Integrative Medicine in America—How Integrative Medicine Is Being Practiced in Clinical Centers Across the United States

MAJOR FINDINGS

1. All of the centers in the study reported being affiliated with a hospital, a healthcare system, and/or a medical or nursing school.

2. The integrative centers use 3 models of care delivery, which are not mutually exclusive:

   • 26 of the 29 centers (90%) offer consultative care (care delivered in collaboration with the patient’s primary care provider)

   • 18 centers (62%) offer comprehensive care (complete care for a specified condition in which the integrative practitioner acts as the primary caregiver for the patient during the course of treatment)

   • 13 centers (45%) offer primary care (overall care of a person’s health across the lifespan)

3. Fifteen centers offer in-patient services in the hospitals to which they are affiliated.

4. The entire spectrum of patient populations is addressed.

   • All centers provide care to adults

   • 28 centers (97%) offer geriatric services

   • 25 centers (86%) provide adolescent care

   • 21 centers (72%) offer OB-GYN services

   • 18 centers (62%) provide pediatric care

5. Overall, 63% of patients seen are self-referred. But 38% of the centers receive more than half of their patients from within their own healthcare system.

6. The care patients receive is individualized.

   • 27 centers (93%) create a unique health plan for their patients

   • 26 centers (90%) involve the family in patient care

7. All centers measure patient satisfaction on an ongoing basis.

8. Twenty-five centers (86%) conduct research.

9. Twenty-one centers (72%) use electronic medical records.

10. The most frequently employed practitioners at integrative medicine centers are, in descending order, physicians, massage therapists, meditation instructors, and acupuncturists.

11. Twenty-one centers (72%) reported offering self-care and wellness programs to their practitioners and staff.

12. The survey asked about the use of 34 different interventions in treating 20 different conditions. The centers were asked to report which therapies were used for which conditions. The interventions prescribed most frequently across all conditions, in descending order, are:

    • Food/Nutrition

    • Supplements

    • Yoga

    • Meditation

    • TCM/Acupuncture

    • Massage

    • Pharmaceuticals

13. From a list of 20 clinical conditions, respondents chose the top 5 for which they perceive integrative medicine to be most successful at their centers. These are, in descending order:

    • Chronic pain

    • Gastrointestinal conditions

    • Depression

    • Stress

    • Cancer

14. The survey grouped the therapies into 4 categories—mind-body, dietary/biological, movement/energy, and manual interventions. In all cases, centers used interventions from more than 1 treatment category to address each specified health condition. More than half of the centers reported using at least 1 intervention from all treatment categories for 12 of the 20 conditions covered in the survey.

15. The authors asked which of the 34 interventions listed in the survey the centers used in treating the 20 different conditions. The frequency of use of each intervention for each condition was ranked, and the correlations between treatment ranks were calculated. This analysis revealed that there was a high degree of concordance of interventions used for similar clinical conditions across the centers.

CONCLUSIONS

The strong affiliations to hospitals, healthcare systems, and medical and nursing schools as well as the centers’ collaborative work with and growing referrals from their own health systems reveal that integrative medicine is now an established part of healthcare in the United States.

The fact that integrative medicine is being practiced in diverse sites across the country with high levels of concordance of interventions for specific conditions suggests that integrative medicine practice is informed by a common knowledge base.

The data from the survey reveals that integrative medicine centers embrace a group of core values that inform and radiate through their practice and interactions with their patients. Integrative care is, in practice, patient-centered care and is a fundamentally collaborative enterprise fostering cooperation between patients and practitioners, and among the practitioners themselves.

One of the most striking, though perhaps predictable, conclusions of this study is that integrative medicine is, in fact, integrative. It integrates conventional care with non-conventional or non-Western therapies; ancient healing wisdom with modern science; and the whole person—mind, body, and spirit in the context of community.

PRACTICE MODELS

Over the past 2 decades, different models of integrative medicine practice have developed. The 3 most common models in use (Figure 1 and defined below) are: (1) primary care, (2) consultative care, and (3) comprehensive care. Often, one center will utilize 2 or all 3 models of operation.

Figure 1

Practice models in use.

INPATIENT SERVICES

Of the 29 centers surveyed, 15 offer inpatient services at their affiliated hospitals (Figure 2).

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Figure 2

Centers offering inpatient services.

Examples of inpatient programs:

• Institute for Health & Healing (IHH) at California Pacific Medical Center in San Francisco, California. In addition to services at the clinic, IHH integrative practitioners provide services to patients admitted to California Pacific Medical Center hospitals, including massage, guided imagery, expressive arts, healing harp, and medical clowns. IHH also offers holistic nursing and spiritual care. The IHH practitioners make more than 10 000 patient visits per year in the in-patient program.

• Penny George Institute for Health and Healing in Minneapolis, Minnesota. This center provides integrative services to the patients admitted at Abbott Northwestern Hospital, in addition to caring for patients at its clinic. Each integrative provider who works in the hospital is trained in Korean hand therapy, guided imagery, aromatherapy, acupressure, biofeedback, and massage. A triage team decides which patients the integrative providers should visit. This program has been so successful for pain, anxiety, and nausea reduction that Allina Hospitals & Clinics is now instituting it at the 10 other Allina hospitals. Abbott Northwestern funds the operating expenses of all direct inpatient integrative care.

