Integrative Medicine

Treating the Whole Person
Both doctors and patients alike are bonding with the philosophy of integrative medicine and its whole-person approach — designed to treat the person, not just the disease.

IM, as it’s often called, depends on a partnership between the patient and the doctor, where the goal is to treat the mind, body, and spirit, all at the same time.

While some of the therapies used may be nonconventional, a guiding principle within integrative medicine is to use therapies that have some high-quality evidence to support them.

Conventional and Alternative Approaches
The Duke Center for Integrative Medicine is a classic model of integrative care. It combines conventional Western medicine with alternative or complementary treatments, such as herbal medicine, acupuncture, massage, biofeedback, yoga, and stress reduction techniques — all in the effort to treat the whole person. Proponents prefer the term “complementary” to emphasize that such treatments are used with mainstream medicine, not as replacements or alternatives.

Integrative medicine got a boost of greater public awareness — and funding — after a landmark 1993 study. That study showed that one in three Americans had used an alternative therapy, often under the medical radar.

In the past decade, integrative medicine centers have opened across the country. According to the American Hospital Association, the percentage of U.S. hospitals that offer complementary therapies has more than doubled in less than a decade, from 8.6% in 1998 to almost 20% in 2004. Another 24% of hospitals said they planned to add complementary therapies in the future. Patients usually pay out of pocket, although some services — such as nutritional counseling, chiropractic treatments, and biofeedback — are more likely to be reimbursed by insurance.

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The Appeal of Integrative Medicine
What makes integrative medicine appealing? Advocates point to deep dissatisfaction with a health care system that often leaves doctors feeling rushed and overwhelmed and patients feeling as if they’re nothing more than diseased livers or damaged joints. Integrative medicine seems to promise more time, more attention, and a broader approach to healing — one that is not based solely on the Western biomedical model, but also draws from other cultures.

“Patients want to be considered whole human beings in the context of their world,” says Esther Sternberg, MD, a National Institutes of Health senior scientist and author of The Balance Within: The Science Connecting Health and Emotions.

The Mind-Body Connection
Sternberg, a researcher who has done groundbreaking work on interactions between the brain and the immune system, says technological breakthroughs in science during the past decade have convinced even skeptics that the mind-body connection is real.

“Physicians and academic researchers finally have the science to understand the connection between the brain and the immune system, emotions and disease,” she says. “All of that we can now finally understand in terms of sophisticated biology.”

That newfound knowledge may help doctors to see why an integrative approach is important, she says.

“It’s no longer considered fringe,” Sternberg says. “Medical students are being taught to think in an integrated way about the patient, and ultimately, that will improve the management of illness at all levels.”

The Osher Center for Integrative Medicine at the University of California, San Francisco, takes a similarly broad view of health and disease. The center, which includes a patient clinic, says on its web site: “Integrative medicine seeks to incorporate treatment options from conventional and alternative approaches, taking into account not only physical symptoms, but also psychological, social and spiritual aspects of health and illness.”

To promote integrative medicine at the national level, the Osher Center and Duke have joined with 42 other academic medical centers — including those at Harvard, Columbia, Georgetown, and the University of Pennsylvania — to form the Consortium of Academic Health Centers for Integrative Medicine.

Medical Schools and Integrative Medicine
Even medical schools have added courses on nontraditional therapies, although doing so can sometimes be a point of contention among faculty.

At the University of California, San Francisco, medical students can augment their coursework in infectious disease and immunology with electives, such as “Herbs and Dietary Supplements” or “Massage and Meditation.” They can even opt to study as exchange students at the American College of Traditional Chinese Medicine. In the world of integrative medicine, it’s not unusual to see a Western-trained MD who also has credentials in acupuncture or hypnosis, or a registered nurse who is also a yoga teacher and massage therapist.

Opposing Views
Not all doctors are jumping onboard, though. Some critics have charged that integrative medicine is driven largely by market forces, as well as public fascination and demand for alternative treatments.

“This is a very faddish country,” says Tom Delbanco, MD, a Harvard Medical School professor and doctor at Beth Israel Deaconess Medical Center in Boston. In one national survey of hospitals that offer complementary therapies, 44% listed “physician resistance” as one of the top three hurdles in implementing programs, along with “budgetary constraints” (65%) and “lack of evidence-based research” (39%).

Delbanco says he’s concerned that there’s not enough scientific evidence to justify the amount of resources spent on integrative medicine and complementary therapies. “I worry that people are making claims in the context of scientific medicine that they cannot really justify. I think there have been few rigorously controlled, scientifically sound studies in the area, and when they have been done, the vast majority have shown these medicines to be no different from placebo.”

“I have no trouble with offering hope,” he adds. “I think people need hope and optimism. Where I have trouble is when we promise things to people that aren’t real.”

Finding the Evidence
The search for solid evidence is key: which therapies help and which don’t? “There’s a clamoring for understanding the biology of this,” Sternberg says. Many proponents of integrative care say that it’s crucial to hold alternative therapies up to scientific scrutiny, rather than dismissing them outright, because doctors and patients alike need answers. For example, a patient may be taking an herb that is harmful or may interfere with prescription drugs.

As a result, researchers across the country are studying complementary and alternative therapies for safety and effectiveness. Duke is studying whether stress-reduction techniques, such as meditation and writing in a journal, can help prevent preterm labor, which can be precipitated by stress-related hormones. In other clinical trials, researchers are trying to determine, among other things, how acupuncture affects brain activity, how biofeedback can better treat incontinence, and whether the medicinal herb valerian improves sleep in patients with Parkinson’s disease.

With the large numbers of people using nontraditional therapies, even finding out what doesn’t work can be valuable. For example, researchers affiliated with the Osher Center at the University of California, San Francisco, completed a study that showed that saw palmetto did not improve benign prostate hyperplasia, a noncancerous enlargement of the prostate gland. More than 2 million men in the U.S. take saw palmetto as an alternative to drugs. The results were published in The New England Journal of Medicine.

Tracy Gaudet, MD, director of the Duke Center for Integrative Medicine, says she encounters little resistance once fellow doctors understand that integrative medicine doesn’t entail “blindly advocating for alternative approaches and rejecting conventional ones.”

“That’s not what we’re about,” she says. “There’s a lot of quackery out there and a lot of dangerous therapies. Our first priority is to guide people away from them.”