Introduction to the practice of integrative medicine

CHAPTER 6 INTRODUCTION TO THE PRACTICE OF INTEGRATIVE MEDICINE


Throughout history, every civilisation and culture has developed its own form of medicine. The rise of modern technology and scientific enquiry has added new therapeutic techniques, products and services to the range of traditional therapies. Thus, within today’s pluralistic, multicultural and increasingly globalised societies, the wisdom and therapeutic interventions of many different traditions are becoming available. While it is impossible for any practitioner to have access to, or even know something about, the many hundreds of therapeutic interventions available, it is possible to incorporate some of the key principles into today’s conventional healthcare practice. This leads to the practice of integrative medicine (IM), which attempts to define and embrace these principles.


The practice of IM is more than simply an expansion of conventional medical practice to include ‘complementary therapies’ such as mind–body techniques, acupuncture, herbs, nutrients and body work (for example, massage and manipulation). It involves:


• a focus on the whole person: the interplay between the physical, emotional, spiritual and psychological states

• highly individualised treatment plans that are tailored to meet the needs of the person

• development of a therapeutic partnership between the patient and practitioner as a fundamental part of the healing process

• a primary focus on prevention, health enhancement and addressing predisposing, exacerbating and sustaining causes of disease

• integration of the best available, evidence-based, safe and ethical therapies from different traditions.

As such, IM implements principles that form the basis for clinical decision making and improving patient outcomes, by providing each patient with effective and compassionate care and healing on many levels. IM is increasingly being acknowledged as ‘best practice’; however, it requires some fundamental shifts in the way in which healthcare is delivered and has not yet become widely implemented (Cohen 2005a). For example, the use of complementary medicines is an integral part of IM practice, yet this use raises many issues for medical practitioners, particularly those who have not received training in how to use them. Some of the questions are:


• What can be reasonably expected by providing integrative care?

• What are the safety issues?

• Which therapies are cost-effective?

• What advice should be given to patients in the absence of definitive evidence?

• Which therapies or products are useful for which conditions and which patients?

• Where can high-quality complementary and alternative medicine (CAM) products be obtained?

• Which specially trained practitioners should patients be referred to, and when, how and for what reasons should referrals be made?

• Where can reliable information about CAM be found, and what pathways are there for further study?

These are core issues in any healthcare practice and are not specific to the use of complementary medicines or even to the practice of IM. The practice of IM, however, poses additional challenges to medical practitioners, both professionally and personally. It requires being prepared to learn about new and different treatment systems, traditions and ways of thinking, and recognising the advantages and limitations of both complementary and conventional medicine and the potential benefits of combining them. It also requires adopting a collaborative approach with patients and a variety of different healthcare professionals, while allowing old beliefs to be challenged and re-evaluated. Furthermore, the practice of IM challenges medical practitioners to develop their intuition, empathy and compassion, address their own health and personal growth, and become role models for their patients and the wider community. From a practical perspective, developing IM takes extra time. Time is needed to keep up to date with the changing evidence base, as well as to establish a holistic understanding of patients and then apply the principles of IM to address their needs.



HOLISM AND THE INDIVIDUAL


In their professional training, medical practitioners study the biological, psychological and social aspects of health, as well as the signs, symptoms and pathophysiology of specific illnesses, to achieve an understanding of health and disease in a clinical context. This knowledge base must be updated and modified with new knowledge provided by new scientific evidence and cumulative clinical experience. Although consideration of the best available evidence is an important dimension of clinical practice, scientific data are often based on a group of observations that give statistical information about research populations, but which may not provide definitive information about what will happen to any individual patient in certain circumstances.


Each human being is unique and presents in a specific clinical context, in which the outcome will be determined by personal attributes such as attitudes, education and understanding, as well as by genetics, physiology, past experiences, socioeconomic and cultural circumstances, available resources and lifestyle. Accounting for individual differences is an essential aspect of the art of medicine and is a cornerstone of many ancient systems of medicine.


Chinese medicine, Ayurvedic medicine and Western herbal medicine all have sophisticated systems of categorising people according to their different physiological and psychological characteristics in order to guide treatment selection. In comparison, modern Western medicine has been slow to accept and use this individualistic approach, preferring to standardise treatment approaches through clinical guidelines and protocols. The fields of pharmacogenomics and nutrigenomics, which have emerged out of the Human Genome Project, are beginning to provide a scientific rationale for individualising treatments. These new fields emphasise two factors: individualised response to medicines and nutrients, and the roles of dietary and genetic interactions in patient health.


The practice of IM combines both ancient and modern knowledge, and takes a holistic perspective that recognises that health involves physical, psychological, social, spiritual and environmental dimensions. This is in line with increasing patient expectations to have the accompanying social and psychological aspects of their illness addressed, not just their presenting symptoms (Jonas 2001). Thus the practice of IM requires careful history taking and physical examination, which may include obtaining information from different philosophical perspectives, together with astute and appropriate investigations and obtaining other information from relatives or carers.


