Toward a Merger
Experts see a coming integration of conventional and
complementary approaches to healthcare.
But how soon?
July / August 2016
By Lisa James
Beth Krumbein felt lousy, pretty much all the time. No one could explain her sleeplessness, her bloating, her fatigue, her inability to concentrate.
“I’ve been to a lot of doctors and they would give me different pills that weren’t really helping. I just felt so terrible,” says Krumbein, 25, a video strategist and coach from Cincinnati. And her attempts at self-care—“changing my diet, herbs”—didn’t do the trick either.
Krumbein is one of many patients who go for seemingly endless consultations with no definitive answers. What’s more, our current healthcare system often provides a pound of cure versus an ounce of prevention.
“We’re trying to catch up with the results of lifestyle decisions someone has already made,” says Molly Roberts, MD, of LightHearted Medicine in San Francisco (lightheartedmedicine.com). “Medicine needs to look at all parts of the health and happiness of the person in front of you, not just what we can do about this person’s clogged arteries but what we can do about prevention, what we can do with their environment to create a healthy lifestyle.”
One way to address all of a patient’s needs is to combine conventional medicine—with its high-tech diagnostics, drugs and surgery—with the whole-person, energy- and plant-based approaches favored by the range of therapies that have come to be known as complementary and alternative medicine (CAM). This emerging fusion is called integrated medicine.
Healthcare at a Tipping Point
Everyone can agree that healthcare in the United States can stand improvement.
A 2012 international study found that the US spends $8,745 per person on healthcare annually, thousands more than any other developed country. Worse, a recent Johns Hopkins University study, published in BMJ, found that medical errors constitute the third leading cause of death. “Many of us who take care of patients know that healthcare continues to struggle with endemic variations in quality stemming from poor coordination, misdiagnoses and inappropriate care,” wrote Martin Adel Makary, MD, MPH, one of the study authors, in an essay published on CNN.com.
Part of the problem is that healthcare is an industry, with industrial standards of production. “The CEOs of hospitals consider it a good year when they do more of something than less of something,” says John Weeks, editor of The Integrator Blog News & Reports, who writes for Huffington Post. This leads to short provider visits that usually end in the writing of prescriptions. As Weeks puts it, “That’s where the most money is. We force our practitioners to deny the complexity of the person in front of them.”
“I have a lot of friends in the medical world and the thing they most bemoan is the schedules they have to keep and the paperwork,” says naturopathic physician Amy Rothenberg, ND, of Enfield, Connecticut (nhcmed.com).
In response to these problems, the Institute for Healthcare Improvement (ihi.org) in 2008 launched its Triple Aim initiative, guidelines for promoting a better experience for the patient at a lower per-capita cost, resulting in greater health of the overall population. The idea was that putting the patient at the center of healthcare would shift the emphasis from treatment to prevention, from dealing with symptoms to addressing root causes.
CAM had flourished in the previous decade, especially after the 1993 publication of a New England Journal of Medicine study showing that a third of Americans used such forms of “unconventional therapy” as herbalism and acupuncture. Other CAM milestones followed, such as the 1994 passage of the Dietary Supplement Health and Education Act (DSHEA), classifying supplements as foods and not medicines. When Andrew Weil, MD, a leading proponent of integrative medicine, appeared on the cover of TIME in 1997, the movement pushed its way into the public consciousness.
CAM therapies emphasize helping patients improve their health through lifestyle changes, making incorporation of CAM into standard care a natural starting point for achieving the Triple Aim. “Integrative medicine encourages that patients receive the care they need—and the care they want,” a study team wrote in the Annals of Allergy, Asthma and Immunology.
Communication, Education and Evidence
One way conventional medicine has responded to the need for better outcomes is by creating care teams consisting of physicians and, for example, nurses and social workers. For integrative medicine to flourish, however, practitioners with very different training backgrounds will have to find a mutual language centered on the patient’s needs.
Robert Kachko, ND, LAc, of Inner Source
Health in New York City (innersourcehealth.com), says, “If I get 10 minutes with any kind of physician and they’re willing to put the patient first, we find common ground.”
Beth Howlett, MAcOM, LAc, adjunct professor and director of communications at the Oregon College of Oriental Medicine in Portland (ocom.edu), finds that the competitive atmosphere students experience in standard medical education can carry over into their careers. “That leads to a non-collaborative attitude they take with them when they go into practice,” she says.
“I started as a CAM practitioner before I went to medical school,” says Ann Marie Chiasson, MD, MPH, author of Energy Healing: The Essentials of Self Care (Sounds True). “The hardest thing is giving both practitioners time to learn about the other. There is a way the fields can be set against each other but that’s just a matter of education.”
