Miles Reid, L.Ac., Dipl. Ac., C.H.

MEDICINE AT A CROSSROADS

WESTERN MEDICINE & TCM:

AN INTEGRATIVE MODEL FOR THE 21^ST CENTURY

Integrative Medicine: Facts and trends

A paradigm shift in health care is taking place in the US: the incorporation of complementary medical modalities into traditional medicine.

Integrative Medicine is a rapidly emerging field that seeks to improve medical care by combining the best of bio-medicine with mind-body-spirit approaches to health that have proven efficacy.

This is a crucial time in medicine in the US. Health care has become too expensive, due in part to advances in medicine itself: as people live longer, there is a higher incidence of chronic disease. Also we have become attracted to “technology” medicine: expensive, complex interventions. Hospitals—even large institutions—are going bankrupt. So managed care has come in to balance the books, bringing what many described as misery for both doctors and patients.

Surveys suggest that doctors are as unhappy as patients about the current state of health care. Doctors want to leave their practices and patients are turned off from medical care unless it is an absolute necessity.

(From the physician standpoint, there is a growing trend towards dissatisfaction fueled by increasing pressure to see more patients in shorter amounts of time; greater administrative demands, a perceived loss of control and more complex liability issues. There is a critical mismatch between the original intention for entering the medical field and the realities of practice.

A recent study by Spickard, et al. In the Journal of the American Medical Association (JAMA), mid-career burnout has risen to 76% in a sample of internal medicine residency. Up to half of the physicians in California have explored ways to exit from the practice of medicine (according to Sullivan, M.D.)

This has created an environment in which physicians are more open to alternative health modalities, and most are eager to expand their roles. Another, even bigger driving factor is that the public in general is asking for them with a force that conventional medicine cannot ignore.

CAM is becoming mainstream.

The term CAM (complementary alternative medicine) itself is somewhat misleading. The word alternative suggests “instead of,” but integrative medicine seeks to find complements of care, where the total interaction is more than the sum of its parts.

One important point to stress is that not all of these CAM practices have been proven effective. Research support for the efficacy of these therapies varies considerably, and there is a growing interest for solid research to assess them.

Most conventional medical scientists are unaware of the evidence that already exists for the safety and efficacy of many CAM treatments. At the same time, the evidence base for many widely used allopathic treatments is not very solid.

Research on CAM has exploded in the last 5 years. Created in1993 by a congressional decree based on public support, the NIH (National Institutes of Health) CAM office has risen in status. In 1998 it turned into a full-strength federal agency called the National Center for Complementary and Alternative Medicine (NCCAM) and quadrupled its annual research budget to $100 million. An example of their research funding is a recent $1.2 million grant to Bastyr University in Seattle to train scientists to conduct research in the field of CAM.

One study documented that up to 95% of the public would utilize CAM services if proven effective and delivered in a traditional setting.

Nevertheless, for the average healthcare consumer integrative medicine is still hard to access for the simple reason that qualified practitioners are few and far between. Demand greatly exceeds supply for physicians trained in the new paradigm, and training opportunities are limited (Andrew Weil, 2002)

There are a growing number of medical centers and HMO’s that are incorporating CAM into their patient service lines.

- More than one third of medical schools in the U.S. currently offer courses on alternative medicine.

- -Formal programs in mind-body and integrative medicine are in place at Harvard, Duke, Stanford, Columbia, the University of Arizona (under Andrew Weil, M.D.), the University of Massachusetts and UC San Francisco, among others.

- At UCLA, Dr. Ka-Kit Hui formed the Center for East West Medicine in 1993, with the goal of integrating Western medicine and TCM, and creating a setting where acupuncturists and physicians can work side by side.

An example of this is a well-known study by Zang-Hee Cho of the University of California, Irvine, where he demonstrated, using fMRI (functional magnetic resonance imaging) that inserting a needle in the acupuncture point GB35 (a point on the outside of the calf) and stimulating the point, caused a marked activation of the visual cortex.

According to author Geoffrey Cowley, what draws people to CAM and integrative medicine is not a desire for efficiency but a longing to be cared for. For example, from a patient’s perspective, he says, acupuncture is a ritual in which a therapist touches us and helps us feel better. By the logic of scientific medicine, acupuncture is measured as an encounter between a patient and a needle, and it doesn’t factor in such intangibles as care and compassion, which count but which can’t be measured by Western medicine’s current standards. (p. 50)

Supporters of integrative medicine think it will fundamentally change the way patients are treated. As the director of Duke University Center for Integrative Medicine Martin Sullivan, M.D. says: “If we can manage to combine the best of what these two systems have to offer, we’ll be creating a radically new kind of health care. Many of us, in fact, think that this is what the medicine of the future will look like.”

