The beginning of the RAND project proposal captures dimensions of an awful tend: “The future of research in the Complementary and Integrative Health (CIH) institutions is in jeopardy. A number of CIH colleges and universities are losing their research departments due to lack of consistent funding and the understandable inability to subsidize them with tuition costs. The CIH Colleges are in danger of becoming technical teaching institutions and not institutions of learning. Those teaching the students will not be scholars and researchers who are producing new knowledge for their profession. NIH offers several training grants for researchers and these have been very effective in training CIH practitioners to be researchers. Unfortunately, these CIH practitioners generally leave their institutions for research training and degrees, and without robust research centers at the CIH institutions, they are rarely able to go back.” In December 2019, RAND received a $1-million gift to kick-start a strategy – led by Patricia Herman, ND, PhD and Ian Coulter, PhD – to overcome these structural flaws. Here is a look at the project.
The Need for a Creative Solution
The plight is real. After the excitement of over $60-million of research investment (slide 22) between 1999 and 2010 from the NIH National Center for Complementary and Integrative Health in the schools educating chiropractors, naturopathic doctors and acupuncturists, direct grants – never more that 5% of NCCIH budget – fell slowly and then precipitously. Ironically, this pattern of divestiture in the on-boarding of these institutions into the evidence-finding milieu happened after the 2011 NCCIH Strategic Plan declared that “CAM practitioners are the key holders of knowledge related to the potential application of CAM interventions and disciplines.”
The NIH strategy turned away from the schools, and in fact from the licensed CIH professions. Instead, the strategy featured giving top clinician-researchers in these fields the opportunity to work in conventional academic research institutions. The result has been a classic brain drain. Many of the best have been skimmed off. The institutions, losing their indirect costs, have less reason to put their own skin in the game to avert the downward spiral. That NCCIH simultaneously turned its focus away from the CIH fields they are charged to research in the first directive in the Congressional mandate also hurt. As valuable as the mindfulness, yoga and tai chi research has been, it’s been at the expense of further exploring the value of the integration of licensed chiropractors, naturopathic doctors, acupuncturists and massage therapists – in the words of the mandate – “with the practice of conventional medicine as a complement to such medicine and into health care delivery systems in the United States.”
The wreckage has quietly accumulated. Among the colleges and universities with significant downturns in research investment and activity are many that were guiding lights for research: Northwestern Health Sciences University (former leaders now at University of Minnesota), Bastyr University (research center a shadow of its former status), University of Western States (key rainmaker retired), and the National University of Health Sciences (challenges in grant-getting). Even Palmer College, which has accounted for perhaps 35%-40% of all grant funds to colleges educating doctoral level clinicians in natural health – chiropractic, naturopathic medicine, acupuncture and Oriental medicine (DAOM) – may presently be less secure. It’s powerful past director now has a research professorship at Duke University Medical School. Other than Palmer, only National University of Natural Medicine has recently been a recipient of a major NIH grant. (See An Examination of Research Action at 7 Multidisciplinary Universities of Integrative Health.)
A solution? The Rand Center for Collaborative CIH Research
Herman and Coulter are an intriguing team for this project. Each has a high level of discipline-specific and general integrative health research credibility. Coulter served as president of Canadian Memorial Chiropractic College before research work with the Samueli Institute and as the RAND/Samueli Chair for Integrative Medicine at RAND. Herman completed her naturopathic medical degree from Bastyr and then translated a prior career as an energy economist and a doctoral degree in behavioral health science research into becoming the leading North American cost-effectiveness researcher in the integrative space.
Each carries a belief that there is value that can come of CIH clinicians working among themselves, formulating and asking their own questions, testing their own hypotheses – while in dialogue with their conventionally based colleagues but housed separately. Whatever benefits a chiropractor or naturopathic doctor might receive inside a academic medicine research juggernaut – and there are many – rich, day-to-day, collegial exploration inside CIH culture is presently at risk. More important in the long run than the opportunity to the practitioner, the knowledge, resources and culture of research at are stripped, in this model, from the CIH institutions. The potential to grow such a culture in other colleges in these fields becomes nearly impossible. The loss goes beyond the institutions themselves. What would become of these “key holders of knowledge” as the integration dialogue expands – especially as the nation awakens to the potentially transformative value of these professionals as providers of non-pharmacologic approaches amidst the nation’s crisis in management of patients with chronic pain (a.k.a. the “opioid crisis”) ?
