Fall 2011 - Vol.6, No.3

The Power is Within; The Time is Now
A Primer on Integrative Medicine

WHAT IS INTEGRATIVE MEDICINE?

“People often think that advances in medicine have to be a new drug, a new laser, or a new surgical approach to be powerful - something really high-tech and expensive. They often have a hard time believing that the simple choices we make in our lives each day - what we eat, how we respond to stress, whether or not we smoke, how much we exercise, and the quality of our relationships - can make such a powerful difference in our health, our well-being, and our survival, but they often do.”1

The Consortium of Academic Health Centers for Integrative Medicine defines integrative medicine as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health and healing.”2 Integrative Care represents a return to the core values of medicine.

This evolving, promising approach addresses the powerful interaction of every individual’s mind, body, and spirit. For example, treatment for cancer might include everything from surgery and chemotherapy to diet, spiritual counseling, and yoga. “Integrative Medicine acknowledges the many resources a patient has beside the traditional medical system, including the body’s innate capacity for healing, the support of family and friends, cultural or religious beliefs, and the ability to find meaning in illness and suffering.”3

Integrative Medicine is not be confused with Holistic/Alternative Medicine which can include many unsubstantiated approaches such as homeopathic nostrums, and is regarded somewhat skeptically by many Western trained physicians. Rather, integrative Services include 3 main components, Nutrition, Exercise, and Social Connections. The objective of Integrative Medicine is to educate and thereby empower patients to take personal responsibility for their own health and well-being.

EVIDENCE FOR INTEGRATIVE MEDICINE

Dean Ornish, M.D., the founder of the non-profit Preventive Medicine Research Institute in Sausalito, CA, has been doing research in Integrative Medicine for 30 years. His most well-known study is “The Lifestyle Heart Trial.” This was the first randomized clinical trial to investigate whether ambulatory patients could be motivated to make and sustain comprehensive lifestyle changes, and whether such changes could stop or reverse the progression of coronary atherosclerosis without using lipid-lowering drugs.4 Patients with moderate to severe coronary artery disease were randomized to an intensive lifestyle change group or to a usual-care control group, and were followed for five years with quantitative coronary arteriography. After one year, the intensive lifestyle change group showed regression of coronary artery disease, which was even greater at five years. In the control group coronary atherosclerosis continued to progress and there were twice as many cardiac events.

Other ground-breaking research in Integrative Medicine has been performed by Kenneth Pelletier, M.D., director of the University of Arizona’s Corporate Health Improvement Program. Pelletier helps companies evaluate and implement a range of integrative health interventions in the workplace. Back pain has been identified as a leading cause of job-related disability among U.S. employers that results in significant productivity losses for businesses. In a pilot study at a Ford Motor Company assembly plant in Louisville, KY,5 50 employees with acute low back pain were randomized to receive either usual care, or usual-care plus integrative services. Participants in the integrative program showed a 60% decrease in the use of opiates which translated into earlier return to work and money saved on disability rates. The single best predictor of improvement was participants’ use of a guided meditation CD. The results of this study were so impressive that Ford’s insurance company is paying to replicate the program at all of Ford’s health clinics.

In the field of Integrative Oncology, research has been performed on patients with metastatic breast cancer and metastatic prostate cancer. For example, the Block Center in Evanston, IL offers an integrative care program called “Life Over Cancer” (LOC) which includes a tailored diet, supplements, exercise, and mind-spirit programs. Survival of women with stage IV metastatic breast cancer who participated in the Life Over Cancer program was compared with survival of similar patients in other studies conducted by leading researchers in the United States in which the patients received conventional hormonal and/or chemotherapy treatment. Median survival of the breast cancer patients in the LOC program was 38 months - nearly twice as long as the 15-23 month survival reported in comparison studies of stage IV patients who received conventional treatment.6

The Block Center conducted a similar study of metastatic prostate cancer in which patients received conventional treatment plus a semi-vegetarian diet, nutritional supplements (fish oil and vitamins), psychosocial support, and exercise. Integrative care patients with minimal disease had a median survival time of 88 months, while patients with severe disease had a median survival time of 50 months.7 In published studies of conventional treatment alone in similar patients, median survival was only 52 months in those with minimal disease, and 28-34 months with severe disease.8 These results suggest that integrative care may contribute to improved survival of patients with metastatic prostate cancer.

Why Implement Integrative Medicine Now?

Integrative Medicine has become the one bright spot in our struggling health care system. “It promises to control costs, prevent or reverse many chronic conditions, improve quality of life, even return the idea of ‘health’ to what is better described as a disease care system.”9

Despite superbly trained medical personnel, state-of-the-art equipment, and stupendous research output, the U.S. healthcare system is failing. Costs continue to skyrocket; insurance companies and Medicare are slashing reimbursement; and the number of uninsured patients continues to rise. There is a compelling argument that a greater focus on disease prevention and healthy living could lower the cost of medical care significantly.

Implementation of Integrative Healthcare in Mainstream Western Medicine

Integrative Medicine is a practice that “seeks to restore core values of the medical profession that have eroded in recent times. It honors such ancient precepts as Hippocrates’ injunctions to ‘first do no harm’ and ‘to value the healing power of nature.”10 With this in mind, it could be argued that it is every medical doctor’s duty to practice Integrative Medicine.

Dr. Scott Deron, a Lancaster General Health cardiologist, feels that practicing Integrative Medicine fulfills a responsibility to The Hippocratic Oath he took upon graduating from medical school. “When medicine is at its best, every physician practices Integrative Medicine,” says Deron. After practicing Cardiology for 23 years, he feels strongly that “it is abundantly clear that for every level of disease, how one conducts one’s life impacts its outcome and quality.”

Unfortunately, the media and highly advanced medical technology have been successful in negating this truth for a large portion of our Western population. When Pfizer advertises the slogan “I trust my heart to Lipitor” on television networks across the nation, what message does it convey? This message relieves the patient of any personal responsibility for their own health and well-being. Can we fault the public for not embracing self-care ? Why wouldn’t it be ok to continue a steady diet of pizza and McDonald’s French fries while trusting pills to deal with any elevation of cholesterol? Coronary artery disease is “no big deal” because Modern Medicine offers pills and procedures to correct this condition. This is not the message we should want our patients to receive. It is our obligation as physicians to insist that patients take responsibility for their own health, and we as healthcare providers are obligated to educate our patients.

As Modern Western Medicine is practiced now, there are several factors that severely restrict the ability of physicians to provide Integrative Medical Services: limitations on physicians’ time, the medical system’s capital and resources, and insurance carrier policies. When a physician is required to see 30 patients in a half-day of office hours, it is just not possible to provide these additional services. When one hospital employee is required to do the work of three, and no new positions are being created, the manpower simply does not exist to provide complementary services to patients. Lastly, as long as insurance companies deny reimbursement for Integrative Services, it is going to be very challenging to implement them in mainstream Western Medicine.

Conveying “The Message” to Our Patients

Much to the detriment of our patients, for reasons mentioned earlier, the practice of Modern Western Medicine has become very mechanical. If we as modern day physicians are to be successful in motivating patients to change their behavior, “we need to tell a better story,” through new and innovative techniques of communication.

Dr. Scott Deron has been working on a fascinating project to develop a “gift box,” a small yet sturdy box that can be given to any patient in most any setting. He intends to gift the boxes to his patients hospitalized for congestive heart failure. Upon opening the box the patient finds a cardboard tri-fold stating, “Knowledge is Power.” Within this tri-fold is a CD with personal success stories of patients who have taken responsibility for their own health and well-being. It is theorized that the symbolic gift box will heighten patient awareness and serve as a reminder of the power that exists within each of us. Patients empowered with this knowledge will be expected to take greater responsibility for their health and well-being by eating better, exercising regularly, and pursuing social connections.

The term “social connections” implies not only interaction with others but also an understanding of ourselves. Up until recent years, Western Medicine (as opposed to Eastern medicine) has dismissed the irrefutable connection between the mind and the body. There are undeniable examples of mind-body interactions that affect medical conditions seen daily in emergency rooms across the country. These include, but are certainly not limited to, myocardial infarctions and hypertension (related to stress), and panic attacks with overt physiologic manifestations. These common examples are merely “the tip of the iceberg.”

In order to provide optimal care, healthcare providers must have both awareness and understanding of the mind-body connection. Traditionally trained Western clinicians will gain the greatest understanding of this connection through the personal practice of mindfulness.

What is Mindfulness?

Mindfulness is an attentive awareness of the reality of things, especially in the present moment. It is a calm awareness of the reality of one’s bodily functions, feelings, thoughts and perceptions. When one is mindful, one observes one’s thoughts and feelings from a distance, without judging them as good or bad. Mindfulness practice means that rather than letting life pass you by, you live in the moment and awaken to each and every experience. There is evidence that mindfulness is not only profoundly healing, but it aids in prevention of disease through stress reduction, early diagnosis, and healthy lifestyle choices.

Drs. Herbert Benson and Jon Kabat-Zinn have been pioneers in the practice of mind/body medicine and mindfulness. Dr. Benson of Harvard University was one of the first Western physicians to discuss the importance of spirituality and mental processes in healing. He has extensively studied and defined the relaxation response and its effectiveness in counteracting the harmful effects of stress. Kabat-Zinn teaches mindfulness meditation as a technique for coping with stress, anxiety, pain and illness. He is the founder of the renowned Mindful-Based Stress Reduction (MBSR) programs, and is the author of Full Catastrophe Living, a book that describes these programs in detail.

Clinical trials of Mindfulness-based Stress Reduction Programs are being performed on a wide spectrum of patients and diseases including, but not limited to, depression, cancer, and HIV.11-15

Are Integrative Services Available at Lancaster General Health

Dr. Scott Deron has established a forum for educating patients who have received a coronary artery stent. His patients are offered “shared medical appointments” which typically include a group of 10 patients and their spouses. Each patient first receives a private physical examination and then is part of a physician-facilitated group discussion. The topics discussed include the main elements of Integrative Medicine: good nutrition, adequate exercise, and supportive social connections. Patient feedback on this program has been very positive.

I had the opportunity to interview one of Dr. Deron’s patients who participated in “shared medical appointments.” He found it very helpful to have group support and to know that “others were going through the same thing.” The group was diverse in age and the duration of their disease. Although this was the patient’s first cardiac stent, there were others in the group for whom this was their second or third. He said, “it made me realize, I didn’t want to do this again and I was going to listen.” He also explained that these group sessions effectively reinforced and elaborated on nutritional and exercise counseling provided during his hospital stay.

Some of Deron’s patients have shared their positive experiences in this program with other cardiologists in his group, with the result that some of his skeptical colleagues have become supporters of the program. One of Deron’s partners, Dr. Jose Ibarra, offers a complementary service to his patients; he takes groups of patients to the grocery store and instructs them how to read and understand food package labels.

I had a personal journey with breast cancer three years ago. Prior to my diagnosis, I read The Way of the Peaceful Warrior by Dan Millman and Full Catastrophe Living by Kabat-Zinn. Both works are testaments to the empowering effects of the practice of mindfulness. It was not until I was in the midst of my journey with breast cancer that I experienced the power of mindfulness fully. Now that I have completed my journey with breast cancer and work daily with breast cancer patients, it is my goal to bring an awareness of the power of mindfulness to my patients.

In October of 2011, The Suzanne H. Arnold Center for Breast Health will begin a Pilot Program in Integrative Medicine for breast cancer patients. Participants will benefit from a time of sharing, nutrition counseling, guided meditation, and instruction in yoga. As one foundation of this program, voluntary staff training in these areas will be offered to Lancaster General healthcare providers who will be directly involved in the care of breast cancer patients.

It is exciting that there is a ground swell of physician support for Integrative Medicine Services at the hospital. Taking advantage of the current momentum, Mary LeVasseur of The Wellness Center is developing and implementing a system-wide network of “mindfulness champions.” The goal is to expose as many caregivers - and thus patients - to this valuable practice.

The next article in this series will provide a report on the above programs. Articles on Integrative Medicine Services throughout the Lancaster General Alliance will also be forthcoming. Stay tuned, these are exciting times!

SUGGESTED READING LIST

Eating Well for Optimum Health by Andrew Weil, M.D., 2001

Flourish by Martin Seligman, 2011

Full Catastrophe Living by Jon Kabat-Zinn, PhD., 1990

The Happiness Hypothesis by Jonathan Haidt, 2006

Integrative Oncology by Donald Abrams, M.D. and Andrew Weil, M.D., 2009

Life Over Cancer by Keith Block, M.D., 2009

The Power of Now by Eckhart Tolle, M.D., 2004

The Spectrum by Dean Ornish, M.D., 2007

Way of the Peaceful Warrior by Dan Millman, 2006

Why We Get Fat and What to Do About It by Gary Taubes, 2010

RESOURCES

1. Ornish, D. The Spectrum. Ballantine Books, New York 2007;7.

2. McGonigal, K., Healing the Whole Person, Shambhala Sun, Jan. 2011; 58

3. McGonigal, K., Healing the Whole Person, Shambhala Sun, Jan. 2011; 59

4. Ornish, D., et.al., Intensive Lifestyle Changes for Reversal of Coronary Heart Disease, JAMA.1998; 280: 23.

5. Kimbrough, E., Pelletier, K., et.al., An Integrative Medicine Intervention in a Ford Motor Company Assembly Plant, J Occ Env Med, 2010; 52; 3:256-257.

6. Block, K., et.al., Survival Impact of Integrative Cancer Care in Advanced Metastatic Breast Cancer, The Breast Journal, 2009; 15;4: 357-366.

7. Block, K., et.al., Survival Impact of Integrative Care in Advanced Prostate Cancer, Pro Am Soc Clin Oncol, 2003: 22.

8. McGonigal, K., Healing the Whole Person, Shambhala Sun, 2011; Jan.:57-58.

9. Abrams, D. and Weil, A. Integrative Oncology. (p.4). Oxford University Press, New York; 2009: 4.

10. Teasdale, J., et.al., Prevention of Relapse/Recurrence in Major Depression by Mindfulness-Based Cognitive Therapy, J Cons Clin Psych, 2000; 68; 4: 615-623.

11. Speca, M., et.al., A Randomized, Wait-List Controlled Clinical Trial: The Effect of a Mindfulness-Based Stress Reduction Program on Mood and Symptoms of Stress in Cancer Outpatients, Psychosomatic Medicine, 2000; 62: 613-622.

12. Smith, J., et.al., Mindfulness-Based Stress Reduction as supportive therapy in cancer care: systematic review, J Adv Nursing, 2005; 52; 3: 315-327.

13. Lengacher, C., et.al., University of South Florida. Mindfulness-Based Stress Reduction Symptom Cluster Trial for Breast Cancer Survivors. In: Clinical Trials. gov [Internet]. Bethesda: (MD): National Library of Medicine (US). 2000 - [cited 2011 July 27]. Available from: clinicaltrials.gov/show/NCT01177124 NLM Identifier: NCT01177124.

14. Department of Psychosocial Research; University of Copenhagen. A Prospective, Randomized Controlled Trial of Mindfulness-based Stress Reduction Among Women Operated for Breast Cancer. In: Clinical Trials. gov [Internet]. Bethesda: (MD): National Library of Medicine (US). 2000 - [cited 2011 July 27]. Available from: clinicaltrials.gov/show/NCT00990977 NLM Identifier: NCT00990977.

15. National Center for Complementary and Alternative Medicine; University of California, San Francisco. Staying Well: A Clinical Trial of Mindfulness-Based Stress Reduction and Education Groups for HIV.In: Clinical Trials. gov [Internet]. Bethesda: (MD): National Library of Medicine (US). 2000 - [cited 2011 July 27]. Available from: clinicaltrials.gov/show/NCT00271856 NLM Identifier: NCT00271856.