Introduction to the concept of integrative medicine

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chapter 1 Introduction to the concept of integrative medicine

Professor Kerryn Phelps

Dr Craig Hassed

This is a general practice textbook with a difference. It is designed to be a practical guide to integrative general practice.

We have been general practitioners (GPs) for over two decades. In that time a GP will have seen and heard just about every clinical scenario. We have also seen many medical fads come and go, such as the fashion for prescribing hormone replacement therapy to every perimenopausal woman because it was supposed to improve her future health, the rise and fall of non-steroidal anti-inflammatory drugs for managing arthritis pain, and the passing epidemic of repetitive strain injury. We have similarly seen many natural therapy and dietary fads come and go. Many experienced practitioners will remember the era when every other patient arrived with the news that they had ‘hypoglycaemia’, and then there was the ‘systemic candida’ phase.

We have experienced the intellectual excitement of the ‘clever’ diagnosis, the sadness of delivering bad news to a patient, the delight of guiding a patient back to health, and the frustration of hitting a brick wall when our Western medical training left us feeling there was nothing further we could offer.

The emergence of evidence-based medicine and, more recently, evidence-based complementary medicine is challenging many previously held notions of best practice. As evidence emerges, many Western medical therapies are being confirmed as correct, or challenged as ineffective or harmful. Similarly, many complementary therapies are being confirmed as correct, while others are being found ineffective or harmful. Such is the inevitable evolution of healthcare.

It is also important that evidence-based healthcare at every level be considered a ‘work-in-progress’, whether it is in the discovery of the genetic basis of disease, the development of previously untested technology or the clinical application of a treatment. The nature of scientific research is such that new information becomes available at a great rate, and that knowledge often changes the status quo.

It is in the GP’s consulting room that patients ideally have the opportunity to explore what is likely to be the best option for their healthcare. We see the gamut of health concerns, from a person wanting a check-up and interested in doing more to maintain good health, to a patient who is symptomatic and wanting a diagnosis and treatment, or a patient with an established diagnosis who is looking for either a cure or a way of optimising their wellbeing as they live with their illness.

Like that of our colleagues, our medical training was in the allopathic model. Through a combination of professional and personal experience and further study, our practice paradigm has gradually evolved into an integrative model of healthcare.

We do not expect to become proficient in every modality of therapy. However, we do believe that patients should expect their doctor to be familiar with a comprehensive range of therapies likely to work in their circumstances, and what the risks and benefits are likely to be. In this way general practice will be enriched and patient outcomes enhanced. Patients are increasingly looking for an integrated model of healthcare and much prefer it to be delivered, or at least coordinated and supervised, by their family doctor rather than having to fly blind, often without their doctor’s knowledge or approval.

Western medical practice coexists with many other healing traditions, whether doctors are aware of it or not. And just as GPs work in partnership with other medical specialties, so we can also work more effectively with appropriately qualified complementary and alternative healthcare providers.

One of the impediments to working in an integrative model is the lack of a common language between practitioners of different persuasions. For example, the concepts of ‘yin and yang’ and ‘chakra’ are not easily explained in medical school language. However, the fact that we may not understand the language, mechanisms or concepts of these therapies and modalities does not mean that they do not have a great deal to offer. As doctors become more familiar with different therapeutic options, so their familiarity with these terms will increase. Similarly, as doctors and other healthcare practitioners increasingly work together in teams or ‘virtual teams’, a common form of communication is emerging.

WHAT IS INTEGRATIVE MEDICINE?

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.

(Developed and adopted by the Consortium of Academic Health Centers for Integrative Medicine, May 2004, edited May 2005)

Integrative medicine, as defined by the US National Center for Complementary and Alternative Medicine, combines conventional medical treatments and alternative treatments for which there is some high-quality scientific evidence of their safety and effectiveness. Integrative medicine also implies a greater emphasis on patient empowerment and choice, holism, lifestyle interventions and, wherever possible, using the safest and simplest option available.

The term ‘integrative medicine’ is not interchangeable with ‘complementary or alternative medicine’ (CAM), although many people confuse them. Integrative medicine is about incorporating a range of modalities of healthcare into practice so that practitioners can expand the options available to patients, with healthcare providers from different paradigms ideally working in cooperation rather than competition.

