Good Medicine

“It is more important to know what patient has the disease than to know what disease the patient has.” Sir William Osler

Acupuncture, yoga, fish oil, nutrition, mind-body connection, herbal remedies, prayer – holistic and integrative medical practices, once looked upon as frivolous and fringe, are gaining new ground and respect in conventional medicine because you, the medical consumer, demand to be heard and push for more options and approaches in healthcare.

Dr. Victor Sierpina, professor of Family and Integrative Medicine (IM) at the University of Texas Medical Branch in Galveston, is a recognized leader in the field and has been a practitioner of the integrative approach for more than 25 years. He is recognized as one of the Best Doctors in the USA in Family Medicine, a peer-nominated distinction.

“This is a patient driven movement,” he explains. “We’re leading from the bottom. The change is coming from the informed consumer who can go to the Internet if they have a condition, or want to learn about a supplement or try some different kind of treatment. They can look it up – things that were once only available to physicians are easily accessible now to all.”

A short definition of integrative medicine is patient-centered care, which focuses on positive relationships between the doctor and patient, emphasizing the whole person (mind, body, and spirit) and using all conventional and all complementary therapies, as well as working with other disciplines.

Sierpina believes, though, that integrative medicine is much more. It’s true that it does incorporate using the whole spectrum of the patient’s lifestyle – their culture and their belief system are essential to understanding how to change their health. But it’s not just that a physician might use an herb instead of a drug, or acupuncture instead of surgery, although that does occur, as well. “It is really a more ecological and systems biology approach to the person’s whole life space including practices that are going to make the difference long term, not just using a different product to treat their particular condition,” Sierpina explains. “Most of us would like the term (integrative medicine) to go away and just call it good medicine, so that in five or ten years these techniques, as scientific evidence continues to mount, don’t get characterized as complementary or alternative or integrative, but just good Victor Sierpinamedicine.”

A Time of Change

The practice of IM is no longer a “side show.” Sierpina chairs the Consortium of Academic Health Centers for Integrated Medicine (CAHCIM), a group of 44 medical schools and centers in the U.S. and Canada, all with active IM programs – clinical, research-based, educational, or a combination of the three. CAHCIM is a non-profit organization dedicated to helping physicians, educators, clinicians, and researchers develop and refine skills and background in IM practices. The group includes not only the University of Texas, but Stanford, Yale, Harvard, the Mayo Clinic, Duke University, Vanderbilt, three University of California schools, and four schools in Canada.

In February the prestigious National Academy of Science Institute of Medicine, an independent, non-governmental agency, held a summit in Washington, D.C. called Integrative Medicine and the Health of the Public. More than 600 people attended the two-and-a-half day program, among them all the major opinion, thought, and policy leaders in the country, Sierpina adds. It was the largest event the Institute of Medicine has ever held. “They got it,” he says. “They got that this is a time of change in medicine and integrative medicine needs to be a part of the solution.”

At the same time as the summit, the Senate was interviewing many of Sierpina’s colleagues in integrative medicine at hearings in preparation for healthcare reform.

Of note, too, is the fact that every major cancer center in the U.S. has an active IM program. Houston’s M.D. Anderson has had one for many years. Surveys show cancer patients to be high users of complementary therapies. Patients use them to improve their health and well being and to reduce the side effects and risk of recurrence, yet, Sierpina notes, there is little information about how the herbs, supplements and high dose antioxidants interact with conventional chemotherapy and radiation therapy.

On a smaller scale but equally impressive is the widespread acceptance now of such supplements and treatments as fish oil (omega fatty acids) and glucosamine and chondroitin. Omega fatty acids have long been recommended by holistic practitioners and integrated and complementary physicians as part of a healthy diet. “This was out in the hinterland of medicine,” Sierpina says. “It wasn’t a drug, so there wasn’t a lot of big money to sponsor or research it, and it wasn’t a novel treatment like a ‘new-to-nature’ molecule that could be patented.” Now mainstream cardiologists are recognizing that fish oil reduces stroke risk, improves lipid profile, reduces the risk of heart attack and arrhythmia, and it can even reverse atherosclerosis. Once considered leading edge integrative medicine, it has become a part of mainstream medical practice.