• University of Maryland Center for Integrative Medicine in Baltimore, Maryland. The center’s holistic pain team offers inpatient services—reiki, massage, acupuncture, and sound therapy—at the University of Maryland’s R Adams Cowley Shock Trauma Center. Services are provided at the request of the patient and/or the attending physician.

• Duke Integrative Medicine in Durham, North Carolina. Duke Integrative Medicine offers special pre- and postsurgery services that any patient can request. These are a personalized mind-body session (which includes guided imagery, hypnosis, or relaxation training), acupuncture, massage, yoga therapy, and mindfulness training.

RESEARCH

The centers in the study voiced a strong commitment to evidence-informed medicine, and most (25) conduct research as part of their regular activities (Figure 3).

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Figure 3

Centers conducting integrative medicine research.

The broad spectrum of research programs range from the robust, multi-million dollar research programs at the University of Maryland Center for Integrative Medicine and the UCSF Osher Center for Integrative Medicine, both of which are NIH Centers of Excellence for Research; to ongoing research programs such as those at Duke Integrative Medicine, Vanderbilt Center for Integrative Health, Jefferson–Myrna Brind Center of Integrative Medicine, Continuum Center for Health and Healing, and the Integrative Medicine Program at Mayo Clinic; to single studies conducted at non-academic centers such as the Alliance Institute for Integrative Medicine’s participation in BraveNet, a practice-based research network for integrative medicine established by The Bravewell Collaborative.

While the research programs most typically conduct clinical trials, some centers such as the Penny George Institute for Health and Healing and the Marino Center for Integrative Health also conduct outcomes-based research in their hospitals and/or clinics.

PATIENT SOURCES

The 29 centers see a total of 19,200 unique patients per month. The total number of patient visits per month for all centers is about 41,100.

Overall, nearly two-thirds of the patients coming to integrative medicine centers are currently self-referred (63%).

Nine centers reported that more than half of their patients are referred from within their own healthcare system, and 5 of the 9 reported receiving 90% or more of their patients from within their own healthcare system, suggesting a growing integration within the parent organizations.

Most of the centers reported receiving a very low percentage of their patients from local practitioners outside their healthcare system.

Examples of patient referral systems:

• Center for Integrative Medicine and Wellness at Stamford Hospital in Stamford, Connecticut. Nearly 60% of the patients who visit this center are self-referred, with the other 40% referred by primary care physicians and specialists in the Stamford Hospital system. For example, primary care physicians, spine surgeons, neurologists, rheumatologists, anesthesiologists, dentists, and oral surgeons refer patients with pain. Primary care physicians, endocrinologists, cardiologists, and bariatric surgeons refer patients to the “food as medicine”nutritional consultation program to minimize cardiac risk factors such as high cholesterol and obesity. Surgeons automatically refer their patients for a mind-body “Prepare for Surgery”program to reduce perioperative anxiety. About 30% of the patients are also cross-referred between practitioners within the center.

• Susan Samueli Center of Integrative Medicine at the University of California, Irvine, Medical Center, in Irvine, California. The center attributes its high number of self-referrals to “happy patients who refer other patients to the clinic.”

• Integrative Medicine Program, Mayo Clinic in Rochester, Minnesota. About 90 percent of referrals to this program are made by other practitioners at the Mayo Clinic. Any practitioner can directly refer to an integrative medicine practitioner—such as a licensed acupuncturist or certified massage therapist—or patients can be referred to the integrative physician or integrative health nurse specialist in the program for a consultation.

• The OSU Center for Integrative Medicine in Columbus, Ohio. Nearly half of the patients at this center come from within the Ohio State University Health System. About 25% are self-referred, and the remaining 25% are referred by unaffiliated providers in the region.

TRIAGE

Most centers (20) do not require patients to see a physician when they first come to the center (Figure 7). Patients are allowed to schedule a visit with the provider of their choice.

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Figure 7

How centers triage.

Several of the centers noted that when the integrative provider visit is based on self-referral, their practitioners are trained to identify when the patient should be referred to a physician or other primary care provider for medical assessment.

The centers use a wide variety of triage and referral systems that do not require an initial physician visit.

Examples of these systems:

• Northwestern Integrative Medicine in Chicago, Illinois. Patients at this center can choose a physician consultation to develop a wellness plan and monitor their health goals, or they can self-refer or be referred by a physician to one of the center’s complementary medicine practitioners.

• GW Center for Integrative Medicine in Washington, DC. At this center, most patients automatically see a physician first, unless they are seeking such therapies as acupuncture, hypnotherapy, and massage for “simple medical conditions.”

• UCSF Osher Center for Integrative Medicine in San Francisco, California. Patients have the choice to self-refer or to consult with an integrative physician at the center, who can advise them of appropriate therapeutic options for their health needs.

• Vanderbilt Center for Integrative Health in Nashville, Tennessee. Patients usually see an integrative nurse practitioner or integrative physician for their initial consultation. If appropriate, they are referred to one of the members of the psychotherapy team for the remainder of their treatment planning process. Patients can also choose to participate in one of the group classes or sessions with individual practitioners such as a massage therapist or acupuncturist without having a full consultation.

• Osher Clinical Center (Harvard) in Chestnut Hill, Massachusetts. Whether patients at the Osher Center first see a physician depends on their specific medical condition. For example, patients presenting with back pain are scheduled directly for chiropractic treatment.

