The following is a commencement address I was honored to deliver on Aug. 3, 2013. My audience was the graduates of the programs of Doctor of Chiropractic, Master of Acupuncture and Oriental Medicine, and Master of Applied Clinical Nutrition at New York Chiropractic College/Finger Lakes School of Acupuncture and Oriental Medicine. The NYCC press release on the ceremony stimulated some requests to read the talk and in turn the suggestion that I make it more broadly available. I hope you find it of interest.
Thank you President [Frank] Nicchi, Trustees, members of the faculty, and most of all to the students of the graduating classes here today, and to your families and friends. It is an honor to be with you in this ceremony marking your transition from students into clinicians. Big day.
It is also a pleasure to be here with professionals with whom I have had a chance to collaborate in work to advance a more inclusive, health-focused system: Dr. Nicchi, Finger Lakes College of Acupuncture and Oriental Medicine director Jason Wright, LAc, and his faculty member Kathy Taromina, LAc.
I was pleased to have time for a tour of this gorgeous campus yesterday. In the midst of a successful search for tonsils and vocal chords in the body of some poor soul at the cadaver lab, the lab director popped a question: "So what are you planning to talk about?"
I replied: "The world into which the students will graduate."
My campus tour, guide, Dr. Van Tyle responded a bit worried sounding: "It'll be depressing then?"
I didn't say anything more. Perhaps the shift in attention from cadaver voice box to commencement ideas left be unable to use my own. But I recall the series of graduation platitudes that Dr. Van Tyle's quiet query evoked:
It's the best of times, it's the worst of times.
It is the Chinese character for both crisis and opportunity.
You can focus on the glass half full or the glass half empty.
It's a Tale of Two Cities.
What most came to mind was a statement that has guided me for the last half decade through these paradoxes, opposites, challenges, and excitement. It's a perspective I learned via my friendship with Paul Loeb, the best-selling author and expert on citizen activism. His work has titles like Hope in Hard Times, Generation at the Crossroads, Soul of a Citizen, and, my favorite among the titles, The Impossible Will Take a Little While, a line he took from the blues singer Billie Holiday.
My relationship with Paul is built on us each being part writer and part organizer. Our writing is in service to our activism. Because we are each of us engaged as professionals in moving people to action, we sometimes joke that we are hope-mongers. We each make our living selling hope.
This is my disclosure of self-interest in the perspectives I will offer you here as you walk out of these doors and into your practices. I'll err on the side of hope.
But let me explain what I mean by hope. I learned this via one of Paul's books. His edited volume, The Impossible, includes an excerpt from a speech of former Czech writer, dissident, and then president, Vaclav Havel. Havel writes this about hope:
"Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out."
I invite you to let that phrase guide you as it does me. We need engaged people. Health care needs engaged doctors of chiropractic, clinical nutritionists, quality educators, engaged practitioners of acupuncture and Oriental medicine.
Hope is not the same as optimism. What Havel connects hope to is not whether you can guarantee that you will be successful, that your view, perspectives or hard work will come to fruition. Rather, he connects us to doing something because it makes sense.
Let me share the kind of sense in the world of medicine and health today that I believe can make us all hopeful.
First, two items from the Institute of Medicine (IOM) from the National Academy of Sciences.
The IOM's To Err is Human came out in 2000, estimating that we are killing over 100,000 people a year with the regular practice of medicine. Some have since put the number at closer to 250,000. Listen to that again for a moment: 100,000-250,000 killed, annually.
More recently, other IOM studies led to a conclusion that between 30 percent and 50 percent of what we do in our medical industry is waste -- and that much of the waste is harmful. I first saw these data in an editorial in the Journal of the American Medical Association in February 2008. The IOM published a report on this again in 2012. Think about it: upwards of $750 billion a year of waste. That's most of the U.S. military-related budget. Think of all the foregone schools, investments in education, in environment, in good food and farming policy.
Now my tour guide from yesterday, Dr. Van Tyle, may well be thinking: Told you so -- there he is just as I guessed, depressing us all.
But here's the hope. These data are finally out there, in the light, in the dialogue, informing policy, shaping aspects of the 2010 Affordable Care Act, informing the behavior of executives and line workers in health systems across this country. That waste and all that unnecessary mortality and morbidity was undeclared and unacknowledged until these reports.
