Integrative Medicine & Patient Centered Care: Continuing the Work

In 2009, a paper was published in Explore Journal that summarized the status of integrative medicine and patient centered care in America, and also recommended 10 key directives to facilitate systemic changes needed for a functional health care delivery system.

As a co-author, I find there is still the need to focus on this mission and stir our acupuncture community to take part in revamping the medical system we currently have in our country. The paper, "Integrative Medicine and Patient-Centered Care,"¹ defined integrative medicine and its principles (patient-centered, healing-oriented, emphasizes the therapeutic relationship, uses therapeutic approaches originating from both conventional and alternative medicine, understands the whole person).

Understanding Integrative Medicine

The paper also included patient empowerment, behavior change, continuity of care, and outcomes research as key factors to help with integration of these principles. In addition to identifying integrative medicine and how to integrate, the paper addressed the function of a team-based approach for health care, since indeed, it often takes "a village" to care for the patient.

In drafting the paper, it was an interesting process among the author team to move from the conventional model where the physician (or physician assistant or nurse practitioner) was the leader of the team "calling the shots" to one that reflected more of what was really happening in the community.

As a representative of the alternative health care field, I informed my colleagues who sat on the other side of the integrative medicine hill how it typically works outside of the conventional model. The patient coordinates their own care and is the team leader who sometimes shares that lead with one or two valued and trusted health care providers.

Additional peripheral providers often joined that team. Often, the conventional physician was one of those peripheral team members, primarily for ordering medical tests and scrutiny of potentially more grave conditions. The patient's primary co-leader was someone who would spend more time, provide coaching and emotional support, and help alleviate a significant portion of the condition.

The co-leader could be an acupuncturist, wellness coach, naturopath, holistic nurse, bodyworker, chiropractor, or another practitioner skilled in some form of care. Of concern to all authors was the potential for the co-leader to lack certain skills: an inability to lead/assist with finding or being aware of other providers and types of therapies to supplement and complete the picture of care, a potential lack of sufficient education, skills and training to spot hidden areas of concern such that referral to a conventional medical provider was necessary, and the ability to communicate effectively to other providers using a common language.

Communication Models

We found that creating standardized communication models based on symptoms (such as urinary pain) and not labels (e.g. CAM pattern model nomenclature such as Kidney yin deficiency) and use of electronic medical records would greatly facilitate integrative care. Also significant, especially in the case where the patient chose a more conventional health care provider, was the issue that the conventional provider was not aware of all the holistic and alternative medicines and modalities and what they do.

Likewise, most holistic providers did not have a sufficient understanding of conventional medicine and its resources, including those support systems in the community around various diseases. Given the typical lack of communication among all of these providers, we felt it was important to teach providers about the skills and scope of offerings of each other, and how to communicate about and manage the diversity of options to the patient.

This was especially the case since the therapeutic relationship of the provider and patient is the most important influence in creating positive care. Indeed the provider is one of the "means" of treating the patient and creating effective behavioral change, along with any therapy or form of medication. This positive therapeutic relationship while even using a placebo is more powerful than a less gifted physician using an active drug.² This is true in most non-medical emergency situations. The practitioner can be the primary factor in positive change.

Our Role Within Integrative Medicine

While we have made strides since 2009, and acupuncturists have an opportunity to move even further with our role in the opioid crisis, there is still much we need to do to ensure we play a key role in the growth of integrative medicine. While the 2009 paper's list of action items list recommendations, key actors and examples or needs for what will help make changes that involve other players, acupuncturists can still take part in the list. These deliverables include:

1. Aligning incentives so that they support health
2. Developing systems that recognize total costs, including costs of benefit and harm
3. Passage of congressional mandates to required insurers to fairly reimburse providers for longer more therapeutic visits
4. Creating competencies among health care providers to better understand each others fields, patient communication, coaching and referral
5. Competencies for CAM providers on critical health issues, prevention and screening, and health care
6. Establish credentialing and privileges for CAM providers in conventional settings, especially in primary care teams
7. Fund outcomes studies on cost and clinical effectiveness of integrative medicine
8. Create societal incentives to sup-port and educate patients
9. Create insurance incentives to maintain continuous healing relationships with practitioner and health teams
10. Health care providers practicing self-care

Supporting Health Care Reform

Whether we work on the global level with our associations to make change, we can also as individual practitioners help move the dial in the right direction. Specifically our acupuncture industry and community can support this health care reform by:

• Becoming more educated in conventional and integrative medicine (pursue a doctorate or join an integrative healthcare association or obtain integrative medicine continuing education units)
• Socializing more with other integrative healthcare providers and learn who they are and let them get to know you (you might be surprised by the collaborations that could occur)
• Getting familiar with electronic medical records and communication of shared common terminology
• Working towards marketing and training ourselves as being part of a patient's health care team
• Seeking credentialing or privileges in conventional settings if you so desire, but also find other health care providers who will refer to or work with you
• Fighting for insurance parity, credentialing and privileges, and legislative reform
• Improving your skills in motivational interviewing and coaching
• Living and practicing our medicine with self-care

Indeed, there are a variety of ways to support the effectiveness and success of the patient care team, whether it be in our own neighborhoods, or for the whole nation. We can always be independent providers, but as the patient assembles their own health care team, we are called upon to be team players to ensure the patient's success. As one of the "means" to that success, we need to exercise confidence, humility, compassion, patience, and optimism.

References

1. Maizes V, Rakel D, et al. Integrative Medicine and Patient-Centered Care. Explore (NY), 2009 Sep-Oct; 5(5):277-89.
2. McKay KM, Imel ZE , et al. Psychiatrist effects in the psychopharmacological treatment of depression. J Affect Disord, 2006;92:287-290.