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The-Promise-of-Integrated-Medicine

Barbara Wick always had a gut feeling she’d get cancer – and when her younger sister died of breast cancer in 1996, Wick’s concerns became even more concrete. So when she began feeling bloated and experiencing abdominal discomfort a couple of summers ago, she felt certain she knew the diagnosis. When she went to the doctor, her internist told her the symptoms were probably nothing. Wick, 63, insisted on more testing.

Her gynecologist found ovarian cancer. “He told me it didn’t look very good,” says the Chicago-area resident. “I underwent a full hysterectomy and debulking (the removal of as much cancerous tissue as possible), and they removed cancer cells from my abdomen, too.”

After the surgery, Wick’s oncologist started her on the typical routine of chemotherapy. And then he did something that is a relatively new development in conventional medicine: He referred her to an integrative medicine (IM) program. Under the care of Karen Koffler, MD, director of the IM program at Evanston Northwestern Healthcare (ENH) in Glenview, Ill., Wick began to meditate and practice yoga. On Koffler’s advice she made major changes to her diet, cutting sugar because it exacerbates inflammation, and increasing cruciferous vegetables known to help fight cancer. She also sought massage therapy, which decreases stress and eases pain.

Nearly three years later, and 10 months after chemotherapy, Wick believes this integrative approach – blending conventional medical treatments with unconventional therapies – has been essential to her healing.

Wick isn’t alone: Thirty-six percent of Americans used some form of complementary and alternative therapies in 2002, according to a nationwide government survey. Rising healthcare costs – combined with frustration and disappointment about the limitations of conventional medicine – are driving many to explore complementary, alternative and integrative solutions they might have previously overlooked.

What Is Integrative Medicine?

Complementary? Alternative? It’s tempting to lump everything outside of mainstream medical care into one big heap, but the terms describing these new options for healthcare aren’t interchangeable. The National Center for Complementary and Alternative Medicine (NCCAM), a division of the National Institutes of Health, provides these definitions:

Complementary and Alternative Medicine (CAM) is a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine. Therapies encompassed by CAM include things like acupuncture, nutrition, chiropractic, herbs, bodywork, yoga, qigong and aromatherapy.

Complementary Medicine is used together with conventional medicine. An example of a complementary therapy is using aromatherapy to help lessen a patient’s discomfort following surgery.

Alternative Medicine is used in place of conventional medicine. An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation or chemotherapy that has been recommended by a conventional doctor.

Integrative Medicine may incorporate any of these therapies, which are finding their way into the conventional medical world. NCCAM defines integrative medicine as the combination of “mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.” The U.S. government estimates that CAM is currently a $27 billion industry, according to The New York Times.

The Benefits of Integration

Integrative approaches offer broad appeal in part because they address patient concerns at so many levels. “Some patients seek integrative medicine therapies because their symptoms are not responding to conventional treatment,” explains Gary Deng, MD, a senior physician with Memorial Sloan-Kettering’s Bendheim Integrative Medicine Center in New York City. Other patients, he notes, simply “want to take a holistic approach to their body, mind and spirit to improve health and wellness.”

Complementary and alternative therapies are rooted in this comprehensive approach to wellness, aiming to help the body recover from illness, but also to prevent disease and imbalance from occurring in the first place.

Wick, who still practices the healthy eating habits she learned at the ENH Integrative Medicine Clinic and continues to see Koffler several times a year, believes part of the power of her treatment plan was the time doctors took to get to know her as a whole person. “They looked at every part of my life: health, exercise, cholesterol, family history, and my emotional and psychological needs and concerns – and they listened to what I thought I should do,” she says. “Only then did they give me their advice. I really felt comfortable and cared for.”

She also appreciated that the IM practitioners let her chart her own course for healing. “I revised my whole diet, but I didn’t go whole hog for the macrobiotic diet they suggested. I practiced yoga, but I chose not to do acupuncture or Chinese medicine.” Since beginning the therapies in response to her cancer diagnosis, she’s felt a significant increase in her energy. She credits the IM therapies she practiced for giving her a greater overall sense of health and well-being.

Andrew Weil, MD, widely considered to be the founding father of integrative medicine in the United States, describes this combined approach as an effort to restore “the focus of medicine on health and healing.”

“In addition to providing the best conventional care,” he notes, “integrative medicine focuses on preventive maintenance of health by paying attention to all relative components of lifestyle, including diet, exercise, stress management and emotional well-being. It insists on patients being active participants in their healthcare as well as on physicians viewing patients as whole persons – minds, community members and spiritual beings, as well as physical bodies.”

Proactive Approach

While working the night shift as an intensive-care-unit physician in 1996, Koffler recognized a patient who had been admitted several times before. Looking around the intensive-care unit at 2 a.m., she realized that her department had become a revolving door. “We patched people up, sent them home, and they often came back again with the same problem,” Koffler recalls. Her epiphany? Physicians are trained to deal with sick people – not to keep people healthy or to prevent them from getting sick in the first place.