Similarly, glucosamine and chondroitin were once used only by veterinarians for arthritis in horses and by alternative practitioners for arthritis in humans. Now every medical journal article about arthritis not only incorporates mention of the potential benefits of glucosamine and chondroitin, but also includes mention of things such as MSM, SAM-e, acupuncture, aquatherapy, herbal anti-inflammatories and various other kinds of therapies that were once considered marginal.

A third area of IM advancement is the mind-body connection. There have been several cover articles in both Time and Newsweek on how meditation, relaxation therapy, happiness, optimism, and positive attitudes can have a major effect on positive health. Though well documented scientifically, they are still not part of the culture of medicine. When people come in with anxiety, depression, mood problems, and even chronic pain, most physicians are still more likely to give them a pharmacological treatment rather than a self-actuated, personal self-care method like breathing techniques or meditation practice. While well evidenced, they are not part of the culture of what people expect doctors to do.

But that’s where IM expands the playing field, Sierpina says, offering a broader spectrum of therapies not necessarily expert-based. People can do much for themselves – go to a health food store, take a class, or learn yoga. They’re not expensive, and don’t require a co-pay or involve an insurance company. There is an incredibly broad body of literature, but it’s not as widely accepted as the newest drug.

Physician Larry Dossey, author of several books on the role of consciousness and prayer in healing, writes that people who attend church regularly will live seven years longer than those who don’t, and for African Americans it is 13 years longer. If church attendance was a drug with similar results, Sierpina notes, it would be on the cover of major medical journals or popular magazines. “There’s no diabetic drug or hypertension drug we know that can offer that kind of effect size. Yet those are in the realm of integrative medicine that we accept as a powerful dimension of a healthy lifestyle that isn’t a major part of the consciousness of conventional medical care.”

Seasoned clinicians are among the most interested in learning more about IM practices, says Sierpina, who addresses many physicians groups each year. A recent survey showed approximately 75 percent of doctors to be very interested in learning about nutritional supplements and botanicals, though they might never consider prescribing them. “The doctors feel their patients self-prescribe these things, so they feel they need to have a sense about what the common interactions are.”

In 2003 Sierpina received a $1.6 million dollar grant from the National Institute of Health to start IM curriculum at UTMB to educate medical and nursing students. “We at least need to connect doctors with how patients are acting, and how to counsel them and encourage their self-motivated approaches to good health instead of dismissing the things in which patients have such interest.”

Healthcare Reform

Sierpina is adamant that integrative healthcare is essential to the healthcare reform being debated in Washington. “We have to not only change what we do in medicine, but we really need to change the medicine that we do. If we’re mainly talking about how to pay for everything, it’s a little bit like rearranging deck chairs on the Titanic. You have to cut a little Medicare money, and you have to put a little bit over here and a little bit over there. It’s really not going to change fundamentally the way the system is set up to deliver the highest quality of care to patients at the lowest cost and where they feel heard, or feel their lifestyles are impacted.”

For instance, the intake interview – it can’t happen in 15 minutes, Sierpina says, noting that Sir William Olser, the father of modern medicine, said over 100 years ago that it takes a minimum of 30 minutes to get the patient’s whole story. It’s not any different than it was a hundred years ago. “Maybe you can get it in 30, but if it’s a new patient, maybe you can get it in an hour, depending on their age and the complexity of their problems. We don’t get paid equitably for this compared to performing a procedure. Yet at the same time those of us in holistic and integrative practice realize that the patient can pretty much tell us their disease if we have time to actually listen to all of the pieces of the puzzle.”

Integrative functional medicine uses a “systems biology” approach that says the patient is greater than the sum of all of their diseases, Sierpina explains. For example a patient might have five or six complaints. They might have a pain, be tired, worried, and not sleeping well in addition to experiencing easy bruising and some digestive problems. Rather than seeing that as depression, headache, irritable bowel syndrome, and fibromyalgia or arthritis, Sierpina says there are ways that use the latest medical and scientific knowledge and technology, genomics, to put all those complaints into one picture. “With a functional medicine approach you look at all the parts of the story instead of going to seven different doctors. But in order for that story to emerge, you have to have the time to hear it. If you don’t, it never will come out and the patient gives a piece of the story to whoever is listening, but nobody actually puts the whole piece together,” he says.

