Monday, July 21, 2014

The Value of Integrative Medicine in Primary Care

Beginning with a deep understanding of medical science and years of training and experience, the primary care physician (PCP) needs to delve deeply into the patient’s personal, family and social setting in order to fully understand the context and causes of the patient’s illness. The PCP also needs to know when it is important or even critical to call upon others with specific knowledge, techniques or approaches that might be best suited for a particular patient. Sometimes this means calling in the cardiologist, the surgeon, the gastroenterologist or the psychiatrist. But it may also mean making good use of other modalities and practitioners such as chiropractic, social work, acupuncture, psychology, massage, nutritional therapy and exercise physiology.
Integrative medicine means, at least, a healing environment, a passion for prevention and wellness and not just diagnosis and treatment; working with the patient and the patient’s family as partners; understanding the deeper causes of illness and symptoms; providing approaches for self-care and taking enough time to address all of the patent’s concerns. For some integrative medicine physicians it also means being intimately familiar with proven complementary practices such as acupuncture, yoga, massage, nutrition and health coaching and personal fitness training. Some PCPs have learned techniques such as acupuncture, meditation or the Benson relaxation response and can use or teach their patients directly. The Duke Integrative Center defines integrative medicine as an “approach to medical care that brings you and your provider together in a dynamic partnership dedicated to optimizing your health and healing. Our approach focuses on all of who you are, recognizing that the subtle interactions of mind, body, spirit and community have a direct impact on your vitality and well-being.”
I heard this patient story of an integrated approach to a medical dilemma from Delia Chiaramonte, MD, director of education at the University of Maryland Center forIntegrative Medicine. A medical student had suffered from severe headaches for many years that were limiting his quality of life and his effectiveness as a student. His personal physician had identified them as cluster headaches a few years before and had tried standard medications without much success. Dr. Chiaramonte evaluated him differently - using an integrative approach. She did intensive probing and listening about not just his headaches but also his lifestyle including diet and activity, his stresses and his school work. Like almost all medical students, he studied hard. He said he stayed up until about 3:00am studying, but in part this was because he couldn’t fall asleep any earlier. His diet included a lot of doughnuts and other high carbohydrate and processed foods plus about 12 cups of caffeinated coffee each day, sometimes interspersed with colas. He had no time for exercise. He sat - hunched over - in front of his computer for many hours each day, and his posture showed it.
Instead of recommending other diagnostic procedures or new medications, his integrative medicine “prescription” included the following: He needed to start on a better diet that included protein at breakfast, healthy snacks during the day and he was to establish a set time for exercise. He was to get away from the computer for ten minutes every hour and walk around and stretch. He was also to get eight hours of sleep each night. To assist him, he was to see a nutritionist to devise a more healthy diet. He was to work with a personal trainer to establish the exercise program - one that could be done anywhere without impacting on his studies. He was to visit a chiropractor to release his sternocleidomastoid muscles and other neck muscles back to their normal length. Since caffeine, of which he was getting a dose multiple times throughout the day, has a long half-life in the body, he was to have no caffeine after noon time. The combination of a better diet, exercise, less total caffeine and none after noon meant he should be able to study more effectively and to sleep better; he was instructed to get to bed by 11:00pm each night.  

Given the pain and debility of his headaches, he was more than willing to give this prescription a try although he was somewhat skeptical since it included no medications. It worked. The headaches disappeared, he felt generally better, he was no longer drowsy in class and he began to truly enjoy medical school.  And he was off all medications.

This is the power of integrative medicine. It used a holistic approach that began with careful listening and then brought to bear many different disciplines including the best of western scientific medicine plus nutritional medicine, exercise physiology, stress management and chiropractic. Together and coordinated by one PCP, the combined approach had a dramatic effect.
Today most medical schools are teaching about the proven complementary modalities and some PCPs are learning not only when to refer but how to personally use some of these approaches.
In interviews of over 20 primary care physicians, most were unsure of what the term integrative medicine meant. However, they would respond in other questions that they frequently referred to nutrition, health and fitness coaches. Some but certainly not all, were very positive about complementary medicine. They felt it had real value, noted that most patients sought out complementary practitioners anyway, and that there was increasing evidence-based data on the value of some techniques and practices. One PCP had taken a course in acupuncture for physicians and used it frequently. Another said “I am very respectful of complementary medicine. I refer to chiropractic and many other complementary practitioners just as I refer to behavioral health or surgery. I am learning every day. Patients are thirsty for complementary medicine. Traditional medical docs who are not on board are just behind the times.” Another said “Integrative medicine is not a catch all for complementary medicine, it is just good primary care. I think of it as connoting the medical home concept.”  “It is part and parcel of my practice.”
But always the PCPs interviewed stated that the key attribute of the superb PCP (or any physician for that matter) is to listen – to listen deeply and without interruption as the patient explains the narrative of their situation. Such was the case with the medical student evaluation described above. It was not just about the nature of the headaches but just as much if not more about the totality of his life and how the headaches fit into that life story. Armed with that knowledge, his integrative medicine physician was able to offer not a symptom abating drug but a means to deal with the headaches through the root causes - an unhealthy life style that was dramatically affecting his entire life and his ability to be an effective medical student.
Next time - Reframing the Question of Doctor Frustration

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