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

Further Disruptive Changes in Health Care Delivery

Technology to lower costs rather than accelerate them. Smart phones to increase physician and other providers’ productivity. Fewer primary care physicians but more involvement by nurse practioneers and others. And increasing appreciation of the value of integrative medicine. These are but a few of the disruptive changes in care delivery that are coming. 

In my last post I observed that  the health care delivery system will change in coming years – quite unrelated to reform – and gave the most important drivers of change and how these changes will often be disruptive, transformative or both. Here are a few more. 

We think of new technologies as exacerbating health care costs. But it is also quite correct to look to technology to reduce costs or at least slow the growth of expenditures. There will become a new value proposition for technology. Today and tomorrow technology wil be accepted if it to helps health care professionals to 1) compensate for shortages, 2) enhance their responsiveness to patients 3) control costs and 4) improve quality and safety. 

Smart phones with wireless connectivity and multiple apps are a good example of technology to assist, compensate, enhance responsiveness and improve quality. Increasingly, physicians are becoming very reliant on their phones as a shortcut to knowledge, to stay well informed, to argue and debate among themselves and perform many other functions. 

Robotics can likewise benefit all four parameters. A good example is how robots have made the hospital pharmacy more efficient while substantially safer. One robot selects pills via bar code; another prepares intravenous medications and solutions more accurately then a technician and a third transports medications to the nursing unit using wireless technology – sort of like R2D2. This frees up the pharmacist to do what he or she does best such as watching for drug-drug interactions, proper dosing, and critical higher order functions.  

But the coming changes are not just in technology but in the distribution and work of providers. With shortages of physicians, especially primary care physicians, appropriate integration of nurse practioneers and physician assistants can not only partially compensate but provide quality interaction with patients, augment preventive programs and enhance care coordination for those with chronic illnesses. And although there is considerable controversy as to appropriate scope of practice, it is certainly clear that the interaction of PCPs with NPs and PAs can enhance the totality of patient care.  Similarly, expect to see more mental health delivered by psychologists and social workers; visual care by optometrists; and hearing care by audiologists. 

Consumers (patients) will press for and expect a more integrative approach from their PCP and other providers. Patients today increasingly search out and use practioneers of acupuncture, massage, chiropractic, yoga, mind body techniques, energy channeling (Healing Touch, Therapeutic Touch, and Reiki) and other complementary medical modalities. More and more medical students are graduating with at least some understanding and training in the use of these approaches. And the acceptance by already practicing physicians is growing, albeit slowly in many cases.  

Integrative medicine means more attention to the whole person – family history, social situation, work environment, and how all of these plus stress, eating, smoking and drug preferences interact with the patient’s illnesses. A “prescription” for high cholesterol may still include a statin but it might well also include a trip to a nutritionist, a personal trainer, a program for stress reduction, etc. The end result is better medicine yet completely coordinated by the primary care physician.  

Health care delivery is transforming. It will come in fits and starts but it is and will continue to change. Hopefully most of the changes will be for the betterment of patients and providers alike.

 

 

Integrative Medicine Part V - Busting Stress

Stress is with us all the time. Issues at work or at home, getting a traffic ticket, the grocery store out of your favorite yogurt. Life has stresses. We can go to the doctor and ask for a pill or we can learn to deal with our stresses effectively without much medication. 

Acute stress is normal and can even be lifesaving – seeing a truck barreling down the road at us. But when stress is chronic it becomes a major cause of ill health.  

Chronic stress builds up when the demands upon us become greater than our resources to respond in an effective manner. Stress tends to become cumulative. You can handle the first stressor and even the second, but when the third one occurs, even if it was rather minor, it tips over your balance point. Since we cannot completely escape stress, our agenda must be to boost our resources – to “fill up our cup” as Delia Chiaramonte, MD of the University of Maryland Center for Integrative Medicine liked to term it during her “Busting Stress” workshop at the Center’s recent Health and Wellness Conference held in Baltimore, MD.  

Integrative medicine does not avoid traditional “western” medical approaches such as medications. But it does look at the whole person to determine if there are other parts to the “prescription” that might be equally or even more valuable. The agenda is to maintain health and further develop wellness.

There are external and internal sources of stress. Our boss ignored our hard work or disparaged our report – these are obvious external stresses. If they become too much it may be best to just look elsewhere for a new job and escape the situation.  

But other stresses are internally mediated. We might convert an event into a thought that in turn leads to a negative feeling that in turn causes stress. Imagine that a loved one is late to get home and has not called. That is the event. The thoughts can be quite different. One thought might be that he was in an accident resulting in a stressful feeling of anxiety. Or perhaps this event leads to the thought that he is having an affair – leading to a feeling of hurt. Or perhaps the thought is that he just didn’t care that he was late and didn’t bother to call – leading to a feeling of anger. Perhaps more likely he is just stuck in bad traffic and doesn’t have his cell phone with him – in that case you might have a feeling compassion. The three stressful feelings came from your thought interpretation of the event. The question you need to ask yourself is what is the likelihood of any of these thoughts being correct?  