According to Ralph Snyderman. M.D., chancellor of Duke Medical School, the transformation underway could prove as pivotal as the birth of scientific medicine a century ago. What is at stake is not just the status of some individual therapies but the whole meaning of health care.

In the long run, the larger mission is to forge a new kind of medicine, an integrative medicine. The terms complementary and alternative will become meaningless and we will have one inclusive health system instead of two. All healing modalities will work in conjunction with the common reference point of science.

Figure 2: The Emergence of Integrative Medicine

I. Integrative medicine is a consumer-driven movement

A- Healthcare consumers are educating themselves

B- Sales of botanicals and other supplements are increasing,

as are visits to other alternative practitioners

II. Why physicians are interested in integrative medicine

A- Doctors are growing dissatisfied with their practices

B- Patients are requesting more information on alternative therapies

III. Aims of integrative medicine

A- Establish a true partnership between patient and practitioner

B- Revive the art of medicine

1. Develop and improve listening skills

2. Communicate clearly and thoroughly

3. Make appropriate treatment and lifestyle suggestions

4. Acknowledge patients’ belief systems

C- Change the focus of medicine from disease to healing

D- Emphasize prevention and wellness

Andrew Weil, M.D.

Integrative Medicine: Medicine of the future

Thoughtful combination of alternative and conventional medicine

Emphasizes healing and health

Emphasizes doctor-patient relationship

Looks at the whole person not just the body

It is the approach that people want; sensible, common-sense medicine

Some Statistical Images

Recent studies support this mainstream emergence: A landmark study from Harvard Medical School in 1993 by Eisenberg et al, showed that 34% of all U.S. adults had received at least one unconventional therapy in 1990 and showed that $13 billion was spent out-of-pocket for CAM therapies each year. By the late 90’s studies estimated this figure at $24 billion, with close to 40% of the public seeking integrative medicine practitioners, making 425 million visits per year to this type of health care. Last year, those figures had increased to $30 billion and 600 million visits, and rising.

Patients are also demanding less aggressive forms of therapy and they are more and more concerned about the toxicity of pharmaceutical drugs. Adverse reactions were found to be the sixth leading cause of death, and in 1994, botanicals were the largest growth area in retail pharmacy.

In the early 1900’s the average life expectancy was 47 years and people died mostly of infectious diseases. In 1990 the life expectancy had risen to 75 years with the leading causes of death being heart disease, autoimmune conditions and cancer; these are chronic diseases. More and more research supports the theory that the reason they are chronic is due to diet and lifestyle conditions.

Insurance companies have already begun to take note that patients who use both Western and CAM therapies are healthier by a number of indices, are more inclined to take preventive responsibility for their health and remain healthier and productive longer.

A recent survey in Washington State demonstrated that patients with chronic illness found conventional bio-medicine to be effective or helpful 46% of the time, while they found complementary care helpful or effective 89% of the time.

When the use of western medicine is most relevant:

Crisis, emergencies, severe diseases, trauma, fast moving illnesses, disease involving vital organs, complicated diseases which amount to 20% of cases.

In 1996, a study by the Maryland Commission on Complementary Medical Methods found that 46% of the physicians surveyed had made a referral for or discussed complementary medicine with their patients. (Sullivan, Institute for Healing in Society and Medicine). The most frequently referred ailments were allergies, lower back pain, asthma and chemical dependency.

The most frequently referred CAM therapies were:

Biofeedback (34%)

Chiropractic (30%)

Acupuncture (27%)

Nutrition (27%) –

It is interesting to note that nutrition was considered outside the frame of conventional medicine.

(Sullivan, TCM World, p. 11)

Another similar study by Eisenberg, published in JAMA in 1999 compared the most common symptoms referred by patients who consulted CAM therapies:

Neck 57%

Back 48%

Headache 32%

Arthritis 27%

Strain/sprain 24%

THE TOP FIVE WERE MUSCLE-SQUELETAL COMPLAINTS

Another study by Long, et al., in 2001 compared the efficacy of CAM therapies on different symptoms. The best results were obtained for:

1- Stress/anxiety

2- Back pain

3- Insomnia

4- Muscle-squeletal conditions

The Role of TCM

So think for a moment about the possibilities of TCM within this emerging model. Chinese medicine is likely to find a growing place in western medical practice. Since the 1980’s more than 20,000 Americans have studied TCM in U.S. schools. There is solid research that supports the efficacy of acupuncture’s therapeutic value, and it is one of the CAM modalities most suited to grow and become a standard player in the integrative network.

In November 1997, the NIH held a conference to come up with a consensus statement about acupuncture. This conference was motivated by the need to establish parameters and promote further research in this area. The NIH announced acupuncture as a legitimate treatment, which means that a practitioner of this medicine can file a claim to an HMO or insurance company and qualify for reimbursement.

