: So far, I am hearing that we need to be clearer about the credit that needs to be given to the movements that have preceded and what CAM has contributed. I am just hearing that.
Joe, and then Effie, and Charlotte.
DR. PIZZORNO: One of the huge dangers is defining CAM as anything that is not conventional. We must remember there is overlap in these fields.
Second is I am concerned that we not lose our understanding of why the public is going to CAM professionals. While it is true that there is some prevention taught in conventional medical schools, and I understand that now most medical schools actually even offer courses in nutrition, that is only a recent development. The reality is that what is described on this piece of paper: nutrition; lifestyle; health promotion, people go to CAM professionals to get it because they do not get it from the conventional medical practitioner.
There are some enlightened people like Tieraona and others, actually many sitting around this table today, who are medical doctors who understand that, but the vast majority of services being provided to the public don't get that, and that is why people go elsewhere.
In terms of the numbers, I agree that there are some significant problems with Dave Eisenberg's work. However, let's just do some simple math. There are 600,000 medical doctors in this country. My understanding is, only half of them actually see patients. There are about 100,000 alternative medicine practitioners, when you look at chiropractors, neuropathic doctors, acupuncturists. If you add massage therapists to that, that comes out to 200,000. So the reality is there is a tremendous amount of care being provided right now.
If you look at areas like Washington State, where we have equality of insurance, equality of life insurance, one community hospital did a survey -- this was in Kirkland -- and 75 percent of the people in Kirkland went to a CAM professional within three months before the survey was done.
So realize, this really is happening out there, people are getting services they don't get from conventional medicine.
DR. GORDON: Let me just interpolate. Can you give us that survey? Because that is a very interesting one.
DR. PIZZORNO: I will see if I can get others. That was three years ago, and probably the numbers are higher now.
MR. CHAPPELL: Effie is next. Thank you, Joe.
DR. CHOW: Some of the basic principles, adding to what Joe says, is that prevention in a medical system is still doing things for the fear of disease, and prevention in CAM is really doing things to promote health, for the love of being healthy. It is a positive aspect.
I would add to his list, Joe's list, of why people go to CAM practitioners, because they are listened to and they are touched, physically touched and mentally touched.
So I think I like the gist of what this is saying. It does need to be elaborated on. Do give credit to the Western system about the prevention, but you see, it is still all sort of fear of accident and those things. You know what I am talking about?
So anyway, I like the gist of this, but it needs to be elaborated.
DR. GORDON: Tom, let me just interpolate. If you are making a suggestion for what needs to be elaborated on, aside from the references to prevention and Healthy People , which we got, we have got that one down, what other elaborations?
If you have something specific, please say it now. The more specific people can be, the more helpful, the more we can get a consensus. Then we can get it down here, okay.
MR. CHAPPELL: Go ahead, Charlotte.
SISTER KERR: I want to keep, for myself, using the discipline today of going back to what we identified as our guiding principles. One of the principles is that people have a right to choose the modality and the practitioner of choice.
Having said that, and pointing to Jim's request of what other elaboration, I am wondering if we need to include the possibility of what may be there as healing opportunities, that which is not spoken yet as health promotion; the inclusion of practices that may not be spoken, but are things like the coins on the back or the bee stings for the MS.
How do we create the space to safeguard the right to choose what the person wishes? Do you understand?
DR. GORDON: Charlotte, what I would like to do as the guardian of the overall structure is to say, I would like to put that into access because that is really about treatment. This is really about wellness and health promotion.
MR. CHAPPELL: This is also trying to describe a background to specific recommendations. So it is pointing us to five recommendations.
Wayne, I think you were next.
DR. JONAS: Yes. I think I agree in general, but I think we should go back to the principles that we outlined, and I wish we could get them up on the wall so we could refer to them.
I think Number 3, that we identified, really is that we believe enhancing the healing capacities, and that this provides an important, my wording, perspective and opportunities for prevention, treatment, palliation of disease, and the enhancement of wellness.
I think that that is the core issue that we are talking about in here. I agree that we need to contextualize this within the tremendous efforts that are going on in conventional medical care for prevention. We need to use that word "prevention." That is what it is. We need to explain that. I think by describing those efforts in Healthy People 2010 is a great way to ground that.