Our medical industry was trumpeting itself as the best in the world even as these data described the horror of what was actually going on. The claim had an ugly, hidden shadow.
Undeclared, these facts of our experience of medicine and health were the darkest hour just before the dawn.
The sense in rescuing these outcomes and experiences from the shadows is a dawning.
The sense we are collectively making about how to right our course flows from, in, and around our owning of these horrible dark strains in our medical industry and practices. The sense in our emerging directions is a basis for hope as Havel's defines it.
Here are examples.
One direction is that we need to get our disciplines out of their isolated silos. The harm, waste and death the IOM found are each linked to a long history of top-down, abusive relationships among the professions, fighting between doctors and nurses, wars of the oppressors and the oppressed inside the walls that are supposed to support healing. That fight at the top filtered into all interprofessional exclusion and guild one-up-man-ship. Now however, we are seeing a campaign on many fronts to focus on team-building, on developing competencies to work collaboratively. Google the Interprofessional Education Collaborative, for starters. Then Google the National Center for Interprofessional Practice and Education. Teaming is an opening to each of you.
It makes sense that our care will be better if you each know better how to team with other disciplines and that others know what you have to offer in your shared service to your patients.
A related step was a 2010 report, also from the IOM in partnership with the influential Robert Wood Johnson Foundation. Their team examined the evidence on the practice of nurses and declared, in The Future of Nursing, that advanced practice nurses could safely treat patients, whether in primary care or in anesthesiology, without supervision from medical doctors. In fact, the care of nurses was often better than that from their medical doctor comparators. Perhaps more notable even than this finding was the decision of the IOM and Robert Wood Johnson to hang a powerful suffix on the report's title: "Leading Change, Advancing Health." They called the nurses to leadership.
Now I know I am not speaking to a room of nursing school graduates. My point is that the hegemony of the medical doctor as the font of all wisdom, the necessary controller of care delivery, was broken forever by this report, and the evidence that supported it. This creates openness for you and your fields. The report creates more possibilities for chiropractors to lead, for practitioners of acupuncture and Oriental medicine to be providing key new directions, and for nutritionists to be guiding better chronic care strategies.
It makes sense that leadership could and should come from many.
A second reaction to the coming to light in those reports is the empowerment of the movement toward patient-centered care. I suspect that no one in this room will question that patient experience and perceived positive outcomes as reported by your patients is your best friend. One thing that all studies continuously show is that people like the care received by you and your people-centric, relationship-centered, hands-on disciplines.
The sense is clear. Since we know that 45 percent to 85 percent of people with chronic conditions will explore one or more form of so-called "alternative medicine," then the only way to be patient-centered in our care delivery is to include those practitioners who are experts in these areas on these teams.
This is you and your colleagues in integrative health and medicine. To exclude you is a provider-centered decision, and old-line guild move. Or it is system-centered or someone's analysis of cost-centered. Exclusion of you is NOT patient-centered. You have them to rights on a core value.
Another form of sense that we are making of those deaths and particularly that waste is that it is an awful mistake to allow profit to be the dominant value in driving care decisions and medical system investments. Don Berwick is the medical doctor who headed up the early Institute of Medicine exploration of errors and waste. To keep those reports from gathering dust on shelves, Berwick announced, through his Harvard-based Institute for Health Improvement, the 100,000 Lives Campaign. With this he first forced medicine's noses into the carnage: Look at the mess you've made!
More importantly, to address the values-based causes of these problems, he and his associates announced the Triple Aim of values to replace that of profits: better patient experience, enhance population health, and lower per-capita cost.
Colleagues and I recently engaged a small survey of 80 academic and organizational leaders in integrative health and medicine. We asked these clinicians and educators to gauge the extent to which they felt that the health care outcomes from their fields of chiropractic, massage, acupuncture and Oriental medicine, home-birth midwifery and naturopathic medicine were aligned with these three values. None saw misalignment. Nearly 50 percent judged their practices perfectly aligned.
We are finally beginning to reverse the "perverse incentives" in our payment and delivery system that push medicine to do more, that have hospital CFOs planning on how many coronary arteries they need to have clog so they can place stents, perform bypasses, meet hospital bottom lines. This way of doing business might be called RV medicine. Business likes the margin on products that are more expensive. Medical business not only favors sick people over well people. Medicine's still dominant business model prefers people in tertiary care where the margins are highest. Why focus on extracting the most value to health out of a chiropractic adjustment, a therapeutic nutrition consult, an acupuncture treatment, an hour spent in assisting behavior change -- especially if the outcome is to keep people from needing the high-ticket things on which their business model is based. Healthy, empowered people are antagonistic to medicine's profit centers.