As an anecdote, perhaps the most single influential moment for the development of acupuncture in the U.S. was when then-President Richard Nixon visited China in 1972. Nixon was accompanied by James Reston, senior correspondent for the New York Times, who developed acute appendicitis during the trip and underwent surgery while in Beijing. Upon his return, he reported in the newspaper that acupuncture had been effective in alleviating his post-operative pain, which caused many Americans to seek acupuncture treatments.

The TCM World Foundation organized a landmark conference entitled Building Bridges of Integration for TCM, in the fall of 2002 in New Jersey. The purpose was to serve as a forum to explore ways to integrate TCM with the western medical model.

Another recent event of this nature was the Second World Congress of Integrative Medicine that took place in Beijing, China, in September of last year, with 1,500 researchers, medical doctors and acupuncturists from 27 countries. More than 1,000 research papers evaluating the safety, efficacy and biological mechanisms of Chinese medicine were presented.

Some examples of effective integrated approaches that emerged were: the use of acupuncture and tui-na in addition to conventional physical therapy as an effective alternative to surgery for lumbar herniated discs, and the administration of Xiao Chai Hu Tang modified for the management of Hepatitis C. (Acupuncture, p. 36)

Most of the research showed that Chinese medicine’s strongest area is actually one of conventional medicine’s weakest: the area of chronic diseases.

These conferences reflect a growing trend among both the biomedical and TCM communities: that a combination of western medicine and traditional Chinese medicine gets better results than a single method alone. And this holds true even more for the treatment of complex diseases.

Results from a poll *on Acupuncture Today, in 2002-3.

Question: Have you ever referred a patient to a medical doctor or chiropractor for treatment?

The responses, in a group of 286 acupuncturists, were:

Yes: 78.7%

No: 21.3%

Question: Has a medical doctor or chiropractor ever referred a patient to you for treatment?

The responses, in a group of 233 acupuncturists, were:

Yes: 73%

No: 27%

The majority of referrals (no specific statistics were reported) were to chiropractors, who have a longer history of communication and support for TCM. Clearly, there is still a lot of room for a more fluid referral network between medical doctors and acupuncturists.

Figure 2

Has a medical doctor or chiropractor ever referred

a patient to you for treatment?

Have you ever referred a patient to a medical doctor

or chiropractor for treatment ?

Purpose of integrative medicine:

The fundamental aspects of integrative medicine could be summarized as follows:

Restoring to medicine its healing orientation. Having patients be aware of their options, knowing which modalities are effective for different cases.

Shifting the emphasis of the current Western health care system, which is not really set up as a health care system but as a disease care system. Doctors are trained to recognize disease, and treat it and, ideally, cure it, rather than to promote health. Integrative medicine strives to shift this model to one that supports health, maintains it and enhances it.

Health comes from the old English word “Hal” which means wholeness, soundness, or spiritual wellness. “Health,” is (defined by the World Health Organization) “a state of complete physical, mental and social well-being, and not merely the absence of disease”. To “cure” conversely, refers to doing something that alleviates a troublesome illness or condition.

Healing does not equal curing.

To cure hypertension we give a pharmaceutical without healing the condition. Healing the condition would reduces stress, improve diet, promote exercise and increase the person’s sense of community. (Rakel, Integrative Medicine, 2002)

This shift in emphasis, from curing to healing, also implies that healing is possible even when curing is not.

At present, the trend of medical practice is focused almost entirely on curing and applies little attention to healing. Integrative medicine believes that both curing and healing are needed to bring medicine to a new level. Although a medical system providing healing without curing, like medicine might have been 400 years ago, is inadequate, a medical system which provides curing without healing is not sufficient Healing provides an avenue for patients, specially those with serious chronic and degenerative diseases who cannot be rendered asymptomatic with full functioning even with the best of care, to find meaning and purpose in the midst of illness, and to optimize relationships with family and friends. (Sullivan, TCM World, 2003’)

Success is now defined as helping the patient find an inner peace that results in a better quality of life, whether the problem can be fixed or not.

Providing both evidence-based curing and mind-body-spirit healing is medicine at its best

In spite of the high number of visits to CAM practitioners, most patients do not inform or discuss them with their primary doctors

What patients want from their health care provider:

- That they take time to talk to them and explain in a language that they can understand the nature of their problem

- That they go over options of treatment with them

- That they understand the influence and effects of diet on their health

- That they understand the influence and effects of supplements and herbs on their health

- That they are aware of mind-body interactions and energetic medicine

Western medicine has, in general, a very negative view of illness. Integrative medicine regards health and disease as two aspects of the same whole, much like the concept of yin and yang. For example: a certain degree of illness is essential during childhood to strengthen and develop the immune system. Current theories that are gaining support point towards an “excessive” sanitation that has caused kids to lack a sufficient exposure to allergens, such as dirt, during their upbringing, which in turn prevents the maturation of a strong immune system and could account for the epidemic proportions of asthma in U.S.