Then we can add onto that and say that there are a number of practices outside the conventional health care system, apologize for David Eisenberg's address, focus on health promotion that may be useful in the prevention and the treatment of disease, and the enhancement of wellness and self-care, and in this way acknowledge this, and then acknowledge that there are additional items that are not necessarily addressed in those activities that we still feel are very important, not just for prevention, but enhancement of wellness, also for the treatment.
I mean, health promotion, and the health promotion practices are also useful as treatment, and Dean's program is an example of this.
MR. CHAPPELL: Okay. Thank you, Wayne.
I think Wayne has summed up the sentiments that I have been hearing, that we have been trying to refine in reacting and responding to the text as it was presented. I just want to find out whether any of our writers have captured Wayne's statement. I don't mean Number 3, but --
DR. GORDON: No, no, no. I have those, and I am sure Jim Swyers does as well. I have them down.
Tom, I just wanted to remind you of the time, and that we need to come back to the recommendations as well, if you are ready to do that.
MR. CHAPPELL: I think we are ready to do that. Corinne?
MS. AXELROD: Just to say, as a primary author of this section, I will certainly work with Wayne and everybody else to make sure that we have captured everything people have said.
MR. CHAPPELL: Good. Thank you.
I appreciate you bringing your concerns forward, everyone. Now we will turn to page 20, line 9. On the first recommendation, it has been pointed out that it is too simplified to refer to CAM approaches if we are going to recommend a curriculum to an entire educational system, that we need to be more specific. In fact, we need to develop a curriculum.
DR. GROFT: If I may caution you, Tom?
MR. CHAPPELL: What is that?
DR. GROFT: Tom, I don't think it is really our position to develop a curriculum. I think we have to think beyond that, that someone else is going to have the responsibility for implementing these recommendations. I think for us to try to develop everything that we are suggesting is impossible.
MR. CHAPPELL: Okay.
DR. GROFT: I think it is more important to identify what needs to be done, and then have it implemented.
MR. CHAPPELL: Tieraona is recommending that we be more specific when we use the term CAM approaches.
DR. LOW DOG: My problem was integrating CAM approaches into health education for children in elementary school. I mean, to me, I could not support that sentence because that is just too ambiguous for me, of what you are going to teach my child in school.
DR. GORDON: I think there is potentially a middle ground of giving some examples. We can't articulate the whole curriculum. Clearly, we can't be so vague, if we talk about nutrition, exercise, stress management, however you want to say it, as examples.
MR. CHAPPELL: Charlotte?
SISTER KERR: I just want to say again, I would like the group to either say yea or nay on what I will continue to point out, unless you can convince me otherwise. When we say CAM approaches, I do believe this morning was very important, that what we want if we are going to do school programs or whatever, we want the principles and the practices to be taught, and that goes all the way through everything, integrating CAM principles and approaches.
Do you agree with that or not? I mean, we are going to grow in explaining what those principles are.
DR. GORDON: I do, but I think it is a question of asking that you are asking everyone the question.
SISTER KERR: My fear is that we are talking about integrating approaches means integrating modalities. It is like how every course looks that says we now integrate CAM in our continuing education program. And what is it?
There is a lecture on biofeedback, there is a lecture on acupuncture. Nobody does a conceptual framework, which we haven't even gotten into in terms of energetic concepts, at least the principles.
MR. CHAPPELL: Any other comments? Effie?
DR. CHOW: That is my platform, too, constantly, is that we have to have the overall as well as the technique. Perhaps we could say "appropriate CAM approaches," and then give examples. Then, of course, "appropriate" is up to your school, what is appropriate to it.
MR. CHAPPELL: That does seem to be the sentiment of the circle.
DR. ORNISH: Just again, in the same spirit of avoiding using targets, because if you are not specific, you are going to have people saying, oh, so you are going to stick needles in my kids? You know. I mean you are going to have my kids taking herbal supplements that I haven't approved? I mean let's not give them any easy targets.
MR. CHAPPELL: Thank you. I think the second recommendation is the same as the first. Could I ask for clarification of the writers on this?
DR. TIAN: Yes. What would you say, Corinne? I would say it is a subset of the first, yes.
MR. CHAPPELL: And so we move to the third item, assuring that all conventional health professionals have some training and education in CAM approaches to wellness, et cetera.
SISTER KERR: I still don't feel like I have either gotten affirmed or negated on CAM principles and practices to wellness and self-care. Are we going to leave out the word principles? Or beliefs? Whichever one we decide on.