Efforts to foster such collaborative instruction are underway. In terms of fellowships, “we’re training about 160 physicians a year,” says Chiasson, assistant director for fellowship at the Arizona Center for Integrative Medicine, University of Arizona, College of Medicine (integrativemedicine.arizona.edu). In addition, “medical students have integrative medicine electives. None of it is mandatory yet.”
The Arizona center is part of an 84-member Academic Consortium for Integrative Medicine & Health (imconsortium.org). The group, which includes medical schools at Stanford, Yale, Harvard and other universities, is trying to advance integration by introducing students to integrative techniques at the very beginning of their careers. (The Academic Collaborative for Integrative Health, see accahc.org, consists of CAM-focused educational institutions.)
Education isn’t the only factor in bringing together practitioners from the conventional and CAM worlds. Another is the time spent with each patient, which is a direct result of reimbursement—or lack of it—from health insurance organizations.
“Short visits are becoming more ubiquitous than I think is healthy,” says Roberts, a board member of the Academy of Integrative Health & Medicine (aihm.org). “The insurance companies do pay for people to visit MDs who are integrative; what they don’t pay for as easily is the time needed to do this kind of work.”
As a result, “even the doctors who are not moving to integrative medicine are moving to models outside the insurance model,” says Kachko, a member of the American Association of Naturopathic Physicians (naturopathic.org) board of directors. What’s more, NDs, acupuncturists and other CAM practitioners are often not covered by either private insurers or governmental programs. For instance, Kachko says, “Naturopathic physicians are not covered by Medicare, and that’s a major issue.”
Much of what we now call CAM grew out of traditional medical systems such as Traditional Chinese Medicine and European herbalism. To fully integrate these approaches into standard US healthcare, researchers need to supply scientific evidence that supports their use. As Chiasson puts it, “The question for a family doctor out in the community is, ‘How is this going to work?’”
Much of that responsibility falls onto the National Center for Complementary and Integrative Health (nccih.nih.gov). “We cover science from basic mechanisms through large-scale clinical trials,” says NCCIH deputy director David Shurtleff, PhD. “We’re not for profit. We have to step in and do tests when others may not.”
Being a member of the National Institutes of Health extends the NCCIH’s reach. “It allows us to work across other institutes that have a specific disease focus and to look at how these practices work in real-world trials,” Shurtleff says.
Building a research base allows CAM therapies to be used as part of a full spectrum of care. “There are times when medication or surgery is the right thing for a specific issue; at other times an herbal remedy might be just the thing,” says Roberts. “For others there may be nutritional issues or lifestyle issues or relationship issues.”
When practitioners work together, it can benefit everyone. “There are several doctors who send me patients; I get referrals for people who are not doing well on medications or are tired of the side effects,” says Rothenberg, author of The A Cappella Singer Who Lost Her Voice & Other Stories from Natural Medicine (B. Jain Archibel). “I’m so glad to have my list of people I can refer to who will treat me like any other medical professional.”
A Wider Spectrum
Currently, the medical system emphasizes dealing with the disease process itself. Not that there’s anything wrong with that, as far as it goes.
“There’s a role for disease management,” says Weeks. “For example, I had a tumor burned off my tonsil. That’s good disease management.” However, Weeks says he had to formulate a protocol to prepare his body for radiation therapy and its aftereffects; his practitioner didn’t even bring up the idea.
Integrative healthcare, in which disease management is only part of a spectrum that includes helping people stay well, would require greater coordination among practitioners. As Howlett puts it, “We’re the professionals. We should be the ones figuring out how to manage the care.”
Roberts recommends finding “practitioners who are comfortable working with each other so you’re not in the middle trying to figure this out. There does have to be one practitioner figuring out how to coordinate things.”
As Kachko notes, “patients are often afraid to tell their primary care providers” about CAM usage. “That creates a patient safety problem. Unless we have that open dialogue we won’t have the best outcome.”
Some doctors are incorporating CAM into their practices. “I think there is recognition that we need more tools in the toolbox,” says Roberts. “For example, treating someone with heart disease and not having a conversation about diet and exercise and relationships is missing pieces vital to their health and well-being.”
Looking for medicine that employs a bigger toolkit is what eventually led Beth Krumbein to the Cleveland Clinic (clevelandclinic.org). The clinic has centers for both integrative medicine, which focuses on therapies such as acupuncture and herbs, and functional medicine, another patient-centered approach that takes “a systems-based look at root causes via biochemistry, genetics and other disciplines,” according to Aunna Herbst, DO, the center’s clinical operations director.