I need not say more about the sense in shifting the perverse incentives that dominate medical planning and practice.
Finally, cutting to the heart of the matter, and touching on a piece of the Triple Aim: The theme of health, rather than the mere absence of disease, is emerging as an outcome. If one listens closely one can hear, amidst the continuing reactivity and cost argument over how to manage disease, an insurgent rumbling about health, coaching patients to self-empowerment and well-being, of creating health. These outcomes are emerging in policy discussions, federal health law, and institutional practices.
Ken Paulus, the CEO of Minnesota's Allina Health System, captured this beautifully in a recent speech. He works for the system with the most significant integrative medicine program in the country. Allina has acupuncturists and massage therapists and mind-body workers active in their inpatient care and chiropractors associated with their outpatient clinics. They have provided over 100,000 inpatient integrative care visits. When Paulus came aboard in 2005 and learned about these integrative health offerings he learned that they were made possible by donations of millions from the George Family Foundation of the former chair of the medical technology giant Medtronic. Paulus said he figured integrative practices weren't going to be positive contributors to his bottom line. He said he thought to himself: "Integrative medicine is a cost center."
Now Paulus says, with new kinds of Triple Aim-oriented payments elevated by the Affordable Care Act, and with pressure from employers and government agencies to create models such as Accountable Care Organizations and patient-centered medical homes, now, Paulus says, "for the first time in Allina's 100 years we can get paid to keep people healthy." Now, he says, "I look on this integrative medicine as an asset."
It's a mess out there. The good sense in these directions is reason for hope.
Those shifts in values, orientation, planning, policy and practice are arriving just as we are seeing the most significant recognition in U.S. history of -- and health care leadership from -- members of your professions and the other integrative or "complementary and alternative medicine" professions for which you have been devoting your lives as students and which you are about to enter as clinicians.
The 2010 Affordable Care Act vastly increased recognition of the licensed integrative practice fields such as acupuncture and chiropractic. You are explicitly included in sections of that law related to non-discrimination in reimbursement, research, health promotion and prevention, work force development, and delivery models such as medical homes.
An acupuncturist Charlotte Kerr, MPH, LAc and a massage therapist researcher, Janet Kahn, PhD, CMT, sit on the U.S. Advisory Board for Health Promotion, Integrative and Public Health that is working with the U.S. Surgeon General and most federal agencies.
A licensed acupuncturist and naturopathic physician, Rick Marinelli, ND, LAc, was appointed to an Institute of Medicine Committee, funded via the Affordable Care Act. Marinelli is credited with helping articulate the need for a "culture shift" in pain care toward an integrated approach.
We see this values leadership at the Institute of Medicine from acupuncture and integrative health educator Elizabeth Goldblatt, PhD, MPA/HA. Goldblatt was for many years the chair of the Council of Colleges of Acupuncture and Oriental Medicine and currently chairs the Academic Consortium for Complementary and Alternative Health Care. Her insistence with members of the Global Forum on Innovation in Health Professional Education that health as an outcome be front and center led to an invitation to create a session with integrative nurse colleague Mary Jo Kreitzer, Ph.D., RN, that began to formulate the role of health and well-being in the coming era of team care.
A chiropractor, Christine Goertz, DC, Ph.D., sits on the Board of Governors of the new Patient Centered Outcomes Research Institute. Congress mandated that a licensed integrative health practitioner be appointed to that panel. This is new. That powerful new institute's CEO has directly turned to the organization of integrative health educators to name a member to a panel on a major back pain initiative. Integrative health leaders are integrated in various capacities with that agency.
A chiropractor, Mike Wiles, DC, MEd, co-chaired the program committee, with a colleague from UCSF Medical School, of a major educational meeting at Georgetown University last fall that was a model interprofessional collaboration. Some 350 educators from medicine, chiropractic, nursing, acupuncture and oriental medicine, massage, Yoga therapy, and naturopathic medicine convened.