You need to restore rationale thinking. Do this by labeling the irrational thought and then refute it with a new thought like “I have no evidence of an accident; he is probably just stuck in traffic.” Then detach yourself from the thought with the recognition that “this is an anxious thought, not a rational thought.” Finally, do something to distract yourself like playing with the kids.

To “fill up your cup” Dr Chiaramonte suggests considering these approaches. Begin a “gratitude ritual.” This means to take a time each day for gratitude perhaps while falling asleep or perhaps at dinner time. Think about what is good in life – today – maybe a spring flower, a smile from your loved one, the bright eyes of your child. It can’t be a rote thought however. Make it different every day. Amazingly enough, it works. It will increase your happiness and correlates well with general health and well being. 

Here is a line from the song “Counting My Blessings” sung by Bing Crosby and Rosemary Clooney in the movie “White Christmas.” "When my bank roll is gettin' small, I think of when I had none at all, and I fall asleep counting my blessings..." This is the concept of gratitude. 

A second approach is to aggressively try to be a “benefit finder” rather than a “fault finder.” It’s an approach in which you rethink and with doing so decrease your emotional reactions. Instead of the thought, “I have a vision problem that limits me” you might instead think of, “I still have one good eye and the world looks good to me.” 

Sleep is important. You feel more stressed if you are sleep deprived. Most of us get too little sleep. Fill your resource cup with added sleep. And the gratitude ritual at bed time will help you sleep more soundly.  

Food is equally as important. Things to avoid are processed foods with high levels of carbohydrates and fats (of course, these are the ones that taste so good to us!) like doughnuts, macaroni and cheese or pizza. Instead get more high quality proteins and skip the refined sugars as in sodas.  

And add in some exercise. Just moderately paced walking each day will not only decrease your stress but will improve your cardiovascular health, bone health and overall add to your sense of wellness.  

This may sound like a lot of effort. Actually it’s really not. It doesn’t take much time; it improves your physical health; and it will allow you to cope much better with stress. Better to “fill your cup” than rely on an anti-anxiety medication. 

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp . And you can learn more about improving your health while reducing your costs in my book The Future of Health Care Delivery- Why It Must Change and How It Will Affect You

Integrative Medicine Part IV - Preventive Aging

Does old age necessarily mean declining health and cognition or can one age gracefully with a high quality of life?  

This was another topic discussed at the recent Health and Wellness conference organized by the University of Maryland Center for Integrative Medicine.  Steven Gambert, MD, Professor of Medicine and Surgery and Director of Geriatric Medicine at the University of Maryland Medical Center described preventive aging. Here are my notes from his talk with some personal observations added in. 

America has a rapidly aging population. In 1900 only 4% were over age 65 and 1% over 75 years. By 1950, it was 8% and 2.6% respectively and by 2000 it was 13% and 5% with these expected to grow to 21% and 8% by 2030. In absolute numbers, there are now about 12 million over the age of 80; a doubling since 1957. Older people run the full gamut from the very healthy, to those with a few health issues, to those with multiple problems to the very frail. Frail individuals (see my earlier post of frailty) have a high risk for poor outcomes of any illness, slower recovery and heightened mortality. So the agenda, of course, is to stay as healthy as possible throughout your later years.

Can you do anything to prevent illness? Can you embark on a “preventive aging program?” The answer is definitively “yes” and it is never too late to get started. But just like saving up for retirement, it’s best to begin at an early age so that the value can compound through the years.  

The first major element of the preventive aging program is to prevent an acceleration of the normal aging process. Most physiologic functions begin a slow but steady decline beginning at about age 30 to 35. This includes our bone density, kidney and lung function and cognitive skills. Some decline is inevitable but the process can be slowed. There are four basic steps.  

In no particular order the first step is to avoid environmental risk. It is never too late to stop smoking and so reduce the risk of lung cancer and other cancers but also to slow the decline of general lung function. Noise is an environmental hazard. Hearing declines with age and noise rapidly accelerates that decline. Loud music and loud restaurants are best avoided despite our current cultural attractions to both.  

The second step is proper nutrition. Eating foods with a wide mix of vitamins and minerals, high quality protein in sufficient quantity, good oils and fats and lots of fiber is of critical importance. Vitamin and mineral supplements are still valuable but they should be just that – supplements – not the prime source.  

The third step is exercise. Our muscles were meant to be used and we need to do just that. A regular regimen of moderate aerobic exercise such as walking for 30 minutes each day can’t be beat. Add to that some weight bearing exercise (probably at a gym or similar facility) three times each week to maintain and build strength. And remember to do both range of motion such as simple stretching or adding in yoga and balance exercises regularly.  

The fourth and very critical step to prevent acceleration of normal aging is to exercise your brain. Do some activities that challenge your mind – Sudoku or chess does that; watching TV definitely does not!  