It wasn’t a seven-minute visit. After filling out a 24-page information packet, a functional medicine patient at the Cleveland Clinic sees a doctor for more than an hour before moving onto visits with a nutritionist and a health coach. “We’re looking for clues as to what might cause the patient's system to not function optimally,” says Herbst.
That detailed drill-down is what attracted Krumbein. “They really critically look at your lifestyle, your past medical history, your stress levels and things like that, and ask really relevant questions that helped unravel the mystery of my multiple illnesses.”
Krumbein didn’t leave with just a simple prescription, either. “I had to radically change my diet.
I took a combination of prescription drugs, herbs, probiotics, vitamins and other supplements.”
But it was worth the effort; within less than two months of implementing her treatment plan, “I was feeling so much better.”
A Matter of Time
How close are we to a truly integrative healthcare system? Experts agree that it’s coming but vary in their degrees of optimism about timing.
Herbst is confident that in the next decade such a system “will be very, very common. I think once a large entity like Cleveland Clinic shows the path, it won’t take too long.”
“We don’t have a consistent delivery system yet,” says Chiasson. “We’re at the beginning of an expansion, the very beginning of that curve that’s going to go up logarithmically.”
“I think we are moving down the road,” says Rothenberg. “It’s being driven by patient demand.”
“We’re a ways away,” Howlett says. She cites the need for healthcare administrators who will see an integrative approach as the standard business model, saying, “As you get younger generations making decisions on how money is spent and systems are built, you’ll see barriers removed.” However, Howlett adds that because of differences among the various states, such a model “will be unevenly built.”
Kachko sees progress in what’s been done so far. “What’s most important is that we’ve moved away from the paternalistic model,” he says.
Krumbein agrees. “I don’t think it’s the role of the doctor to be just the person who tells you what to do,” she says. “I think it should be a collaboration because if you as the patient don’t understand what’s going on, there can be such a disconnect.”
Licensing CAM Professionals
Not all CAM practitioners are licensed in all states and even in states where they are licensed, those licenses may come with restrictions on what is called scope-of-practice—the medical actions that specific type of practitioner may or may not engage in. (In addition, license renewal generally requires the practitioner to participate in continuing education activities.)
For example, Robert Kachko says the New York State Association of Naturopathic Physicians has been trying to attain licensure since the early 2000s. But the group has been getting a more respectful hearing from state legislators in recent years: “The conservations that we’ve had were very different than four or five years ago. There’s a demand that’s becoming more and more evident.” In terms of the national group’s efforts at licensure, naturopathic physicians have “been averaging a state every year or two,” he says.
Here’s where several forms of complementary medicine stand in terms of licensure:
Ayurveda: India’s traditional system of medicine, which tries to help individuals attain balance based on constitutional types known as doshas through diet and other means, is a relatively new healthcare option in the US. The National Ayurvedic Medical Association (ayurvedanama.org) recognizes three professional levels—Ayurvedic Health Counselor, Ayurvedic Practitioner and Doctor of Ayurveda—with increasing levels of training. No states currently license practitioners of Ayurveda on any level.
Chiropractic: One of the more firmly established complementary healthcare practices, chiropractic uses spinal manipulation and other means to focus “on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health,” according to the American Chiropractic Association (acatoday.org). Doctors of Chiropractic (DC) take standard pre-med courses before training at accredited colleges for four to five years. Licensure is covered by the National Board of Chiropractic Examiners (nbce.org), and chiropractors are licensed in all 50 states.
Naturopathic Medicine: Like chiropractors, students of naturopathic medicine—which employs diet and lifestyle changes, herbal remedies and other natural means of helping the body heal itself—pursue a pre-med education before training at one of seven accredited naturopathic programs in North America. This qualifies them to sit for the NPLEX Examination administered by the North American Board of Naturopathic Examiners (nabne.org), a prerequisite for licensure. According to the American Association of Naturopathic Physicians (naturopathic.org), 17 states currently license Doctors of Naturopathic Medicine (NDs).
Traditional Chinese Medicine: TCM—which is based on balancing energy flows within the body, particularly a vital energy known as qi—encompasses several specific modalities. The best-known is acupuncture; the National Certification Commission of Acupuncture and Oriental Medicine (nccaom.org) also certifies practitioners of Chinese Herbology, Oriental Medicine and Asian Bodywork. According to the NCCAOM website, 43 states “require the passage of the NCCAOM examinations or NCCAOM certification as a prerequisite for licensure.”