CARE PLANS

Twenty-seven centers in the study reported making individualized care plans for their patients (Figure 8).

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Figure 8

Care plans.

Care plans are created in a variety of ways. In some cases the plan is created by the physician, naturopath, or nurse practitioner who is acting as the primary provider, with input from the patient. In other cases, the plan is developed by an individual practitioner or a team, which could include, in addition to the physician or other primary care provider, a nurse case manager, biofeedback practitioner, dietician, massage therapist, acupuncturist, psychologist, or TCM practitioner.

Examples of how care plans are made:

• Arizona Center for Integrative Medicine in Tucson, Arizona. A new patient appointment at this center can last up to 2 hours, depending upon the intricacies of the case. Patients share their stories, including medical history, personal experiences, beliefs, and goals. The care plan is made by the integrative physician conducting the consultation, and treatment recommendations are usually offered at the time of the first visit. However, with complex conditions, a follow-up visit may be required (typically 2 to 4 weeks after the first meeting). Patients may be asked to return again in 3 to 4 months for a follow-up visit so the physician can properly monitor progress and refine the recommendations if needed.

• Cleveland Clinic Center for Integrative Medicine in Cleveland, Ohio. At this center, each practitioner makes his or her own care plan, but the clinic’s medical director provides oversight.

• Duke Integrative Medicine in Durham, North Carolina. Personalized health plans are provided to members of Duke Integrative Medicine (they have an annual membership program) or to those patients who come to the center for a multiple-day health immersion experience. The plan is developed by an interdisciplinary team of providers including an integrative medicine physician, health coach, nurse, and specific service providers (acupuncturists, massage therapists, nutritionists, yoga therapists, mind-body therapists, etc). Personalized health plans are monitored and revisited regularly by the team of providers.

FAMILY INVOLVEMENT

Twenty-six centers reported incorporating the family into the patient’s care (Figure 9). How this is accomplished ranges from including family members in practitioner visits to providing education to offering services targeted to family members.

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Figure 9

Family involvement in the care.

Examples of family involvement:

• 11th Street Family Health Services of Drexel University in Philadelphia, Pennsylvania. When a patient has a complex condition in need of home care, this center conducts home visits involving family members. It also provides supportive maternity and family care through its Centering Parenting and Centering Pregnancy programs. The center’s goal is to provide “a single point of access for care”for the whole family that addresses psychosocial as well as physiological issues. Its integrative life-course perspective focuses on key periods in an individual’s—and family’s—life, such as prenatal, early childhood, and adolescent care aimed at developing long-term relationships between the care provider and the family/patient.

• Integrative Medicine Center at MD Anderson Cancer Center in Houston, Texas. Patients are encouraged to have a family member or other primary support person accompany them to appointments. The center also provides all services to family members that are available to patients, such as Knowledge Classes for Patients and Caregivers, and Finding Reliable Health Information—a guide to resources on natural products and complementary therapies. Family members are encouraged to participate in the mind-body programs, massage, and educational sessions.

• Greenwich Hospital Integrative Medicine Program in Cos Cob, Connecticut. Greenwich offers programs geared to families such as a parent/child Healing Touch workshop to empower children to self-regulate during times of stress. The center’s Environmental Health Assessment is designed to help parents minimize their children’s exposure to toxins (heavy metals, industrial chemicals, and molds) beginning in utero and to identify food sensitivities. The center provides detoxification services for appropriate patients.

• Simms-Mann Health and Wellness Center at Venice Family Clinic in Venice, California. As part of a family clinic, this center offers many family-oriented programs, such as its Parenting and Nutrition Skills and Obesity Prevention/Weight Management programs. These programs offer parents information and strategies for improving their family’s nutrition and increasing physical activity.

MEDICAL RECORDS

Twenty-one centers reported using electronic medical records (Figure 10). Of those using electronic medical records, 19 of the 21 reported being able to include data on integrative services.

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Figure 10

Use of electronic medical records.

HEALTH COACHING

Eight of the centers offer formal health coaching for patients (Figure 12), which helps patients shift their behaviors and realize their personal health goals.

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Figure 12

Centers offering health coaching.

Some centers offer integrative health coaching through a certified health coach while in other centers, a physician, nurse practitioner, or other provider performs the health coaching function.

Examples of health coaching programs:

• Duke Integrative Medicine in Durham, North Carolina. Integrative health coaches are available to all patients at Duke. Patients enrolled in the Health Immersion Program or who are annual members are assigned a health coach. The health coach works with these patients to help them implement the goals outlined in their personalized health plans. Patients may partner with a health coach alone or as part of other services they receive at Duke. The health coach offers ongoing support, including phone calls, to help the patient embrace new, healthy life skills.

• Vanderbilt Center for Integrative Health in Nashville, Tennessee. Many staff and faculty are trained in a year-long health coaching program and have begun to use health coaching skills in their practices. This patient- and relationship-driven process supports and helps monitor the personalized health plan that was developed either in an integrative health consult or a health coaching session. The patients learn strategies for healthy actions that can effect positive changes such as weight loss, reduced stress, and adherence to a diabetic regimen. Currently, some sessions are in person and many are phone-based.

WELLNESS PROGRAMS

Some integrative medicine clinics offer wellness programs so that healthy people can maximize their health and wellbeing.