MR. CHAPPELL: It is my understanding that we are going to be incorporating that throughout the entire document, where appropriate.
DR. GORDON: Let me say my intention of using the word approach is that an approach is not just a technique, it is a mindset as well. And that is why I use the word approach, and I am pretty sure that is my word that is there, because it includes both. So it is also a word that is somewhat more neutral and is not likely to raise a red flag. I just give you that.
MR. CHAPPELL: Wayne, please.
DR. JONAS: I just had one suggestion that might help with this, and that is that we alter that to say, for example, in No. 3, assuring all conventional health care professionals, and we could do this in the others, have some training and education in the role of complementary and alternative medicine in wellness, self-care and prevention. And that would be a little broader, and it could be done throughout.
DR. GORDON: Tom, does that work for you?
DR. JONAS: The role of complementary and alternative medicine.
MR. CHAPPELL: Well, we will take that under advisement.
Go ahead, Joe.
DR. FINS: I think that fits with the notion of how we modified cross-training yesterday, that people were aware of the other modalities, but they weren't being trained to do the other modality, and a conventional practitioner needs to know about the role, but may not necessarily endorse.
I would also say that on line 9, I want to just point out, because of what Dean said and what Tieraona said earlier, that we are not necessarily recommending this, we are saying there is strong interest in this, which I think also is kind of -- it puts a little distance from the Commission from the recommendation. But we are just saying we are reporting back what we heard.
MR. CHAPPELL: So, in the interest of time, then, let's concentrate on edits, and we have one edit to the Item 3, the third recommendation.
DR. GORDON: Tom, before we do that, I want to make sure that everybody understands the point that Joe made, and that we are in agreement about that point. It is that we are at a slight remove from making these, and that was conscious, right, Corinne? This is a conscious choice that we are at a remove from making these as recommendations.
In some instances we are making recommendations. Here we are saying there is significant public interest in this area, and leaving the room open to make recommendations more specifically in the Final Report. This gives everyone a chance to respond to these. I think that is the thinking that we have.
MR. CHAPPELL: Thanks, Jim. Yes, Effie?
DR. CHOW: That is portrayed right from the beginning of the article here. So witnesses testified, and et cetera, et cetera.
MR. CHAPPELL: All right.
SISTER KERR: My last comment is just to say I believe this is a teaching document, and for myself in a few seconds of reflection, even though I appreciated Jim's interpretation of approaches, I think because the mind has not moved, that approaches still means modalities. I would personally like to invite the group to consider again whether or not we want to say things like principles and practices or some other word that implies we are in a consciousness change. No consciousness change, no new creation of health in my mind.
MR. CHAPPELL: Okay. Gerald? Thank you, Charlotte.
DR. GORDON: You are asking for some kind of agreement or disagreement around the circle, right?
DR. FINS: I think maybe at the outset, in the early part of the report, we might say by approach we mean something greater than modality, and somehow have a definitional footnote or something, so that we can say when we are talking about a modality, we are talking about approach, we are talking about a more comprehensive system of care or something.
MR. CHAPPELL: I would like to comment on this point. Approach is sort of an implementation. Belief is a very clear grounding. And wherever possible, we should be pulling the beliefs into the text, the word belief into the text, to give authenticity and strength to the recommendation, and to give integrity to the whole document.
So I agree with Charlotte that approach needs to be re-looked at, revisited, to see if we can strengthen the recommendation in terms of its relationship to what it is we said we believe in.
I would like to just see whether or not that is a sentiment of the Commissioners. Do we need to spend a little more attention on that?
MS. SCOTT: I think I agree with that, but I also want us to be careful when we are talking as Commissioners, and when we are talking as what we heard or what people told us. I don't know that we heard that people told us what Charlotte is inferring and you are inferring. This sentence starts with "Information provided to the Commission indicates there is a strong interest."
So I mean, I hear what you are saying about the word "approaches" kind of losing the meaning, but I think I am more in favor of what Joe has suggested, that in the beginning of the report, we are very clear about how we are going to sharpen our definition for beliefs or principles.
SISTER KERR: I have a response to that, if I may.
MR. CHAPPELL: Yes, Charlotte.