This is where the integrative practice is challenged by the high throughput, low repayment on primary care today, Sierpina explains. Patients get pushed through. Doctors have to see them fast because they are paid per patient. They have to see a lot of them in order to make the office overhead.

The whole shift in healthcare reform has to be oriented toward changing the incentives for both patients and physicians to take care of problems when they are small rather than to wait until they’re big. “To pay a doctor $50 to counsel a patient for half an hour on how they can control their diabetes, but to pay a hospital $30,000 to cut off that person’s gangrenous foot is a real distortion in the value system of medicine.”

One solution becoming popular is to use a team of people including a health educator, a nurse or nutritionist, for example as a health coach, who works with the patient to shape the behaviors the patient wants – not what the health coach wants. The individual needs encouragement, and the team is like a cheerleading squad, or motivational experts to help move the patient along the path.

“That’s what I mean about changing the way we deliver medicine. It doesn’t necessarily have to all be through a doctor’s office, and it may be that we need to find ways of helping people change at a different level and at different places such as in the community.”

An example is the issue of childhood obesity and diabetes. “I see a little fat kid in my practice that’s in the 95th percentile for his age and height, and I see that his parents are obese as well. I feel really challenged about how to change what they put in their shopping cart or how many times they stop at a fast food restaurant or how many quarts of high fructose corn syrup soft drinks they consume per year…It’s a difficult hurdle culturally, but if we educated the children in the schools, if we took out the vending machine and the high fat, fried foods they have in schools, and improved their exercise program, then you start changing the culture and the kids can affect the way the parents shop and eat.”

In order for health to change for an individual you have to add the society level. “We’ve been able to cut down on smoking rates by 50% or more in this country just in the last 15 or 20 years because of a “group will” to do it. You can’t change people in isolation from their families and from their communities. You have to incorporate those families and communities educationally, culturally, and socially in order to activate change in a healthy direction.”

We must become more oriented around wellness than illness, Sierpina says. Because illness will cause us to have to ration healthcare and make more distasteful, ethical decisions such as how much public health insurance to pay for a treatment that would extend a patient’s life one year. “In England I think they came up with a number like $50,000. That means one year of your life is worth $50,000 – that seems like a harsh metric to think about your life being worth anything like $50,000 or even five million dollars or whatever. That’s the down side of not taking an integrative approach to healthcare. We’re going to end up focusing more on disease management and rationing how much we can pay and making very difficult ethical choices for ourselves, our children, and our parents that are fundamentally against our human moral code.”

Sierpina is hopeful that IM will play a stronger role through healthcare reform. He cites the recent discovery of the wide variation in our genome (genetic information), so that now we understand the way we respond to stress, changes in our diets, and exercise, etc, are very individualized. It’s not one size fits all. “We have the opportunity to take the highest science, the predictive tools of genomics, nutrigenomics, pharmacogenomics, etc. and to personalize care. We can make it oriented around an individual’s specific needs.”

And yet a fear lingers that in a top down healthcare reform plan, individuals could be stratified into disease risks categories and treatment doled out not according to individualized needs, but based on an average approach.

The outcome of the healthcare reform debate is to be decided soon. In the meantime, Sierpina continues his work in educating others on the benefits of practicing “good” medicine.

“You take the moral ground that this is something that we’re doing in defense of our patients and their health, then we can win, or lose – but be proud of what we’ve done.”

 

Integrative Medicine Resources and Links

To learn more about integrative medicine or to find practitioners visit these links.

UTMB Galveston: http://cam.utmb.edu

M. D. Anderson: www.mdanderson.org/education-and-research/departments-programs-and-labs/programs-centers-institutes/integrative-medicine-program/index.html

University of Arizona Center for Integrative Medicine: http://integrativemedicine.arizona.edu

Consortium of Academic Health Centers for Integrated Medicine: http://www.imconsortium.org

American Holistic Medical Association: http://www.holisticmedicine.org