Examples of wellness programs:

• Center for Life at the University of New Mexico in Albuquerque, New Mexico. For people who do not have a serious health condition but simply want to maximize their health, Center for Life offers wellness consultations during which patients can receive a customized wellness plan. The consultation involves a comprehensive integrative evaluation and nutritional counseling, among other strategies.

• Jefferson–Myrna Brind Center of Integrative Medicine in Philadelphia, Pennsylvania. This center offers The Great Life Program, a wellness program for executives, which is designed to facilitate improved health and wellbeing. The full evaluation covers diet and exercise, sexual health, energy level, illness risk factors, heart health, stress levels, a complete physical exam, genetics testing, and an evaluation of hormonal balance. Patients receive a personalized plan for achieving their health goals.

CHRONIC PAIN

Chronic pain is the condition for which patients seek integrative care most frequently.

Examples of how chronic pain is treated:

• Stanford Center for Integrative Medicine at Stanford University in Palo Alto, California. This center specializes in the treatment of chronic pain among other conditions and operates a clinic that concentrates on “the pathways of mind/body regulation.”The practitioners use acupuncture, medical hypnosis, massage, applied psychophysiology, and mindfulness meditation. They operate from Osler’s belief that “a good physician treats the disease, but a great physician treats the person.”

• Center for Life at the University of New Mexico in Albuquerque, New Mexico. This center offers inpatient pediatric care (an adult program is in development) and a strong ambulatory component. Treatment for chronic bone or soft tissue pain may include: comprehensive evaluation with a physician; trigger point injections as well as topical applications of botanicals and homeopathics; acupuncture; massage/myofascial therapy; Healing Touch; and chiropractic care (ambulatory only), including Frequency Specific Microcurrent, Graston, and Flexion/Distraction techniques. These therapies are complemented with medical hypnotherapy, mindfulness meditation, and psychotherapy. Cancer pain is treated through psychological and mindful interventions offering comfort and emotional support along with oncology massage, acupuncture, nutrition, and lifestyle modifications.

• The Center for Integrative Medicine at the University of Colorado in Aurora, Colorado. The majority of patients referred to the clinic from the University of Colorado Health System are suffering from fibromyalgia. Sleep interventions (with judicious medication use if needed and/or referral to sleep specialists), exercise, and cognitive behavioral therapy are the mainstays of treatment. The center also uses acupuncture, chiropractic, massage, mind-body approaches, supplements, and medications. The center notes that “these therapies are much more effective in conjunction with lifestyle changes,”including dietary adjustments.

GASTROINTESTINAL DISORDERS

Sixteen of the centers (55%) reported having success with gastrointestinal disorders such as chronic constipation, irritable bowel syndrome, hemorrhoids, diverticular disease, and colitis.

Examples of how gastrointestinal conditions are treated:

• GW Center for Integrative Medicine at George Washington University in Washington, DC. Whether patients at the GW Center have a diagnosis for a specific gastrointestinal disorder or not, they receive a GI functional assessment and treatment to address gastrointestinal permeability and dysbiosis, among other issues, which have been implicated in inflammation and chronic disease.

• Alliance Institute for Integrative Medicine in Cincinnati, Ohio. The Alliance Institute utilizes a systematized diagnostic and therapeutic approach to gastrointestinal disorders. The Institute combines conventional medical and functional diagnostic tools to formulate an individualized assessment. The physicians then design a treatment protocol combining conventional medicine and functional medicine with an array of integrative therapies, which include, among others, nutritional interventions, supplementation, acupuncture, energy balancing, and stress reduction.

• Continuum Center for Health and Healing in New York, New York. This center creates a personalized care plan, which may include mind-body strategies, nutritional interventions, dietary supplementation, yoga, osteopathic manipulation, and acupuncture. Depending on the patient, this may also include functional medicine to make a biochemical assessment to identify potential triggers for poor gastrointestinal health, and an assessment of environmental exposure to toxins, subtle allergic reactions, and extreme nutritional depletion.

DEPRESSION/ANXIETY

Depression/anxiety is one of the main reasons people seek care of any kind, conventional or integrative.

Examples of how integrative medicine centers treat depression and anxiety:

• Center for Integrative Medicine at the Cleveland Clinic Wellness Institute in Cleveland, Ohio. For the treatment of depression and anxiety, the center offers holistic psychotherapy provided by licensed mental healthcare professionals, including mind-body therapies such as hypnotherapy, guided imagery, and meditation/relaxation.

• 11th Street Family Health Services at Drexel University in Philadelphia, Pennsylvania. The community clinic offers outpatient behavioral health and brief therapy with behavioral health consultants in primary care. The complementary and integrative therapist (CIT) works with all the behavioral health providers. The CIT offers yoga, meditation, reiki, reflexology, and Mindfulness-Based Stress Reduction as adjunctive care to traditional behavioral health interventions. Often, patients are referred to a CIT through primary care to aid medical management of mental health and encourage individual accountability for care, self-empowerment, and independence.

• The Penny George Institute for Health and Healing at Abbott Northwestern Hospital in Minneapolis, Minnesota. This center developed and researched a Resilience Training program inspired by the book The Chemistry of Joy by Dr Henry Emmons. Participants in the eight-week program receive individual psychiatric, nutritional, and fitness assessments, and as a group, develop meditation skills and personal insight for working through difficult emotions and managing stress. Institute researchers found that participants in Resilience Training experienced significant improvement in depression symptoms, quality of life measures, and work productivity. This program is now offered as an employee benefit.