SISTER KERR: If you remember, it wasn't everybody, but in New York. I forget the names of the people, but they were founders or foundresses of schools. They were two women doctors, I believe, who had a long history in complementary medicine. They spoke, and I remember it because of my own bias, without the work at the level of the philosophical level, epistemological level, that nothing changed, and if you didn't get to the essence of the change at the level of consciousness and conceptual thinking, it wasn't the real thing.
So I heard it, and I thought it was a great point, Julia.
DR. ORNISH: Well, again, playing my role here, I can just say that the word all in Points 3, 4, and 5, in lines 13 through 17, that all conventional health professionals have some training, that we integrate CAM approaches to wellness, et cetera, into all workplace health activities, we explore placing CAM approaches into national health and wellness initiatives for the entire population.
I really think it would be wise to try to tone that down a little bit, because even if you say there is a strong interest in these things, that semantic distinction is going to get lost. I can just tell you, people are going to say -- I mean, you just have to appreciate what kind of reaction that is going to get in the workplace, for one thing.
I mean, employers are going to look at this, and they are rolling back the repetitive stress industry. The Commission spent four years and thousands of witnesses talking about the importance of repetitive stress injuries. They have completely rescinded it because even something as well documented -- we are not talking about epistemology here, we are talking about something that is pretty obvious to everybody -- that was well documented, and when employers saw that, they were able to lobby to get it removed. Just that line alone will get a lot of people against this report.
DR. GORDON: So, Dean, I think your point is well taken. In places where we are too inclusive, or we seem like we are mandating something, we have to tread lightly.
DR. ORNISH: We are mandating this, when you are talking about everyone, the entire population.
DR. GORDON: I understand. I understand. We are not actually mandating it. We are saying that people suggested, but I think you are right, the distinction will get lost.
DR. ORNISH: By the time you get seven lines down, there is a very small distinction in most people's mind between strong interest.
MR. CHAPPELL: Fine. I think Corinne points out it is already out. Thank you, Dean.
DR. LOW DOG: I appreciate so much the use of the word "belief and principles." I just want to be careful where and when we use it, because if you read the sentence, "integrating CAM approaches into programs of health education for children in elementary school," it sounds very different than when you say, integrating CAM beliefs into programs for children in school.
Now, you may be talking about the same thing, but people hear the word "belief" in different ways. So I think, in some places, we want to talk about our beliefs and our values, and in other places I think that word might not be the best word. I would keep the "approach" here, and I would define "approach" earlier, but I wouldn't shy away from using it in places where I think it sounds appropriate.
But here, I know I can tell you, as myself, I have some issues with beliefs and when you start talking about what things, what kind of beliefs you are going to teach my child in school.
SISTER KERR: I couldn't agree with you more, which is why I don't like the word "belief," and principle includes belief, but it is coded as guidelines. I couldn't agree more, but I am not arguing on the content you were. I was arguing for when we make a statement of what we want to do, that we be sure we put it in a theoretical framework.
MR. CHAPPELL: Yes. Let me point out that the operating word universally for beliefs is "values." You can use them interchangeably. When you want a more neutral response from an audience, "values" is the word.
I am also hearing Tieraona say, let's also be specific where we can if we have got practices. So I think all of these are great sensitivities.
DR. CHOW: Actually, I didn't hear Charlotte use the word "belief." She used "principle." Tom's word is "belief." Okay. Everybody has been directing belief at Charlotte.
DR. CHOW: I just want to protect you a bit, Charlotte. The thing is, I think "philosophy" may be a good word. I want to throw out "philosophy," "philosophy and approaches."
MR. CHAPPELL: May I hear from Jim, please?
DR. GORDON: My suggestion is, first of all, I think we are agreed that there are certain core principles that go with the practices, that we have to be careful, that that has to be part of the introduction, and we have to be judicious about which words we use when.
I also think, Tom, that you have taken us through this. We only have the fifth, the last item to go, and we really need to break for lunch, because this is only a couple pages of the report that we have gone through, and we have a significant amount still to do.
SISTER KERR: Wayne wants to use commandments so we can get faith in.
DR. GORDON: Wayne, is that a tactic or a strategy?
DR. JONAS: A strategy.
MR. CHAPPELL: Jim has called this to a covenantal issue here, and that is lunch. We thank you for everything.
Could we look at Item 5, Exploring ways to integrate CAM approaches and practices into national health and wellness initiatives.
DR. GORDON: I mean, I am happy with dropping out for the entire population. I think this makes it general, and anybody who doesn't join in is going to be in big trouble.