Accounting for individual factors takes considerable time, yet this time is well spent because there is mounting evidence to suggest a direct relationship between consultation length and the quality of care. Longer consultations are likely to result in better health outcomes and better handling of psychosocial problems, fewer prescriptions, more lifestyle advice and lower costs, less litigation and more patient and doctor satisfaction (Cohen et al 2002).



THERAPEUTIC RELATIONSHIPS


Although amassing personal information about a patient is a time-consuming process, it is an extremely valuable one, not only for the information gleaned but also because it facilitates the development of rapport, respect and trust, thus laying the foundation for the therapeutic relationship. The development of close and meaningful relationships with people in a clinical context is one of the great challenges of holistic or integrative practice. It is also one of the most powerful therapeutic tools clinicians have and may be more important than any specific treatment modality.


The therapeutic relationship is a profound and sacred one, acknowledged since ancient times and codified in the Hippocratic oath, which has specific phrases that dictate the principle of doctor–patient confidentiality, as well as the responsibility of clinicians to exercise a duty of care. A therapeutic relationship is established with the specific intention of healing, and the act of establishing such a relationship, in which intuition and empathy are valued alongside information and evidence, may be therapeutic in itself. Simply articulating one’s personal story and expressing traumatic experiences to a sympathetic listener can help people make connections and better understand the causes and implications of their disease, as well as providing much needed psychosocial support.


Healthcare professionals commonly see people at their worst: when they are in pain and/or feeling sick, scared, sleep deprived and fearful of the possible implications of an illness. The constant stream of ‘sick people’ can make it easy to start differentiating patients by their illnesses; however, thinking of people in terms of their highest level of functioning may be more productive. To this end, some of the most important questions a practitioner can ask are: ‘What makes you happy?’ or ‘What makes you feel alive?’ The answers to these questions can provide valuable insight into an individual and form the basis for a more meaningful relationship than the answer to the question: ‘What is the problem?’


Developing rapport, trust and a holistic understanding of patients’ lives is one of the most important elements in IM, because it places practitioners in a better position to allay their patients’ fears, adequately address the issues of most concern, and help to reduce the burden of stress that accompanies virtually all illness. A holistic understanding of a person also enables clinicians to recommend treatments that are more likely to be successfully integrated into a patient’s social and cultural environment, thus improving efficacy and compliance. Furthermore, a sound therapeutic relationship provides the camaraderie and sense of therapeutic adventure necessary to underpin a partnership model of health and provides a solid foundation for clinical decision making.



PRACTITIONER WELLBEING


Healthcare professionals experience significant mental, physical and spiritual demands during the course of everyday practice. In addition, personal stress can influence the ability to deliver effective care, establish therapeutic relationships and maintain good health. Over time, exposure to multiple stressors can lead to physical and emotional exhaustion, or burn out, with its accompanying physical and psychological burden (Dunning 2005).


For some practitioners, there is a perceived pressure to symbolise perfect health and be invulnerable to disease. As a result, there is the temptation to avoid indications of ill health in themselves and their colleagues and a failure to see the need for self-care.


The practice of IM compels clinicians to address their own health and lifestyle, explore their emotional life and develop self-care routines to maintain wellbeing and prevent disease. In addition, the therapeutic relationship developed with patients can be nurturing for the practitioner, with rewards that flow in both directions (Cohen 2005b).


In advocating a holistic view of health, the practice of IM can motivate practitioners to become more involved in broader community, public health and global issues, such as social justice, fair trade, environmental preservation, regeneration and sustainability, as well as spiritual, ethical and philosophical debates and pursuits.



INTUITION, BEDSIDE MANNER AND PLACEBO


Medicine is an art informed by science, yet with so much recent attention being given to scientific evidence, it is easy to forget the importance of intuition and clinical experience. A holistic understanding of a patient, together with empathy and compassion for a patient’s circumstances, adds important information to any clinical encounter. It is likely that the best and most inspired practice occurs when the practitioner’s academic knowledge, clinical experience and intuitive understanding of the individual merge to provide a picture of the clinical situation as a coherent whole, known as the ‘Gestalt’ approach.


Developing an intimate therapeutic relationship and integrating rational and intuitive knowledge enlists the full capacity of the practitioner. It may also be the best way to tap into patients’ unconscious healing processes and elicit the ‘placebo response’. The placebo effect is often considered a source of bias and a scientific distraction that research methodology must minimise; however, the placebo response is ubiquitous and cannot be avoided in the clinical setting. All interventions have a non-specific therapeutic action, in addition to their purported activity, and the best clinicians will always use their ‘bedside manner’ to harness the ‘placebo response’ and enhance the therapeutic benefits of any specific intervention. Herbert Benson suggested that the placebo response is based on a good therapeutic relationship, as well as positive beliefs and expectations on the part of the patient and practitioner and furthermore can yield beneficial clinical results and be a powerful adjunct to therapy. Benson, who coined the term ‘the relaxation response’ in reference to meditation, further suggested that the placebo response should be renamed ‘remembered wellness’, and that it may be one of medicine’s most potent assets because it is safe, inexpensive and accessible to many people (Benson & Friedman 1996).