CANCER

While most cancer patients are referred from a conventional cancer treatment center, some patients self-refer to an integrative medicine center that is not directly involved in their cancer care. The integrative medicine centers in the study tended to offer emotional and nutritional support, as well as complementary therapies such as acupuncture and massage therapy to people who are undergoing, or have completed, cancer treatment.

Examples of care for cancer patients:

• Integrative Medicine Program at the University of Wisconsin in Madison, Wisconsin. This center offers integrative health services, including massage therapy/bodywork and acupuncture, to cancer patients in collaboration with the University’s Carbone Cancer Center, where patients receive their cancer treatment. These integrative therapies are intended to help people cope with pain and other symptoms as well as treatment side effects such as nausea, fatigue, and distress.

• Cancer Treatment Centers of America (CTCA) at Midwestern Regional Medical Center in Zion, Illinois and The Integrative Medicine Center at MD Anderson Cancer Center in Houston, Texas. These two institutions only treat people with cancer. At CTCA, all treatment teams include a dietician, naturopathic doctor, mind-body therapist, chiropractor, and pain management clinician (including an acupuncturist) as well as a medical oncologist. MD Anderson’s integrative medicine center offers acupuncture, massage therapy, and mind-body-spirit practices such as meditation, guided imagery, yoga, tai chi, and music therapy. Therapies are provided to caregivers as well as patients.

• Northwestern Integrative Medicine in Chicago, Illinois. Through its 360 Integrative Oncology program, this center offers free acupuncture, massage, and Healing Touch in Northwestern’s cancer center’s chemotherapy infusion suites on a daily basis. Patients in the program receive free inpatient treatments by the center’s staff and are eligible to receive five free sessions of acupuncture, massage, energy medicine, or naturopathic medicine on an outpatient basis as well. The program is funded through philanthropy.

STRESS

Stress management is a major component of integrative medicine. Stress has been demonstrated to be an important risk factor for many health conditions. In addition, people with chronic health issues experience added stress from their illness.

Directors of a number of the centers articulated a mission to help relieve suffering and offer hope to the people who come to them for healthcare. The therapeutic relationship is seen universally to be a key to relieving suffering, as is being in a healing environment.

Examples of programs for stress reduction:

• Mayo Clinic Complementary and Integrative Medicine Program in Rochester, Minnesota. Mayo’s Mind Body Initiative uses attention training to develop mindful awareness and resilience to counteract the effects of stress on the mind and body. Individual consultations for stress management strategies and group attention training are offered.

• Marino Center for Integrative Health in Cambridge, Massachusetts. This center offers a qi gong–based stress reduction program, consisting of eight 2-hour weekly sessions in a group therapy environment, led by a clinical psychologist.

• The Jefferson–Myrna Brind Center of Integrative Medicine in Philadelphia, Pennsylvania. The center established its Mindfulness Institute in 1996. The 8-week Mindfulness-Based Stress Reduction (MBSR) course helps people lower distress and increase vitality and well-being. Ongoing support in the form of private sessions is also offered, as are advanced trainings for mental health professionals and mindfulness teachers.

It should be noted that patients can use the skills they learn in MBSR, yoga, and other similar classes to continue effective self-care throughout their lifetime.

Clinical Success

• Listening to and empowering patients

• Treating the whole person

• Providing hope

• Using an evidence-informed approach to care

• Encouraging collaboration among practitioners

• Developing “Best Practices”

• Maintaining a healing environment

Inclusion/Exclusion Criteria

One of the challenges of a survey such as this is identifying which centers to include or exclude. All of the centers surveyed have strong clinical programs, and nearly all of them see a large number of unique patients per month. In addition, centers selected to be surveyed were those that provided an integrative model in which conventional medicine plays an essential role. While these centers do, to some extent, provide care drawn from other health systems—including naturopathy, chiropractic, Traditional Chinese Medicine, Ayurveda, or homeopathy—centers whose sole orientation is to deliver healthcare from these non-conventional medical systems were excluded. The authors acknowledge that the responses may have been different if another cohort of centers was surveyed.

Issues of Affiliation and Configuration

The number of patient visits per center reflects the decision to treat centers with multiple locations differently. University of Wisconsin Integrative Medicine, for example, has three clinics; Marino has 2 locations; and Cancer Treatment Centers of America (CTCA) has 5 centers across the United States. For the purposes of this survey, Marino (despite its 2 locations) and University of Wisconsin Integrative Medicine (despite its 3 clinics) were considered to each be a single center with patient visit data included from their various locations. On the other hand, because of the magnitude of its size, data was collected from only 1 of the CTCA centers, its flagship hospital in Zion, Illinois.

Categorization Overlap

It is challenging to categorize therapies without some overlap. To be as inclusive as possible, some therapeutic approaches—such as supplements, vitamins, probiotics, and herbal remedies—were listed separately although “supplements”is a broad category under which the other three items could reasonably appear. Acupuncture was not listed separately as a therapy (although “acupuncturist”was listed in the practitioner section in addition to “traditional Chinese medicine”practitioner), while tai chi and qi gong were listed separately. So whether a center checked traditional Chinese medicine as a system of care was left to each center’s discretion and own understanding of TCM. For example, a center could state that it offered tai chi and qi gong but did not offer TCM, if that center assumed that offering TCM would necessitate including acupuncture or traditional Chinese herbal remedies.