I think this is a perfectly appropriate way. This certainly reflects the sentiment of what we have heard from many, many people as well as within the Commission, and it gives us a subject for debate. People can express their opinions, and I think it is something that will attract interest without being a mine for us.
MR. CHAPPELL: Any other comments?
DR. GORDON: Except perhaps a gold mine.
MR. CHAPPELL: Well, thank you all very much.
DR. GORDON: Okay, so we are going to go to lunch. We will come back at 1:05, okay?
[Lunch recess taken at 12:28 p.m.]
+ + +
A F T E R N O O N S E S S I O N
DR. GORDON: I want to make a point to the Commissioners and also to the rest of you who are here with us, to the public, that the discussions today and what we have up here, this is not the Interim Report. The Interim Report is what we are working on developing, and so that the critiques that are coming up, the additions, the suggestions, the debates, this is all preparatory to creating the Interim Report, and I want to make sure that everyone knows that the Interim Report has to go through a couple of more iterations before it is ready. So what is involved is pulling together everything that we have heard at this meeting, fashioning another draft which in turn will be reviewed by all of the Commissioners.
So the principles, perspectives, the concerns that have been raised, are helping to contribute to the creation of the Interim Report.
We will present the Interim Report to the Secretary of Health and Human Services on the 16th of July as planned, and it then, before it becomes public, it goes through a clearance process. And once it has gone through the clearance process, the Secretary will present the report to the President, and the report will be available for Congress as well.
So I just want to make sure everybody understands that the drafts that are discussed here are just drafts. What is put up on the wall are simply principles that we agree to. How this is all going to be formed in the Interim Report is still to be determined.
Are there questions about that from any Commissioners? I wanted to make sure that was clear to both Commissioners and the public. Yes, Julia?
MS. SCOTT: So if I am understanding you, Jim, what you are saying is Commissioners are not responsible for releasing the report?
DR. GORDON: Right. The Commission is not only not responsible, the report goes from us to the Secretary, and once it has gone through clearance, he will release it. And the first place that he will be releasing it is to the President, and also he will be releasing it to Congress as well.
So until that time, this is still very much a work in progress. So thank you, Julia, for clarification.
Okay. Bill has to leave in a few minutes, so I wanted to give him a little chance to speak at this point.
DR. FAIR: Well, thank you. I distributed a brochure from our health center. Now this isn't what I think is ideal. All I can tell you, this is a result of one person's search for something that I can coordinate CAM medicine in my own problem, and I found out that, first of all, you don't know who is good.
Secondly, when you find that out, at least in New York, they are all over the area, and I was running back and forth.
And thirdly, and most disappointing, they don't talk to one another. So the way we have set up this is that each patient comes in, we have no physicians in the center, and that my role is simply the scientific validity of it, and basically we run it with nurses, nurse practitioners, and the person comes in, gets an evaluation by the nurse practitioner, and then goes and spends 30 minutes with a nutritionist and an exercise physiologist and someone in stress reduction and someone in movement therapies, yoga and so forth, and then after that we sit around in what I still call a tumor board. It's not a tumor board, because we treat people who don't also -- it is not all cancer. But a case management discussion, where the approach is what is the specific diet for Joe, with his cancer, or Mary with diabetes, or whatever, and so forth, put together a program, and then if the client so wishes, communicate this with the person's physician.
I mean what we are trying to do is to keep the physician in the link, to communicate. The subtle message is also to educate physicians as to what CAM has to offer, and basically that it is an approach, we think of this as an extension of the physician's office, not we are the competition of the physician.
So, again, I don't mean this to be the only way to go. It is one way, and I just wanted to share it with you, because, as I said, it came out of my own search.
DR. GORDON: Thank you. Thank you very much, Bill.
DR. FAIR: Thank you for giving me the time.
DR. GORDON: Yes, I would encourage the Commissioners to take a look at the material, because this really comes out of Bill's personal search, as well as his understanding as a physician and surgeon. I think that is a real power.
I also would ask other Commissioners if you have materials that you would like to share with us. One of the things of the nature of the Commission has been to ask other people to come and tell us what they are doing.
Obviously the people who are sitting around this table have also been spending their lives doing some very interesting and important things. So what we, I think, would welcome is if you want to share the work that you do and the perspectives that you have with all the Commissioners, if you would make available material -- I hope I am not speaking out of turn, because I haven't talked with Steve, but I am assuming that we can facilitate this.