Just last month the Center for Medicare and Medicaid services announced that they will consider paying chiropractors under evaluation and management codes. This is long overdue and represents an important step for all the integrative practice disciplines. Paying for E&M recognizes that chiropractic doctors are not a modality, not things, not mere machines for delivering spinal adjustment, but a profession with important roles in diagnosis, and patient interaction that go well beyond a single treatment. This will pave the way for licensed acupuncture and Oriental medicine professions to not merely be valued as mechanisms for inserting needles but for all that you do through diagnosis and treatment to advance human health.
One more example. The Veterans Administration is integrating chiropractors across the U.S. New York Chiropractic College has played a leadership role through its multiple partnerships. Just last month the VA announced a program to establish six residencies for chiropractic doctors, after seeing, I expect, the success of the pioneering residency here, via NYCC, worked.
The list could go on. If I were a shameless self-promoter I would note these are documented monthly in the Integrator Blog News & Reports. But that would be especially tasteless in a ceremonial gathering like this.
There are great reasons for hope, as Havel defines it, because there is great sense in this work to create a patient-centered, team-based, health-focused, community-oriented future for medicine. There is great sense in health care system that lives up to that name and actually creates health.
I do not mean to downplay the challenges. Nor do these positive steps counteract the awful feeling that things rarely move as quickly in a positive direction as one might want. Yet there is plenty here on which to hang our hats.
I'd like to leave you with three charges.
One is big picture. It follows on the work of a global group of experts who published a 2010 report sponsored by a British medical journal, The Lancet, on what we need to see in health professionals in the 21st century. These practical visionaries were not thinking about chiropractors and acupuncturists or much about nutrition I wouldn't guess either, when they produced this. You won't find yourself directly cited in the report.
But listen to the application to your lives. The team was looking upon this same rapidly changing and challenged world of medicine and health. They concluded that the job of medical education cannot merely be to provide information that sends you out into practice as experts, or even as professionals. Instead, the education to meet the needs of the 21st century needs to be "transformational" in nature. The end-product of such education is not the graduation of "experts" but rather of "leaders." That's right, each of you a leader. Leadership for what? This is the exciting clincher: "change agency."
What does this mean for you?
Most of you will be working clinically, one-on-one or, in some cases, with groups of patients. What might "change agent" mean in that environment? I suspect that this means it is not enough to limit pain, say, but to engage your patients in their personal change processes, find where they are, up their readiness and help them move themselves to health. This means elevating not just needles and your hands, but all the communication, nutritional awareness, exercise knowledge, stress reduction and other therapeutic tools you can bring to a population as riddled with chronic ill-health as is ours. It means putting patient empowerment, self-efficacy as it is being called, as your core outcome.
The focus on leadership and change also puts a premium on pitching in and collaborating. Each of these advances, the directions that make sense, has this in common: groups of people showed up and made them so. They fought for patient-centered care, for collaboration, for organizing care around values, for expanding the circle of who is included. For each directly related to your professions, your colleges, your educational organizations, your professional organizations have been the agent for change. You don't have to do this policy-related work, any of you, though some of you will be drawn to it. But do this: join, support, fund, donate, or volunteer for something. Just do it. There is undeniable sense in [owning/being a member of part of the collective].
Finally, I would like to leave you with a sense of insecurity.
This may seem a peculiar ultimate comment to a group of graduates as you head out into preparation for your licensing exams, and for your work as professionals. Yet I am dead serious. When you look in the mirror, ready for clinical practice, I urge you to see that professional as ill-prepared to provide optimal services for your patients. The reason is that none of us can do this alone. Go out and create relationships. Populate that picture of you with at least one of every other type of practitioner or service provider that may at some time be useful to a patient. Create your own circle of care of medical specialists, nurses, other integrative health providers, addiction services, and farmers markets. Stop the cycle of self-inflation and polarization that are bred by silos of education and practice. Continuously invest in these relationships even as you consult and refer unto others as you would have them consult and refer with you.
With that circle of care surrounding you will be best equipped as a health professional for the Tale of Two Cities, the crises and opportunities, the best and worst of times, and all the ambiguity that is most certainly ahead for each of you, and for your patients, as you work as part of a movement in health and medicine toward respecting the whole person, putting the patient at the center, focusing on health, and teaming with others. You'll be surrounded by hope, because there is just plain good sense in this.
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