Face to Face
Lone Ranger
By Carmen Peota
The sole M.D. on the clinical research staff at Northwestern Health Sciences University talks about her role.
In 2006, family physician Kristine Westrom, M.D., M.S., accepted a position in clinical research at Northwestern Health Sciences University in Bloomington and became the first allopathic physician to work full time in the university’s research facility, the Wolfe-Harris Center for Clinical Studies.
Westrom had just completed a fellowship in complementary and alternative medicine (CAM) research while earning a master’s degree in clinical research from the University of Minnesota when she was hired to assist with ongoing investigations into the efficacy of CAM therapies. She is also helping write a new curriculum for first-year chiropractic, massage, and acupuncture and Oriental medicine students that will be team-taught by faculty in those programs starting this month.
Northwestern, which started as a chiropractic college in 1941, has research facilities and an administrative infrastructure that resemble those of any academic medical center. Its Office of Research Administration and Compliance, for example, oversees its institutional review board, data safety and monitoring, and financial conflict of interest functions.
Since establishing the Wolfe-Harris Center in 1991, the university has received more than $10 million in funding for its neck and back research program. Current projects include a $1.2 million Health Resources and Services Administration-funded study to determine the relative efficacy of chiropractic and integrative care in 200 patients with chronic low-back pain. Westrom shared her thoughts about her role in this and other projects and what it’s like to work on a research team with peers who hold degrees in chiropractic and Oriental medicine.
Tell me about the clinical research you are doing.
We are comparing chiropractic care and integrative care for patients with chronic low-back pain in a randomized controlled trial. In this study, patients are randomized to one of two treatment arms: 12 weeks of chiropractic care or 12 weeks of integrative care, which might include allopathic medical care, cognitive behavioral therapy, massage therapy, exercise therapy, chiropractic care, or acupuncture and Oriental medicine. There is evidence that all of these are effective, but there’s no one treatment that works best for every patient. We do outcome measures at three months, and the patient completes self-assessments at six and 12 months.
What do you mean by integrative care?
The care team, which consists of a psychotherapist, acupuncturist, chiropractor, massage therapist, exercise therapist, and myself, reviews the profile of a patient. We consider what the patient has said about their past experience and their beliefs about which therapies will help them the most. We then recommend two or three treatment packages in most cases, each of which consist of one or more modality. Everybody at the table votes on whether they think a package is a valid option, and we reach our decision by consensus. Then, the options are offered to the patients randomized to the integrative care arm, and they choose the package of care they want.
Are patients asking to see you as well?
We had expected that a number of patients would want to see me. But few patients have opted to, perhaps because those who are in this trial want to try CAM therapies. We know it’s a self-selected population. The other thing is that they may have already tried taking physician-recommended medications such as high doses of ibuprofen. I do get involved with patients when they have an acute exacerbation of pain—they lift something at home and have a sudden back spasm. They get a short course of treatment in those cases.
Tell me about the curriculum you’ve been developing.
Northwestern has received an NIH grant to work in conjunction with the Center for Spirituality and Healing at the University of Minnesota to bring evidence-informed practice to the curriculum. In addition to writing the curriculum, I will be part of a team of five who will teach students an approach for sifting through information. We want them to know that there are two big questions to consider as they read the literature in their field: Is it peer-reviewed? And what is the quality of the trial? We’re teaching students to know where to find research about the things they do. And we want our students to know that there are levels of quality in evidence ranging from historical observation to randomized controlled trials and systematic reviews.
What do you mean by evidence-informed practice?
The old term was “evidence-based medicine.” But it has morphed into “evidence-informed practice,” which takes into consideration the research evidence that exists as well as patient preference and clinical experience.
Is the goal at Northwestern to prove that CAM therapies work?
You have to be careful about trying to “prove” things. When scientists are interested in proving something, they introduce bias. Funding agencies are interested in proving things. But scientists have to be very careful that if they’ve set up a trial to see if X works better than Y, they accept the consequences of that outcome.
If you read Cochrane Reviews on all kinds of therapies, they all say, It appears this intervention may work better than that. Every one of them ends by saying more research needs to be done. Government funding seems to be moving toward practice-based outcomes. They want to see what works best in the real world versus biologically plausible explanations.
Is the evidence showing that CAM therapies are safe?
Yes, it is. However, I would never say that CAM therapies are completely safe—there’s always a downside. But you have to understand that tens of thousands of patients are harmed by allopathic methods. I think the allopathic community is a little blind to the negative aspects of their own care. Of course, there can be harm with anything. But I have to say that overall acupuncture, massage, and chiropractic are extremely safe.
How did you get interested in CAM?
I went to the University of Minnesota Medical School and did a family practice residency through the university. So I really had traditional training. But if you’re a family doctor, you have people coming to you who are trying things you don’t know much about. If you’re open-minded and pragmatic, and most doctors are, you ask your patients to tell you about it. You know there are things outside of your healing background that might be working for your patients. I was very aware that patients sought healing outside of my care. Sometimes they got better. That made me wonder what else is out there besides what I know.
Do you think physicians are becoming more receptive to CAM?
There’s more of an acknowledgment that no one field has the answers. I have yet to see many allopaths working closely with CAM providers. There is some movement within inpatient settings, but if there is extensive integration, I don’t know about it. And although I know some allopathic providers might get trained in Reiki or acupuncture, for example, most allopaths don’t have the time or interest to learn a whole other system.
What’s happening is that they’re becoming open to referring back and forth or at least knowing more about the modalities so that they’re comfortable with their patients seeing outside care providers.
Certainly, medical students are getting much more exposure to CAM in their training. First-year medical classes tour Northwestern. That’s so different from when I was in medical school. Horizons are opening up. If you’re interested, you can see what else there is.
Are CAM providers open to allopathic medicine?
I do think it goes both ways. My being hired at this institution is a sign of movement on the CAM side. This institution went to bat and took a chance and wanted to hire me. They found out that I could fit in.
Do you ever find yourself defending allopathic medicine?
Rarely. But when I get a chance, I do it vocally. For instance, I strongly believe in the benefit of childhood immunizations. I want to be a proponent in the CAM community for why immunizations are so beneficial. If we’re looking at the evidence base, I can flip open a chart from the turn of the century and say, look how many children died of pertussis then, and look at how many die now. I don’t want to imply my institution opposes immunizations because it does not, but there is a strong anti-immunization undercurrent in the CAM world.
Do you feel comfortable in this institution?
I just love my job. I walk a tightrope between worlds. It keeps my brain nimble. MM
Carmen Peota is managing editor of Minnesota Medicine.