With regard to medical conditions, acute and chronic pain were listed as separate conditions, as were specific pain-related conditions such as arthritis, fibromyalgia, and headache. These issues of classification should be carefully considered in the design of future studies investigating integrative care and the work of integrative medicine centers.

Employee Data

This survey asked a number of questions concerning employees, but responses to these were excluded from the analysis to avoid misleading conclusions. For example, questions about total full-time and part-time employees did not differentiate between support staff and clinical staff. Consequently, some centers included administrative staff and others did not. The term “FTE”was not adequately defined—some centers included only people who were employed full time while other centers used “full-time equivalent”as the definition and included full-time positions that were filled by one or more practitioners.

The Bravewell Collaborative Initiatives

By developing strategic programs that support innovation and integrative approaches to medicine, The Bravewell Collaborative believes that it can direct positive and lasting change in our healthcare system. More information about each of the initiatives can be found at www.bravewell.org.

The Bravewell Clinical Network

In 2003, to help develop effective clinical models for the delivery of integrative health-care, The Bravewell Collaborative established a network of 8 leading integrative medicine centers. Bravewell assists the Clinical Network members in building the capacity to serve patients, developing successful models of care, and improving financial sustainability. Today, the nine centers in the Clinical Network provide integrative care to thousands of people across the nation. The Network’s progress was documented in the 2007 publication of Best Practices in Integrative Medicine: A Report from the Bravewell Clinical Network, which is available at www.bravewell.org.

The Bravewell Fellowship Program

To help train new clinical leaders in the field of integrative medicine, The Bravewell Collaborative created the 2-year Bravewell Fellowship Program in conjunction with the highly-respected Fellowship Program at the University of Arizona’s Center for Integrative Medicine. As of 2010, 75 Fellows have graduated from the program, with another 18 currently enrolled. Because the graduates typically return to leadership positions within their organizations, this program is exponentially increasing the availability of integrative medicine for the American people.

BraveNet

Recognizing the pressing need for research that would document the cost and clinical effectiveness of integrative care, The Bravewell Collaborative established BraveNet, the first practice-based research network for integrative medicine. Under the direction of the Duke Clinical Research Institute, BraveNet researchers are currently completing their second study. More information on BraveNet is available at bravenet.dcri.duke.edu.

The Consortium of Academic Health Centers for Integrative Medicine

With Bravewell’s financial support, the Consortium of Academic Health Centers for Integrative Medicine has grown from its four founding members to a strong organization of 50 member schools. This network of clinical centers connected with leading medical universities in the United States and Canada is helping to transform research, patient care, and physician education. More information about the Academic Consortium and a complete list of member schools is available at www.imconsortium.org.

The New Medicine PBS Special

Understanding that educating the public is key in the effort to transform our healthcare system, Bravewell organized and its members helped fund an award-winning two-hour PBS Special on integrative medicine. The New Medicine aired on March 29, 2006 on 516 PBS stations nationwide during prime time and was viewed by over 4.2 million people, with repeat broadcasts ongoing. For more information about The New Medicine, please visit www.thenewmedicine.org.

The Bravewell Leadership and Pioneers of Integrative Medicine Awards

The Bravewell Leadership Award and the Bravewell Pioneers of Integrative Medicine Awards recognize, empower, and support the physician leadership in this field. In 2003, Ralph Snyderman, MD, former Chancellor for Health Affairs, Duke University Medical Center, accepted the $100 000 Leadership Award. In 2005, Brian M. Berman, MD, Director of the Center for Integrative Medicine at the University of Maryland School of Medicine, accepted his award. In 2011, the third Leadership Award was presented to Mimi Guarneri, MD, founder and Medical Director of the Scripps Center of Integrative Medicine. The Inaugural Pioneers of Integrative Medicine Award Event in November 2007 honored 6 early leaders of integrative medicine—Larry Dossey, MD; James Gordon, MD; Jon Kabat-Zinn, PhD; Dean Ornish, MD; Rachel Naomi Remen, MD; and Andrew Weil, MD.

The Summit on Integrative Medicine and the Health of the Public

In partnership with The Bravewell Collaborative, the Institute of Medicine at the National Academies of Science convened a Summit on Integrative Medicine and the Health of the Public on February 25–27, 2009 in Washington, DC. This ground-breaking Summit explored the science and practice of integrative medicine for improving the breadth and depth of patient-centered care and promoting the nation’s health. For more information about the Summit please visit www.iom.edu/integrativemedicine. To view the Summit lectures, please visit www.imsummitwebcast.org.

Educational Resources

To further enhance the adoption of integrative medicine, Bravewell developed a series of targeted educational documents and videos that are offered free from its website. These include the reports Integrative Medicine: Improving Health Care for Patients and Health Care Delivery for Providers and Payors; The Efficacy and Cost Effectiveness of Integrative Medicine; and What Is Integrative Medicine, as well as 12 physician training videos focusing on the patient-provider relationship. Bravewell’s Best Practices Program highlights proven clinical interventions and/or business procedures through the publication of exemplars on www.bravewell.org.