Not long after this “aha” moment, Koffler attended a conference where she heard Weil talk about the shortfalls of the conventional medical system – and she promptly enrolled in his IM fellowship program at the University of Arizona, the first of its kind in the United States. That was in 1996.

Around that same time, administrators at ENH in Illinois recognized the growing demand for alternative medicine, and they began to incorporate Weil’s teachings at its clinic. In 1998, the same year that NCCAM was established, just 6 percent of hospitals indicated that CAM services were available to patients, according to the American Hospital Association (AHA). But CAM was catching on, and from 2000 to 2001, the AHA found that 23 percent of the hospitals that responded to the survey offered CAM services.

In the midst of that growth, ENH hired Koffler to lead its IM program in 2001. Meanwhile, numerous healthcare institutions – including Memorial Sloan-Kettering and Duke University – were busily expanding their own IM offerings (see “Profiles in Integration“).

Researching Remedies

Despite the significant number of Americans who are embracing (or at least dabbling in) integrative medicine – and the dollars being dedicated to such programs by leading health institutions – some questions about complementary medicine remain unanswered. Critics of IM argue that alternative therapies haven’t been adequately studied.

“Integrative medicine lacks scientific basis,” says Jerome Kassirer, MD, former editor of the New England Journal of Medicine and author of On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Health (Oxford University Press, 2005). He asserts that very few studies on alternative medicine test for effectiveness or toxicity. And Congress has never mandated testing of herbal medicines, which the U.S. Food and Drug Administration requires of other drugs.

Advocates of CAM therapies respond that many of these treatments have stood the test of time and have been demonstrated to present far fewer risks and side effects than many conventional treatments and prescription drugs currently approved by the FDA.

Chinese medicine, for example, has been around for 4,000 years. The largely noninvasive system promotes healing by balancing the body’s energy, called Qi (pronounced chee), with acupuncture, herbs, nutrition therapy, bodywork and qigong. It is the third-most sought-after medical treatment in the world.

Advocates also point to research that shows that bodywork, such as massage, can enhance circulation and combat stress, and that psychotherapy can help address emotional issues that underlie physical pain.

Critics like Kassirer remain unimpressed. “In the past three to four years there’s been an attempt to establish such a scientific basis,” he acknowledges, “but often, remedies that are recommended are found to be minimally effective.”

Still, both consumer and scientific interest in IM is growing. And there’s an increasing willingness in both the private and public health sectors to fund more research. NCCAM, for example, designated $123.1 million to fund research in 2005, an increase of $5.4 million from 2004. Doctors such as Memorial Sloan-Kettering’s Deng – an internal medicine physician by training, with a PhD in microbiology and immunology – know that such research is crucial for the advancement of integrative medicine.

The Memorial Sloan-Kettering Bendheim Integrative Medicine Center has 10 ongoing research projects to study the effects of CAM therapies. Their cancer research focuses on controlling symptoms with complementary therapies and using botanical agents (natural remedies) for prevention and treatment. “We are using herbal extracts to target cancer cells directly and looking at the effect on the immune system,” explains Deng. His group is also evaluating whether the use of acupuncture reduces hot flashes, dry mouth, pain and fatigue. “Sometimes we see dramatic results when we use complementary therapies with our patients,” he says.

At the Duke Center for Integrative Medicine at Duke University, director Tracy Gaudet and her team are working with obstetric patients to evaluate how mind-body techniques affect stress and its impact on the onset of labor. They are also studying how mindfulness and meditation help individuals with binge eating disorders regulate their eating patterns and improve their glucose metabolism. Koffler’s team has a grant, in conjunction with the University of Maryland, that’s designed to evaluate the clinical outcomes experienced by patients using an integrative approach.

Studies like these will help determine which CAM therapies are effective treatments for health problems such as cancer, asthma, cardiovascular disease, headaches and hormonal issues. And the IM physicians leading these studies hope that as more sound research is completed, integrative medicine will get more of the respect it has long deserved.

As patients begin demanding integrative care, and as doctors take note of successful patient outcomes, it’s likely that training in (or at least awareness of) integrative methods will find a place in standard medical schooling. Accordingly, the lines between conventional and alternative methods will continue to converge – and perhaps, eventually, to blur.

“Our vision and hope is that the term ‘integrative medicine’ will fall away,” Gaudet explains, “and therapies now considered complementary or alternative will be fully integrated into the standard of care.”

Fee Factor

Because integrative medicine (IM) places less emphasis on prescription drugs and more emphasis on preventative treatments, it holds promise for lowering national healthcare costs. But while IM works its way into the mainstream healthcare machine, the out-of-pocket costs to individuals can be prohibitive.

While costs for treatments vary widely depending on the service, location, provider and other factors, a comprehensive IM consultation for a complex medical condition might last 60 to 90 minutes, and fees may range from $200 to $400. Subsequent 30-minute visits average $135. Some insurance companies offer partial coverage; check with your provider to see if you need preapproval or a referral, or if there are other limitations to seeking services.