A recent survey by Sullivan of 283 North Carolina physicians showed that 89% felt that spirituality was important to health and 64% felt that it was important for physicians to address, yet 75% felt that their training did not prepare them to do so.

Health in body, mind and spirit.

Western medicine is comfortable with the first, somewhat with the second and not with the third.

Integrative medicine is built upon relationships: It is important for the doctor to get to know the patient (family, background, how they see the world, their emotional responses to the environment, their goals and passions, what makes them feel good or enhanced).

“It is much more important to know what sort of patient has the disease than what sort of disease the patient has”

Sir William Osler

Often, the main motivation for patients to seek CAM is not the treatment itself but the higher likelihood to get an explanation for the treatment that they will get and the likelihood to get recommendations for lifestyle and home care.

Perhaps one of the most essential elements of the model of integrative medicine is that practitioner and patient are partners in the healing process, rather than the doctor being on a pedestal imparting his wisdom to the patient. The doctor-patient relationship implies responsibility on the part of the patient for his or her own healing, and an exchange of information that will enhance the healing process.

Albert Schweitzer said:

“Every patient carries his own doctor inside. We are at our best when we give each doctor who resides in each patient the chance to go to work.”

A lot of the care that is part of integrative medicine is comprised of things that a patient can do on his or her own. The medical practitioner can give the patient tools and information that they take away with them to enhance their own health care.

And finally, perhaps the most radical departure from conventional medicine as traditionally taught in medical schools:

Integrative medicine asks the practitioner to model healing and commit to his or her own self-exploration. (Tracey Gaudet, M.D., Andrew Weil’s Integrative Medicine)

A Practice Model

“Cure sometimes, heal often, support always.”

-Hippocrates

Integrative medicine is based on a partnership between patient and practitioner within which conventional and alternative methods are used to stimulate the body’s healing response

In his article “Where Medicine Meets Mind,” Peter Jaret cites a poignant example that illustrates the need for this new model of medicine:

He describes a patient, Carrie Carlson-Scoglio, who, plagued by symptoms for much of her life, was diagnosed 11 years ago with fibromyalgia. After trying alternative treatments such as herbal remedies and homeopathy and traditional prescription drugs like steroids and anti-inflammatories, she found an array of conflicting advice. “You get doctors who say that alternative approaches are nonsense and alternative practitioners who tell you that you’re being poisoned by the drugs doctors prescribe. After a while, you wonder if any of them really knows what they’re talking about,” she says.

Jaret quotes Steven Rosenzweig, M.D., director of the Center for Integrative Medicine at Thomas Jefferson University Hospital in Philadelphia: “There are still plenty of physicians out there who are uninformed, uninterested, or even hostile when it comes to CAM approaches. At the same time, alternative practitioners are often overly suspicious and uninformed about conventional medicine. And patients are the ones who get caught in the cross-fire” (page117)

How can we get the taste and experience of an integrative model?

A possible way to introduce this is saying that it is not just putting under one roof a conventional doctor, an acupuncturist and an aromatherapist and call it integrative. No! There is nothing integrative about that. Finding how we can combine each thing, what works and what not, how can each one work together from different angle on the same patient is a different process.

As the term “Integrative” becomes prestigious, more and more offices and centers are adopting the name without really being so. A genuine integrative medicine center should employ trained medical doctors as well as experts in a variety of alternative disciplines.

Breakdown of CAM:

1- Movement Therapies (Feldenkrais, Alexander Technique)

2- Manual Therapies (Quiropractic, Osteopathy, Massage)

3- Energy Based Medicine (Reiki, Therapeutic Touch)

4- Systems of Care (TCM, Ayurveda, Homeopathy)

5- Botanical Medicine (Western, Chinese)

6- Nutritional Medicine (Diet & Nutrition)

7- Functional Medicine

8- Mind-body therapies (Hypnosis, meditation, guided imagery)

Figure 3

Use western biomedicine to “put out the fire” Use CAM to nourish and restore balance.

Western: acute conditions, trauma, sever infections

CAM: chronic conditions

Treatment Model of Integrative Medicine:

1- Diet

2- Lifestyle

3- Herbs

4- Supplements

5- Modalities

6- Systems of Care

7- Conventional Care

If a person is already combining conventional and CAM therapies on his or her own, it’s worth seeking out a center that offers integrative medicine-especially if it is a chronic condition. That way, there will be a team of experts supervising the treatments with less risk of adverse reactions.

Most of these centers are associated with teaching hospitals and academic medical centers, though a small number of private practices are beginning to integrate themselves.