Coulter and Herman have each had long association with RAND. Recognizing what they believed were structural problems, the two began to wonder whether RAND, a nonprofit where “the mission is to help policymakers make decisions that are based on the best available information” might be an intriguing convener and partner. RAND is known for high-quality research and analysis, a practical real world focus, and a history of multiple collaborations. It also offers a substantial research infrastructure. Herman and Coulter began to explore the idea of a collaborative model where the RAND might be a shared platform through which the professions could continue to have agency while not having to shoulder full responsibility for creating an entire infrastructure on their own. The RAND name could potentially be useful in grant getting, as well.
The first step was a convening, funded through the RAND/Samueli Chair for Integrative Medicine, of presidents of some of the main chiropractic and naturopathic colleges and universities to explore the idea. A draft of a report from the September 2019 meeting, shared for this article, ticked off the key goals for such a RAND Center for Collaborative Research in CIH:
- Provide a platform for collaboration
- Provide a mechanism by which CIH researchers can stay at CIH institutions
- Provide guidance and support to improve the quality of CIH research
- Train CIH researchers
- Improve funding competitiveness through increased scale and lowered transaction costs of research
Four components were identified to bring these goals to fruition. The centerpiece would be development of a CIH Research Network. Supporting that would be a CIH Research Advisory Board and, from inside RAND, a CIH Interest Group to support the Center’s development and growth and assist grant-seekers from the Center’s members. A research training function would be included. The representatives of the institutions who convened quickly identified a substantial list of research projects the Center might support.
NBCE $1-million grant supports infrastructure creation
What was needed was cash to fuel the Center’s development and draw the collaborating members. Such funds arrived in December 2019 in the form of a $1-million gift from the National Board of Chiropractic Examiners. In an interview, Herman clarified that these funds are not meant to carry out research projects but to create and stabilize the entity and buy time to develop and advance priority research proposals.
Membership in the emerging RAND Center, says Herman, will be open to all chiropractic, naturopathic, acupuncture and Oriental medicine and massage schools. She clarified that “this is to support the CAM institutions so that they can get into the game.” It’s an empowerment strategy. Herman anticipates that one outcome will be the enhancement of partnerships between the Center and their conventional academic colleagues on various individual projects. Herman is personally excited with the potential of this collaborative for guideline development: “Can you imagine the power of clinical practice guidelines jointly created across these schools and professions?”
Asked about any examples of successful similar models, Herman notes that Coulter points to Minority Research Centers funded by the NIH linked Centers of Excellence with Minority Institutions to give infrastructure to less advantaged institutions and professionals. In prior professional work, life, Coulter directed one of the minority centers and had an NIH R01 research project in a second. Interesting: a reasonable case can be made that the scarring from years of polarizing prejudice from mainstream institutions against these fields held them down. Might this cultural and institutional prejudice have diminished their value enough to warrant similar affirmative action to get these institutions up to speed, and into the game so that their contributions might be maximized? Thus far, this has not been in the NIH NCCIH mission for the licensed complementary medicine professions and their institutions.
Barring that – especially in this era that is finally elevating the role of non-pharmacologic approaches and that is questioning the first line use of powerful pharma agents in treating people in pain – creative collaborations such as the RAND Collaborative Center for Research in CIH may be not just the best, but the only way for integrative research to guarantee that maximum value is illuminated from these “key holders of knowledge related to the potential application of CAM interventions and disciplines.” The RAND Center could prove to be an efficient vehicle for the NCCIH and other public and private granting agencies to influence the research culture and evidence-informed practice of professions that reflect some 350,000 licensed practitioners. First up: the CIH institutions must choose to become members.