If you want to make available the materials, we can make that available to all the Commissioners, so that we can have the benefit of not only each other's comments on the issues that are raised here, but also the benefits of seeing what your work is like. I think that would be very, very useful.
So, thank you, Bill, for leading the way in doing this.
DR. FAIR: I might also add that anyone else, I would just ask them to send me a bunch and it came out just about a bunch equivalent to the Commissioners, but if anybody else wants it, just give me a call or drop me a note and I would be happy to send it to you.
DR. GORDON: Thank you. Okay. It is time for us to move ahead. We have the majority of the Interim Report to go over, to discuss, as we discussed the wellness section, and what I would like to do is to proceed with the different sections, moving through them, and again hearing issues that are raised, concerns that you have, places where you think the tone may be off, and then moving from a discussion of the text to whatever recommendations there may be, if indeed there are any recommendations at the end.
Does that sound like a reasonable way to proceed with the rest of this? Yes. Okay.
We have approximately two hours to do this, so I am going to take the liberty of moving things along quickly so that we can make sure we cover all the sections and everybody gets heard.
Please, if somebody has made the point, and we are looking for consensus, and everybody agrees, let's just agree, we don't have to have a great number of concurring speeches. In the interest of saving time, let's really try to be disciplined.
Discussion Session VI: Draft Interim Report
DR. GORDON: So let's start. We have had discussion already of the opening and the introduction. We have an outline and a sense of what needs to be covered, and the way it needs to be covered.
The pages 2 and 3 are basically -- and I note that on page 2, the fourth task of the Commission was somehow omitted, there is a typo. But basically page 2 and 3, and the Commission's progress to date are pretty much simply factual accounts of what has happened so far.
So I would like, unless there is some particular concern in those, to move right into a coordination of complementary and alternative medicine research.
MR. DeVRIES: Just a quick comment. Under V, Commission Membership, Sister Charlotte, you may want to check, because it doesn't have you specified as a licensed acupuncturist or as a nurse.
DR. GORDON: Well, thank you. If there are any other errors in titles, please let the staff know about that. Thank you, George.
Dean, do you want to make any opening statement about the research section, since you have led the discussion and have been so intimately involved with it?
DR. ORNISH: Well, I guess I would just be curious to know if anybody has any changes that they would like to make based on what is here. We had a whole session on it, but now that we are actually getting down to the nitty-gritty, what are your thoughts? I guess we are on pages 4 and 5 now, is that right? Four, 5 and 6.
DR. WARREN: Remember that, on page 5, right after line 14, Wayne had something that he thought needed to be added there. Of course, he is not here.
DR. ORNISH: I think one of the things that we talked about was whether on page 5, line 12, the creativity and research methodology and flexibility in study design, whether we want to get into that level of being prescriptive, whether that raises issues of, is there something less rigorous about what we are proposing; would it be enough to just simply say that the research methodology should be appropriate to the approaches and techniques being studied, and leave unstated the second part, which, again, it is an issue of being skillful in not pushing people's buttons early on.
I know this is a big button for a lot of people, the Marcia Angells and the Arnold Relmans, and others, that somehow CAM has a less rigorous approach, that it is more sloppy. There is no point in me even raising that issue if we don't need to, at this point, and save it for the Final Report.
Beyond that, I don't think I have any real suggestions. I think that this was very well written. I want to compliment -- I am not quite sure whether it was Corinne or Gerri, I guess it was Gerri -- for doing this.
I would be curious to know if anyone else has anything that they would like to have changed, based on what is here.
DR. FINS: Just one little thing, on page 4, where we mention the thousand speakers, we might want to make some mention of the folks we didn't hear from.
Then on the section that Dean was referring to, I think in the paragraph that ends on page 5, Safety and Efficacy, I think somewhere in there I would like to have language about hypothesis generation.
DR. GORDON: Joe, could we take you back to the suggestion that Dean made? I would like to deal with that in an orderly way, about you raised the possibility of eliminating Number 2.
DR. ORNISH: Number 2, line 12, page 5. Then somebody mentioned, Wayne, that you had some thoughts you wanted to float, around line 15 on page 5, on the numbered document, on page 5, in between the paragraphs that end on line 14 and begin on line 16. They may be mistaken, but somebody said you might want to add something here.