Following these four steps can dramatically slow the aging process but you next need to prevent age prevalent diseases. Here again the best time to do this begins when you are young. The leading causes of death in the elderly are heart disease, cancer and stroke – no surprise here. Each of these are largely but not entirely preventable by attending to our lifestyles. Unfortunately most Americans eat a non-nutritious diet and too much of it, don’t get enough exercise, are chronically stressed and 20% smoke. The result is a population which is obese, with high blood pressure, an actual developing epidemic of diabetes and over time a high incidence of heart disease, cancer and stroke. So it behooves us to address our lifestyles beginning at whatever age we may be today and following though over the years.  

In addition older people should be sure that their immunizations are up-to-date such as annual influenza in addition to the pneumonia vaccine and shingles vaccine but also the less commonly paid attention ones such as tetanus and diphtheria. And as already suggested, avoid high noise environments, eat a good diet, get regular exercise and use your brain regularly.  

Part of healthy living includes adequate sleep. It’s simply not true that older people need less sleep. It is true that older people don’t sleep as well or as soundly and may need naps.  

Stress reduction (see a later post in this series for more information) in this hectic world is equally important. Seek ways to reduce this burden with tools such as meditation, mindfulness training, yoga, etc. Exercise can in itself be a great way to reduce stress and may have an impact on our own endogenous neurotransmitters to alleviate stress. 

Finally healthy aging also requires social contact. A good social life is actually critical to healthy aging. It will “add life to your years.”  

Aging gracefully is discussed in more detail in the last chapter of my book The Future of Health Care Delivery – Why It Must Change and How It Will Affect You. 

So it is possible to age gracefully with good health. Starting the process when you’re young makes it all that much more effective. But it is never too late to get started. It’s possible to just die of “old age” rather than one of the common chronic illnesses that are today’s plagues.  

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp

Integrative Medicine - Part I

Can integrative medicine add value to standard western practices? Some would say absolutely not; others point to new scientific evidence that demonstrates the value of specific modalities in specific situations.  

Health care is complex, expensive and often depersonalizing. It shouldn’t be. At the University of Maryland Center for Integrative Medicine, the staff focuses on evaluating and involving complementary medicine into traditional western or “scientific” medicine. Founded in 1991 by Brian Berman, M.D., a family medicine trained physician, he had learned the certain alternative approaches could complement the usual diagnostic and therapeutic methods that he had been taught in his medical school education and training. He found that his patients’ experiences were enriched by treating the whole person rather than depending on a technology-focused practice. A grateful and forward looking patient offered him a grant to begin the Center with the proviso that it embrace and study evidence-based science along with education and collaborative patient care to create a comprehensive humanistic approach to patient care.  

Since its founding 20 years ago the Center has been awarded over $30 million in NIH grants and has been named as a center of excellence for research. From this work have come over 340 high quality peer-reviewed scientific articles published in the best medical journals. These have been in areas such as acupuncture, herbal remedies and mind-body therapies focusing on arthritis, pain depression, cancer, trauma and inflammation. The center employs a staff for clinical care that includes family medicine and other physician specialists along with licensed acupuncturists, massage therapists, nutritionists and many other disciplines. 

As just one research example, acupuncture was studied in a double blind fashion to determine if the addition of acupuncture to best standard treatment improved the lot of those with knee osteoarthritis. Those who got acupuncture, when compared to those that got sham acupuncture, has less pain, used fewer pain medications and had greater range of motion. 

At the “Health and Wellness Conference” a few weeks ago to celebrate the 20^th anniversary of the founding of Center, Delia Chiaramonte, MD described what an integrative approach to a medical dilemma might look like. She described a medical student who had suffered from severe headaches for many years that were limiting his quality of life and his effectiveness as a student. His physician had identified them as cluster headaches and had tried various standard medications without success. A frustrating situation. 

He was then evaluated differently using an integrative approach. It involved a lot of probing about his headaches, 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, but in part this was because he couldn’t fall asleep any earlier. His diet included a lot of doughnuts and a lot of other high carbohydrate items plus about 12 cups of caffeinated coffee each day. 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.

 
His headaches fit the description of “cluster” headaches, often with a sense of an ice pick sticking into his right eye - near unbearable pain. The standard medical texts suggest use of ergotamine tartrate for cluster headaches and also note its potential side effects. There is no mention of other modalities or adjustments to lifestyle issues. But cluster headaches can be amplified by stress, worsened by sleep deprivation and the stabbing could well have been posture related. 

So instead of recommending medications, his integrative medicine “prescription” included the following: he was to see a nutritionist to devise a more healthy diet. He was to work with a personal trainer to establish an 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. In addition he was to have no caffeine after noon and he was 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. 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 and brought to bear many different disciplines including nutritional medicine, exercise physiology, stress management, chiropractic and family medicine. I wrote about this extensively in The Future of Medicine – Megatrends in Healthcare . 

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp