Integrative Care – One Clinic at a Time

Do you practice Integrative Medicine? If so, how? Some of you might be thinking that Integrative Medicine (IM) is intuitively obvious, while others may hesitate if pressed to provide a definition. Webster's dictionary defines Integrative Medicine as "medicine that integrates the therapies of alternative medicine with those practiced by mainstream medical practitioners."

That's not a bad definition and reflects what many people believe IM to be. John Weeks, who writes and coordinates www.theintegratorblog.com offered the Consortium of Academic Health Centers for Integrative Medicine's (CAHCIM) definition: "Integrative Medicine is 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, healthcare professionals and disciplines to achieve optimal health and healing."

Weeks is a long-time writer and organizer in integrative care. His blog has been recognized for 14 years as the leading media resource on the policy and business of integrative healthcare. I strongly recommend you visit his website if you have any interest in IM and the politics associated with it.

Dr. Andrew Weil also offers another in-depth definition of IM on his website: "Integrative medicine is healing-oriented medicine that takes account of the whole person (body, mind and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative."

The principles of integrative medicine are:

• A partnership between patient and practitioner in the healing process.
• Appropriate use of conventional and alternative methods to facilitate the body's innate healing response.
• Consideration of all factors that influence health, wellness and disease, including mind, spirit and community as well as body.
• A philosophy that neither rejects conventional medicine nor accepts alternative therapies uncritically.
• Recognition that good medicine should be based in good science, be inquiry driven, and be open to new paradigms.
• Use of natural, effective, less-invasive interventions whenever possible.
• Use of the broader concepts of promotion of health and the prevention of illness as well as the treatment of disease.
• Training of practitioners to be models of health and healing, committed to the process of self-exploration and self-development.

Since AOM is a holistic healing system that takes into account the body, mind and spirit, then one could argue that all of us are practicing integrative medicine.

As a side note, I'd like to address integrated medicine. Although the terms are used interchangeably in casual conversation, legislatively, integrative and integrated medicine are two very different animals. Integrated medicine or integrated healthcare has to do with the integration of patient records into databases that are accessible by all providers. It also provides a seamless interface between providers and insurance carriers. The Health Information Management Systems Society defines Electronic Health Records (EHR) as "a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface—including evidence-based decision support, quality management and outcomes reporting."¹

I approached a number of practitioners across the nation and asked the following question: Do you practice Integrative Medicine? If so, how?

Here are the responses I received:

"As a solo practitioner, referrals from other practitioners are essential for optimal patient care, as well as to the sustainability of my practice. I regularly refer patients to internists, osteopaths, psychotherapists, massage therapists, physical therapists, etc., so in that sense I do practice in an integrative manner. Patients frequently ask for a referral to a new primary care physician, gynecologist or dentist. More importantly, obtaining the information from medical testing and diagnosis helps to guide my treatment plan, particularly with decisions as to whether Chinese herbs would be beneficial for a patient with a chronic medical condition for which they may be taking several medications and utilizing other therapies. I believe it is our ethical duty to know when to refer and to dispel myths that medical doctors are "bad" and we are "good." We need to think about patient care in an integrative manner, whether or not we are working with other practitioners directly, or in a private setting."
-Janet L. Borges, LAc Richmond, Virginia

"When people come to me for a massage and ask me which 'modalities' I practice, my honest answer is, 'I can say whatever you want but my work is an amalgam of everything I learned in both massage and acupuncture school (which was 15 years ago), the wisdom gleaned from four years at Kripalu Yoga Center, the hundreds of hours of treatments of many sorts I've received through the years and then add a couple of shakes of je ne sais quoi (intuition + experience?).'"
-Reid Saunders, LAc, LMT, Vienna, Virginia

"The style of 'integrative medicine' that predominates in my area of Southern California for the most part is actually practiced by Western medicine practitioners with marginal training at best in Eastern/natural medicine. Having been involved with a world famous institute of integrative and complementary medicine in San Diego for some time giving classes to their staff in various aspects of Eastern medicine I still am not clear what 'integrative medicine' actually is. After giving free classes and a special workshop on Chinese medicine for RNs, I was overlooked for staff positions in acupuncture and herbal medicine only to find out that these positions had been filled by MDs and pharmacists to provide acupuncture and herbal medicine. The requirement in California for MDs to practice acupuncture is perhaps 200 hours and no special training is required for prescribing herbal medicine. Surprisingly enough various state and national AOM associations appear oblivious to other poorly trained professions attempting to take control of Eastern medicine. The majority of complementary-integrative medicine being practiced in Southern California, if not nationwide, may somewhat integrate Eastern medicine methods and/or techniques by Western medicine professionals, but appears to neglect for the most part Eastern medicine practitioners working in a Western medicine setting. Cross referrals from Western medicine to Eastern medicine seem more promising at this time although there is much room for improvement."
-Anonymous, Southern California

"I don't think I practice Integrative Medicine. I only practice acupuncture and Traditional Chinese Medicine. I understand that "Integrative Medicine" is a combination of both Western conventional medicine and other type of medicine/modalities."
-Dr. Lixing Lao, Baltimore, Maryland

"I believe I practice Integrative Medicine because I don't treat diseases per se; I treat individuals with disease or other health challenges. I view the person as a whole, from top to bottom and inside out, looking at the body, mind and spirit levels. In diagnosis and treatment, I don't just look at symptoms - I look for the possible root causes behind the symptoms. I think that symptoms are messages from our body -- we shouldn't kill the messengers when they bring bad news. I also pay a great deal of attention to related issues like lifestyle, diet, personal experience, trauma, emotional patterns, relationships and more. All of these factors add up to a whole person who deserves to be treated as such."
-Jasmine Ma, LAc, JD, Rockville, Maryland

"I am not sure what Integrative Medicine actually includes by definition here. Basically, I have training in TCM with a solid background in Western medicine. I used to do TCM in a university hospital in Shanghai, combining Western medicine including ordering lab work and prescribing medications. As an L.Ac. here, technically I practice TCM, but my training and experience do impact the diagnosing and treatment planning in clinic."
-Haiyang Li, OMD, PhD, LAc, Timonium, Maryland

I consider myself practicing Integrative Medicine in that I'm aware of what naturopaths, homeopaths, chiropractors, massage therapists, health coaches, nutritionists, rolfers, kinesiologists, psychologists and counselors, energy workers and physicians of all flavors of specialties do for their patients. A referral notebook thick with business cards on my desk is the result of years of cultivating relationships with local doctors and CAM practitioners. When a new patient comes to my clinic, I'm looking to bring in the most appropriate team of professionals required to assist that person in meeting their health goals.

So, although I do not use Western medical interventions in my practice, I most certainly refer my patients out to get necessary imaging, tests and treatment outside the world of acupuncture and Oriental Medicine. Since the scope of practice law in Virginia is not terribly "confining," I might suggest various supplements in addition to herbal medicine to meet my patients' needs. An example is Omega 3 fatty acids. If a patient presents with sciatic pain, dull and aching and their signs and symptoms point to a Kidney deficiency, I'll recommend this "kidney tonic" for their condition.

The beauty of working in an integrative fashion is that your patients realize the best course of action is a multi-disciplinary approach, and they are always pleased to know that you're communicating regularly with the other healthcare professionals on their case.

What would a center of IM look like? There are quite a few of them popping up across the U.S., and are relatively successful. Typically, they have a central coordinator or triage specialist. This person usually is a nurse practitioner or physician assistant. Their job is to collect a medical history, vital signs and explain what treatment option(s) would be most appropriate to the new patient. he center would employ a general practitioner MD, a few specialists, naturopath, acupuncturist, psychologist/psychiatrist, chiropractor, massage therapist and energy worker. Occasionally, there will be a spiritual counselor. Cross referrals would be common and each patient would have one file with progress notes from a number of practitioners. These healthcare professionals typically gather on a regular basis to discuss cases they share and offer guidance and support for those challenging cases. Working as a team is the central focus with the patient being the number one priority.

Looking at the responses to my question, Dr. Lao's response was very direct: He practices TCM. Period. According to the letter of Webster's definition, he is absolutely correct. Except for those of us with M.D. after our names in addition to L.Ac., none of us offer a "conventional medicine" approach to our patients. In the "spirit" of IM, there are a number of statements on Dr. Weil's website that accurately reflect our daily practice. We routinely partner with our patients for their health and well-being. We consider factors outside of biological/environmental influences on a person's health and we use natural interventions. We also focus on health promotion and prevention and are committed to a process of self-exploration and self-development in the practice of AOM. IM is a multifaceted concept and will eventually be a household word.

The future of healthcare in America is Integrative Medicine. Most European countries already have an integrative system because it's cost effective and their citizens demand the care from a broad spectrum of practitioners. Although there's philosophical resistance to IM by those who prefer the "business as usual" model, the American people are losing patience with drugs and surgery as their only option and are making their opinion known to their physicians and legislators.

Encourage your patients to request AOM to be a covered benefit in their insurance plans and be vocal to their local politicians about the positive benefits they've received through your care.

Reference

1. Jennifer Allan, BSN, RN and Jane Englebright, PhD, RN., "Patient-Centered Documentation: An Effective and Efficient Use of Clinical Information Systems," Journal of Nursing Administration. 30(2):90-95, February 2000.