DR. JONAS: I think what we were talking about is the importance of research being a tool for providing information to particular audiences for particular uses, and I think the phraseology I had suggested was research should be designed to provide the types of information most useful for those seeking delivery of CAM services. It is an issue about prioritization.
DR. ORNISH: Would you be comfortable if we added to that a line something like, "using the most rigorous and appropriate scientific method" or "scientific design"?
DR. JONAS: Well, we actually have another section that deals with rigor and that type of thing, which I think is important, and there would be some easy ways, when we get to that, to addressing that.
DR. ORNISH: Well, I am just trying, again, to avoid pushing people's buttons.
DR. JONAS: I agree. I would like the idea that research design, selection of the research design, needs to be targeted towards the type of information you want your audience, that is going to use it. Within each of those research designs, you should use the best and most rigorous science that you can use, and that should definitely be stated in there. That was already stated in a different section.
DR. ORNISH: Towards the audience or towards the question?
DR. JONAS: It is towards the question. You select the design and your goals, based on the type of information that you want.
DR. ORNISH: Right. Okay.
DR. JONAS: From that, then you put together the best, most rigorous methods to achieve those goals.
DR. ORNISH: Well, I think, maybe, to make it even less questionable, just say that based on the hypothesis that is trying to be answered -- Corinne, you look like you want to say something.
MS. AXELROD: Yes. I did want to say something. Where it says, "the studies need a focused question," line 9, I had originally written, "studies need a clear hypothesis," and I changed it to "focused question" because I thought that actually broadened it. The word "hypothesis" is very conventional.
DR. ORNISH: Well, why don't we do this? I mean, again, my goal is to try to have us be as skillful as we can, and when the Arnold Relmans and the Marcia Angells, and the others who are just waiting for us to mess up, read this, they say, well, I am glad we got through to them; I am glad they listened to me.
So if you say the studies need a clear hypothesis, a good study design, and then leave out Number 2 on line 12 through 13, we can always elaborate things on the Final Report. I think this will pass muster with them and then make them allies, or at least neutral as opposed to giving them an easy target and it sounds sloppy to them.
MS. AXELROD: All right. So basically, the "clear hypothesis" which I originally had, plus the "focused question" in parens.
DR. JONAS: Let me just modify that a little bit. I mean, because there are very important and very rigorous types of studies that explicitly do not do hypothesis testing and generate hypotheses. They are extremely important types of research, and often get at the more relevant issues related to what the patients want. So it is important that we not make a blanket statement about all types of research as a general aspect.
This is why I suggest that there be wording in there that you need to do high-quality research, and that research needs to be appropriately designed to answer the types of questions that you need for the type of information that you want, or the audience that you want. We can rephrase that.
So I think the issue is that we need to use high-quality science, we need to use the best methods and methodology for answering the research questions, obtaining the type of information that we need, and that can be a blanket statement.
To say, then, that everything should be hypothesis-generated ignores one area. Now, you can say that you need to have hypothesis-driven, hypothesis-generated research when you are seeking cause-and-effect relationships, for example, in clinical trials, which are trying to make statements about attribution. Then hypothesis generation is clear.
When you are trying to look at mechanisms, for example, you have to do hypothesis generation. That is the whole basis for basic studies, is the hypothesis. So I don't want to go into the details, but what I am saying is, that you can use a phrase like high-quality research
-- okay, science, the best evidence for obtaining the most relevant information, and this type of thing.
DR. ORNISH: I can go with that. Highest quality science to obtain the most relevant and useful information. That is perfect.
DR. GORDON: One point I want to make, though, is, we need to remember who our audience is. So "highest quality science" is fine. We don't want to become obscure. This is for lay people. Even though the scientific community will read it, it needs to be completely intelligible to our primary audience, otherwise, we will lose them.
DR. ORNISH: Well, I don't think there is anything unintelligible about "high-quality research."
DR. GORDON: No, but when we start talking about "hypothesis generation," I am responding to that. I am just laying out a thought for future discussions.
DR. ORNISH: Okay. Well, that is why I thought putting both in would be useful.
DR. JONAS: I mean, "hypothesis generation" is a little too esoteric, I think, in this area.
DR. ORNISH: Let's not get bogged down in this. I was saying you can say "hypothesis," paren, "focused question," closed paren, so that it is clear to everyone.
MS. AXELROD: I was just going to ask whether it would make sense to say "clear hypothesis" or "hypothesis-driven," or something -- I would have to play with it -- or "focused question," because in any study you have to have a focused question, whether or not it is a hypothesis. It is a question.
DR. ORNISH: I don't want to get bogged down in it. If you could just put "hypothesis," "focused question," it is going to be clear to everyone. It is going to be an Interim Report.
The main thing I am concerned about is the people who are waiting for us to slip up. This is exactly where they are going to be looking for it, and we won't be making ourselves vulnerable to that. That is all. That is my primary concern here.
MS. AXELROD: Okay.
DR. FINS: It is in the same section, but on line 10, before "research." Can we say "qualified research"?
DR. ORNISH: Sure.
DR. FINS: Well, "qualified," has different meanings.
DR. ORNISH: Yes, that is good.
DR. FINS: "Qualified." I mean, we had that whole thing yesterday about the Nuremberg Code. It relates to that. So, "qualified."
DR. GORDON: Where?
DR. FINS: Right before "research."
DR. GORDON: There is no "research" there.
DR. FINS: Line 5.
DR. GORDON: Oh, 5. I'm sorry. Okay.
Wayne, go ahead.
DR. JONAS: I just want to make one suggestion, and I don't know if I want to go into wording here, but we did this in the development of the center work.
What we want is a variety of types of research, and we want good research in all of those variety of types. So you can actually list the main ones. We talked about them: outcomes research; health services research; randomized control trials; basic science research.
My suggestion is that what we put in here is a paragraph which says that it is generally agreed that research of high standards and study design and execution is required. This includes a variety of research types that address the needs of those seeking delivery in and understanding CAM services and products. This includes, and then you can say randomized control trials, health services research, outcomes research.
DR. FINS: I wouldn't use the word "needs," because it sounds like we are tailoring the methodology to the physician. I would just stay to the question, again, not the needs.
DR. JONAS: The question is derived from the need, right? I mean, you design your goal based on the type of information you want, and the type of information you want is based on how you are going to use it, and how you are going to use it is what you need.
DR. GORDON: Let me say there there is a difference here, and the difference, I think, has to do with whether research is directed by the needs of the people for whom one is doing the research, or whether it is driven by questions that arise from science or the state of the science, or the science of an establishment. I think that is a difference. I don't know if it is real or apparent.
DR. JONAS: It is not an either/or. This is not an either/or. In fact, you don't have to use the word "needs." I didn't actually use the word needs in here: "Provides type of information most useful for those seeking the delivery and understanding of complementary and alternative medicine practices." I didn't use the word "needs."
DR. FINS: How about if we said the most information necessary for delivery of safe and effective CAM modalities or something?
DR. JONAS: I think that is okay, except then that eliminates understanding, which is a basic science question. So I mean, it is inclusive. I am not saying that we do either/or. I think it needs to be inclusive. And then if you list the major types of research that you think need to go on, basic research, health services research, outcomes research.
DR. ORNISH: I think all of that is good, I like that. And again, what I am really trying to avoid, and what they are going to be gunning for, is anything that gives the appearance that there is a different quality of research or a different level of science or a different standard, and nothing that you said really pushes that button.
DR. JONAS: I agree. And, in fact, if you want, and I would be happy to do this, I could word this in a way where it is absolutely razor-sharp in terms of saying science is, you know, following our principle number whatever it was, 2, that is up here, that science is the absolute, I mean we believe that science is the important tool for doing this.
DR. ORNISH: Well, I have complete confidence in you, Wayne, so why don't you do that?
DR. GORDON: Let me check in with everybody else. Is everybody else comfortable with that, too? Wayne, do you want to say what you are going to do, then, just very quickly? Does everybody understand? That is okay?
DR. JONAS: Yes, I will just put a paragraph in here that emphasizes the importance of science and science is the basis for understanding complementary medicine and its delivery, and that includes type of research, high quality research and the types of research design that is needed to do that.
DR. GORDON: Okay.
DR. JONAS: And list the basic ones that have been discussed in the last few weeks.
DR. GORDON: Okay. Everybody comfortable with that, then?
DR. GORDON: Good. Dean?
DR. ORNISH: I think it is great. I guess the last part has to do, on page 6, in lines 7 through 17, were there any concerns that people had? Well, actually even on the previous page, beginning at line 23. I am trying to remember whether there were any concerns that were expressed about that.