Many IM programs do not yet submit insurance claims on your behalf, and they tend to require payment (or arrangements for payment) at the time of service. Such programs usually provide a claim form or an invoice you can submit to your insurance provider. If you pay cash, you may qualify for significant discounts.

Coverage of CAM is still spotty, but insurers are taking note of the demand for integrative medicine. In 2002, for instance, Medicare began reimbursing limited CAM services, including chiropractic treatments. And one of the earliest private plans to cover CAM services was Oxford Health Plans, which has been covering them for nine years and is now a part of UnitedHealthcare. Aetna has also covered CAM remedies for many years now. Since January 2000, Blue Cross Blue Shield of Illinois has offered its HMO members BlueExtras, a discount program for acupuncture, chiropractic, physical therapy and therapeutic massage.

Other means of covering CAM costs through your insurer include policy riders that expand coverage of CAM services, discounted services with specific providers and reimbursement for services through flexible spending accounts. For more information about financial issues relating to CAM, visit nccam.nih.gov/health/financial.

The Wide World of Alternative Therapies

Integrative medicine combines conventional Western practices with complementary and alternative therapies. Some of those therapies, like chiropractic, have already become entrenched in mainstream care. Here’s a short guide to a few others you might encounter:

Acupuncture: A healing practice developed in China more than 2,000 years ago. Techniques vary, but the most scientifically studied method involves stimulating key points on the body with hair-thin metallic needles that penetrate the skin.

Aromatherapy: The use of flower or herb extracts (or essences) to help heal and soothe both body and mind.

Ayurveda: A 5,000-year-old medical system that originated on the Indian subcontinent; literally translated as “the science of life,” the practice focuses on treating body, mind and spirit to prevent disease; it also looks at diet’s role in healing and makes use of herbal remedies.

Massage: A practice that manipulates muscle tissue to promote circulation, relaxation, and a greater sense of physical and mental well-being.

Traditional Chinese Medicine (TCM): An ancient healthcare system based on the belief that a vital energy – called Qi – flows through the body and regulates a person’s mental and physical well-being; when the flow of Qi is blocked or disrupted, according to TCM, illness or disease occurs; treatments include herbal therapy, meditation, acupuncture and restorative physical exercises.

Naturopathic medicine: Developed in Western cultures, this medical system is based on the belief that the body has an intrinsic healing power; naturopathic practitioners nourish and support this inner power with nutrition advice, counseling, homeopathy and treatments from Traditional Chinese Medicine.

For more information, visit the National Center for Complementary and Alternative Medicine Web site at: nccam.nih.gov.

Profiles in Integration

If you thought alternative medicine was just a fringe practice or passing fad, think again. A growing number of well-established healthcare institutions are actively embracing a variety of integrative healing methods and philosophies. Consider, for example:

Memorial Sloan-Kettering Bendheim Integrative Medicine Center The Center serves approximately 1,400 patients each month and works together with all the clinical departments of the Memorial Sloan-Kettering hospital, including the surgery and medical oncology departments. Clinicians often recommend acupuncture to help alleviate side effects of chemotherapy or suggest massage therapy for pain management. The center has a fully developed clinical practice and research component, and administrators are currently organizing a training program for physicians who treat cancer patients.

Duke Center for Integrative Medicine at Duke University “Our program focuses on developing new models of healthcare,” says Tracy Gaudet, MD, the center’s director and the founding executive director of the University of Arizona’s Program in Integrative Medicine. Duke’s program has been so well received that a fully equipped, state-of-the-art, 29,800-square-foot building dedicated to IM care and research is scheduled to open its doors this fall.

At the new center, patients and IM students will practice meditation in dedicated meditation rooms, exercise in the fitness center and learn how to cook healthy meals in the demonstration kitchen. The new facility will house treatment rooms, space for educational workshops, a health retail store and a library. Gaudet and her team are also planning to collaborate on patient care with the cancer and heart centers at Duke, as well as with other departments throughout the hospital.|

Resources

Books
Healthy Aging: A Lifelong Guide to Your Physical and Spiritual Well-Being by Andrew Weil, MD (Knopf, 2005)

8 Weeks to Optimum Health by Andrew Weil, MD (Ballantine Books, 1998)

The Alternative Medicine Handbook: The Complete Reference Guide to Alternative and Complementary Therapies by Barrie R. Cassileth, PhD (W. W. Norton & Company, 1999)

Integrative Medicine in America: Merging Alternative Therapies with Biomedicine by Hans Baer (AltaMira Press, 2004)

Web
www.nccam.nih.gov – The National Center for Complementary and Alternative Medicine, part of the National Institutes of Health.

www.csh.umn.edu – The University of Minnesota’s Center for Spirituality & Healing features an online learning program that offers in-depth information on various complementary therapies.

www.drweilselfhealing.com – For information about integrative medicine clinics nationwide, click on Health Advice, and then Featured Articles to read “The Rise of Integrative Medicine Clinics.”

www.mskcc.org/aboutherbs – Memorial Sloan-Kettering Cancer Center’s resource for information on herbs and botanicals.

www.altmedicine.com – A timely resource for the latest news about alternative and conventional medicine.

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