Bonnie J. Horrigan

Bonnie J. Horrigan is the Director of Communications and Public Education for The Bravewell Collaborative. The author of Red Moon Passage (Harmony, 1996) and Voices of Integrative Medicine: Conversations and Encounters (Elsevier Science, 2003), she has published more than 200 articles in Spirituality & Health; Science & Spirit; CHOICES; The Inner Edge; Advances in Mind-Body Medicine; Alternative Therapies in Health and Medicine; EXPLORE: The Journal of Science and Healing; and San Diego Magazine, among others. Horrigan has also penned 3 national reports for The Bravewell Collaborative—Best Practices in Integrative Medicine, Integrative Medicine: Improving Health Care for Patients and Health Care Delivery for Providers and Payors, and The Efficacy and Cost Effectiveness of Integrative Medicine.

In 1995, Bonnie co-founded (with Larry Dossey, MD, and Jeanne Achterberg, PhD) Alternative Therapies in Health and Medicine, a medical journal examining alternative and cross-cultural healing practices and the relationship of the human spirit to health and healing. She is currently editorial director for EXPLORE: The Journal of Science and Healing, a new, indexed medical journal that examines the healing arts and the connection between spirituality and consciousness and health. Prior to working for Bravewell, she served as Director and then President of InnoVision Communications in Laguna Niguel, California (1990–2001) and Vice President of the Publishing House in Westminster, Colorado (1980–1989).

Sheldon Lewis

Sheldon Lewis has served as Editor-in-Chief of Advances in Mind-Body Medicine and as a Contributing Editor for Spirituality & Health magazine. He is co-author of the books The Human Side of Cancer and Stress-Proofing Your Child and magazine and journal articles.

He currently serves as a media and program consultant in the fields of health and business. He leads Meditation/Contemplative Practice groups and workshops and Mind/Body/Spirit groups in New York City and at The Center for Women’s Health in Stamford, Connecticut. He completed the Center for Mind-Body Medicine’s Advanced Professional Training in Mind-Body Medicine.

He served on the advisory panel for EDCAM, the NIH-sponsored American Medical Student Association initiative to develop medical school curricula on Complementary & Alternative Medicine. He currently serves as Chairman of the Board of The Knowledge Project, which provides literacy and mentoring programs to New York City public school children and their teachers.