In addition to the use of rapport, empathy, compassion, trust, confidence and intimacy, an integral part of a good bedside manner is the appropriate and thoughtful use of touch. Touch pulls together psychological and bodily experiences and is important in relationships between people in general, and the therapeutic relationship in particular. It is a basic human need that enhances communication and builds up trust. A simple handshake to acknowledge each other’s presence or hand-holding when bad news is delivered can provide important and reassuring support that goes beyond words. The therapeutic power of touch has been recognised and practised throughout history: for example, through the art of massage, which, when provided by trained practitioners, can produce substantial therapeutic effects, enhance a person’s sense of wellbeing and promote a sense of calm and peace.



BIAS IN MEDICAL DECISION MAKING


How do people make decisions and how do they choose between different treatment options? Decisions are made using ‘heuristics’, or general rules of thumb, which reduce the time and effort required. Normally this method yields fairly good results; however, there are times when they lead to systematic biases (Plous 1993). In these situations, assumptions are made and information is neglected, downplayed or overplayed, or based on what is easily recalled. In healthcare, unrecognised bias of this nature can have dire repercussions, affecting a clinician’s ability to diagnose and treat effectively and a patient’s ability to make good choices.


It is both normal and human to have a range of biases that influence the types of treatments that are considered appropriate, based on the individual’s personal, ideological, religious, ethical, cultural, educational and philosophical ideals and experiences. Good clinicians are aware of their personal biases and will openly disclose those that may influence a patient’s care. In some cases, this is easier said than done. Stating known or potential bias can be particularly sensitive when the practitioner has strongly held religious beliefs that may limit their practice or determine their attitudes to different therapies, as well as when it comes to declaring commercial interests.


Healing is a human vocation that arises from the desire to do the best for humanity. The patient–practitioner relationship, however, is not only a therapeutic one, it is commonly a commercial one. Healing is a business that sustains the personal lives of individual practitioners and drives the pharmaceutical industry. In 2002 the combined profits for the top 10 drug companies in the Fortune 500 list were greater than those of all the other 490 companies combined (Angell 2004).


One important source of bias that is becoming increasingly recognised concerns the millions of dollars spent by the pharmaceutical industry in a bid to influence doctors’ decision making. The seemingly unlimited marketing budgets and provision of gifts, luxuries and educational events has forced the medical profession to attempt to limit these sorts of inducements (Studdert et al 2004). The extent of the industry’s influence is vast and has not always been obvious. In her book on the pharmaceutical industry, Marcia Angell, a former editor-in chief of the New England Journal of Medicine, states:



Over the past two decades the pharmaceutical industry has moved very far from its original high purpose of discovering and producing useful new drugs. Now primarily a marketing machine to sell drugs of dubious benefit, this industry uses its wealth and power to co-opt every institution that might stand in its way, including the US Congress, the FDA, academic medical centers, and the medical profession itself.



Angell 2004


Not only are doctors subject to the influence of the pharmaceutical industry, they may also have other pecuniary interests that could bias their clinical decision making, such as commercial interests in pathology companies and their own clinical dispensaries.



COMPLEMENTARY MEDICINE PRODUCTS


Several thousand complementary medicine products are now available on the market, the vast majority of which are available without prescription. Choosing the best product, correct dose and time frame for use, and having realistic expectations of the treatment are just some of the factors that healthcare practitioners must consider before recommending a specific product (Table 6.1). These factors, which are addressed in further detail in the monographs and chapters of this book, must be considered in the light of each individual patient’s circumstances, including their condition and co-morbidities, renal and hepatic function, personal preferences, financial resources and their ability to self-monitor their condition.


TABLE 6.1 Factors to Consider When Recommending a Complementary Medicine





















Product factors Comments
Mechanism/s of action
How well established are these?

Do they seem plausible?
Evidence and expectations
Is it likely to achieve treatment goals? In what time frame?

Do not rely on label claims alone.

Consider the type of evidence available for this particular indication.

For herbs also consider: extract and plant part/s tested.

For nutrients: consider chemical form and bioavailability.
Dose and administration route Ensure these are correct for the specific indication.
Frequency, timing and ease of use Reduced frequency improves compliance. Consider timing, such as before, during or after meals.
Quality control standards
Not all countries impose high quality control standards on the manufacture of complementary medicines; e.g. the USA.
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Jul 18, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Introduction to the practice of integrative medicine

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