Arizona Center for Integrative Medicine

• PO Box 245153

• Tucson, Arizona 85724

• Hospital Affiliation: University Medical Center

• Healthcare System Affiliation: University Physicians Healthcare

• University Affiliation: University of Arizona College of Medicine

• www.azcim.org

Cancer Treatment Centers of America

• 2520 Elisha Avenue

• Zion, Illinois 60069

• Hospital Affiliation: Midwestern Regional Medical Center

• Healthcare System Affiliation: None

• University Affiliation: None

• cancercenter.com

The Center for Integrative Medicine

• 1635 Aurora Court, F730

• Aurora, Colorado 80045

• Hospital Affiliation: University of Colorado Hospital

• Healthcare System Affiliation: University of Colorado

• University Affiliation: University of Colorado Denver School of Medicine

• www.uch.edu/integrativemed

Center for Life

• 4700 Jefferson NE

• Albuquerque, New Mexico 87108

• Hospital Affiliation: University of New Mexico Hospitals

• Healthcare System Affiliation: UNM Health Sciences Center

• University Affiliation: University of New Mexico School of Medicine

• www.unmcfi.org

Cleveland Clinic Center for Integrative Medicine

• 1950 Richmond Road TR201

• Lyndhurst, Ohio 44124

• Hospital Affiliation: Cleveland Clinic

• Health System Affiliation: Cleveland Clinic

• University Affiliation: Lerner College of Medicine/CWRU

• www.ccf.org/integrativemedicine

Continuum Center for Health and Healing^*

• 245 Fifth Avenue, Second Floor

• New York, New York 10016

• Hospital Affiliation: Beth Israel Medical Center

• Healthcare System Affiliation: Continuum Health Partners

• University Affiliation: Albert Einstein College of Medicine

• www.healthandhealingny.org

Duke Integrative Medicine^*

• DUMC Box 102904, 374 Erwin Road

• Durham, North Carolina 27710

• Hospital Affiliation: Duke University Medical Center

• Healthcare System Affiliation: Duke University Health System

• University Affiliation: Duke University School of Medicine

• www.dukeintegrativemedicine.org

^*Denotes membership in the Bravewell Clinical Network

11th Street Family Health Services of Drexel University

• 850 N 11th Street

• Philadelphia, Pennsylvania 19123–1957

• Hospital Affiliation: None

• Health System Affiliation: Drexel College of Nursing & Health Professions

• University Affiliation: Drexel College of Nursing & Health Professions

• www.drexel.edu/11thStreet/

GW Center for Integrative Medicine

• 908 New Hampshire Avenue, Suite 200, NW

• Washington, DC 20037

• Hospital Affiliation: George Washington University Hospital

• Healthcare System Affiliation: George Washington University

• University Affiliation: George Washington University

• www.integrativemedicinedc.com

Greenwich Hospital Integrative Medicine Program

• 35 River Road

• Cos Cob, Connecticut 06807

• Hospital Affiliation: Greenwich Hospital

• Healthcare System Affiliation: Yale New Haven

• University Affiliation: Yale University

• www.greenwichintegrativemedicine.org

Institute for Health & Healing at California Pacific Medical Center

• 2300 California Street, Suite 207

• San Francisco, California 94115

• Hospital Affiliation: California Pacific Medical Center

• Healthcare System Affiliation: Sutter Health

• University Affiliation: None

• www.myhealthandhealing.org

Jefferson–Myrna Brind Center of Integrative Medicine^*

• 925 Chestnut Street, Suite 120

• Philadelphia, Pennsylvania 19107

• Hospital Affiliation: Thomas Jefferson University Hospital

• Healthcare System Affiliation: Jefferson Health System

• University Affiliation: Thomas Jefferson University

• www.jeffersonhospital/com

Marino Center for Integrative Health

• 372 Washington Street

• Wellesley, Massachusetts 02481

• and

• 2500 Massachusetts Avenue

• Cambridge, Massachusetts 02140

• Hospital Affiliation: Newton Wellesley Hospital

• Healthcare Affiliation: Partners Healthcare

• University Affiliation: None

• www.marinocenter.org

University of Maryland Center for Integrative Medicine^*

• 2200 Kernan Drive

• Baltimore, Maryland 21207

• Hospital Affiliation: Kernan Rehabilitation Hospital

• Healthcare System Affiliation: University of Maryland Medical System

• University Affiliation: University of Maryland School of Medicine

• www.compmed.umm.edu

Integrative Medicine Program, Mayo Clinic

• 200 1st Street SW

• Rochester, Minnesota 55905

• Hospital Affiliation: St. Mary’s Hospital

• Healthcare System Affiliation: Mayo Clinic

• University Affiliation: Mayo Medical School

• mayoresearch.mayo.edu/cimp/

Integrative Medicine Center at MD Anderson Cancer Center

• 1515 Holcombe Blvd, Unit 16

• Houston, Texas 77030

• Hospital Affiliation: University of Texas MD Anderson Cancer Center

• Healthcare System Affiliation: None

• University Affiliation: None

• www.mdanderson.org/integrativemed

Northwestern Integrative Medicine

• 150 E. Huron, Suite 1100

• Chicago, Illinois 60611

• Hospital Affiliation: Northwestern Memorial Hospital

• Healthcare System Affiliation: Northwestern Memorial

• University Affiliation: Northwestern Feinberg School of Medicine

• www.nmpg.com/integrative-medicine

The OSU Center for Integrative Medicine

• 2000 Kenny Road

• Columbus, Ohio 43221

• Hospital Affiliation: Ohio State University Hospitals

• Healthcare System Affiliation: Ohio State University Medical Center

• University Affiliation: Ohio State University

• www.medicalcenter.osu.edu/go/integrative

Osher Center for Integrative Medicine^*

• 1545 Divisadero Street, 4th Floor

• San Francisco, California 94115

• Hospital Affiliation: UCSF Medical Center at Mt. Zion

• Healthcare System Affiliation: UCSF Hospitals

• University Affiliation: University of California, San Francisco School of Medicine

• www.osher.ucsf.edu/

Osher Clinical Center

• 850 Boylston Street

• Chestnut Hill, Massachusetts 02467

• Hospital Affiliation: Brigham and Women’s Hospital

• Healthcare System Affiliation: Partners Healthcare

• University Affiliation: Harvard Medical School

• www.brighamandwomens.org/oshercenter

Penny George Institute for Health and Healing^*

• 2833 Chicago Avenue

• Minneapolis, Minnesota 55407

• Hospital Affiliation: Abbott Northwestern Hospital

• Healthcare System Affiliation: Allina Hospitals and Clinics

• University Affiliation: University of Minnesota Medical School

• www.allina.com/ahs/anw.nsf/page/ihh_home

Scripps Center for Integrative Medicine^*

• 10820 North Torrey Pines Road, FC3

• La Jolla, California 92037

• Hospital Affiliation: Scripps Green Hospital

• Healthcare System Affiliation: Scripps Health

• University Affiliation: None

• www.scrippsintegrativemedicine.org

Simms-Mann Health and Wellness Center at Venice Family Clinic^*

• 604 Rose Avenue

• Venice, California 90291

• Hospital Affiliation: UCLA Hospital

• Healthcare System Affiliation: Venice Family Clinic

• University Affiliation: UCLA School of Medicine

• venicefamilyclinic.org/index.php?view=vic_simms_mann&action=index

Center for Integrative Medicine and Wellness at Stamford Hospital

• 32 Strawberry Hill Court, First Floor

• Stamford, Connecticut 06902

• Hospital Affiliation: Stamford Hospital

• Healthcare System Affiliation: Stamford Hospital

• University Affiliation: Columbia University

• www.stamfordhospitalintegrative.com

Stanford Center for Integrative Medicine

• 1101 Welch Road, Suite A6

• Palo Alto, California 94304

• Hospital Affiliation: Stanford Hospital

• Healthcare System Affiliation: Stanford Hospitals & Clinics

• University Affiliation: Stanford University

• www.scim.stanfordhospital.com

Susan Samueli Center of Integrative Medicine

• 1034 Hewitt Hall

• Irvine, California 92697

• Hospital Affiliation: University of California, Irvine Medical Center

• Healthcare System Affiliation: University of California, Irvine

• University Affiliation: University of California, Irvine

• http://www.sscim.uci.edu/

University of Wisconsin Integrative Medicine

• 595 Science Drive

• Madison, Wisconsin 53711

• Hospital Affiliation: University of Wisconsin Hospitals and Clinics

• Healthcare System Affiliation: University of Wisconsin Health

• University Affiliation: University of Wisconsin School of Medicine and Public Health

• www.fammed.wisc.edu/integrative