In addition to providing best-practice medical care, integrative medicine focuses on prevention of illness, treatment of illness and maintenance of health, by incorporating all factors that may affect health outcomes, including lifestyle—diet, exercise, stress management—and emotional and spiritual wellbeing. It requires patients to be active participants in their own healthcare. The medical practitioner’s role in the integrative model is a combination of advisor, role model, patient advocate and source of reliable recommendations for therapeutic options. Therapeutic options might include nutritional changes, exercise prescription, nutritional supplements, herbal remedies, bodywork, acupuncture, psychological counselling, prescription medication, surgery and more.

THE HEALTHCARE REVOLUTION

Healthcare is about to come full circle. From its beginnings as an integrated and holistic art, through the epochs of allopathic–scientific practice, it is evolving back to its roots as an integrative system of health maintenance and disease management.

THE PAST

Dis-integration and reductionism

Hippocrates, Plato and Aristotle were among the first proponents of the holistic model of healthcare in Western history, believing in the combination of the physical and spiritual elements of the human condition

In the early 1600s, Rene Descartes philosophically split the mind and body, and some time after that the reductionist movement sought to find simple explanations for the function of the human body.

The Flexner report of 1910 ensured that medical training was based strictly on a materialist interpretation of the scientific model, maintaining the principle of the Cartesian split or the mind/body duality, and teaching core disciplines as if they were unrelated to each other. The focus was squarely on illness and little attention was given to wellness and prevention.

Subspecialisation of medical care followed and, philosophically, further fragmented the human body into its composite organs and systems. Rather than subspecialisation, the term ‘partialisation’ could be used.

While there is undoubtedly merit in the concentration of knowledge and expertise in specialised areas, this fragmentation simply does not account for complex or chronic diseases, or for the significant effects of psychological, social, environmental and spiritual factors in the health and healing of the whole person.

An ‘us and them’ mentality

There is still a prevailing, though gradually dwindling, ‘us and them’ mentality in the practice of healthcare, with ‘orthodox’ medical practitioners in one corner and CAM proponents in the other. This mistrust between practitioners in different fields is based on complex historical factors. Non-medical practitioners often see people who have been mistreated, or are disillusioned, disappointed or unable to be helped by traditional Western medicine. Medical practitioners often see patients who have tried alternative treatments unsuccessfully or for whom diagnoses were missed or wrong. With the human tendency to generalise from personal experience, these encounters influence how we view other paradigms. ‘Alternative’ is often held to be synonymous with ‘unproven’. ‘Allopathic’ is often held to be synonymous with ‘soul-less’.

The history of medical science has created a deliberate lack of integration of mind, body and spirit in the pursuit of one possibly narrow interpretation of the scientific model. Many doctors remain unaware of the evidence for CAM. This is partly due to scientific evidence for some modalities being relatively recent or published in other languages and so not readily available to doctors trained in the English language. There is often a false sense of confidence that all allopathic treatments are all strongly evidence-based. Past failed experiments like MUA (spinal manipulation under anaesthesia) for back pain, or bone marrow transplantation for metastatic breast cancer, are examples of non-evidence-based treatments that have since been abandoned. Most antibiotic prescriptions have little evidence to support them. Even the evidence for commonly prescribed antidepressants is under question. The impact of commercialisation on medical research and practice is such that patients and non-medical practitioners are questioning the foundations of conventional medical care.

The integration of CAM modalities into general practice has not been helped by the perception of a ‘lunatic fringe’ making claims that have not or cannot be substantiated and may do harm or delay effective treatments, or of unqualified and unregulated practitioners adversely affecting the reputations of highly trained and skilled practitioners.

NOW

The practice of healthcare is in a state of rapid transition. Technological and pharmaceutical advances have been accompanied by an increasing desire for natural and holistic healing. In this information age, patients are more empowered by knowledge and this has resulted in a change in the balance of power in the therapeutic relationship. Along with the explosion in information and the increased availability of complex technological solutions has come an increase in the expectations of patients and less tolerance of uncertainty. The emergence of evidence-based medicine has created an increased demand for evidence of efficacy for all modalities of treatment.

Ideally, integrative medicine combines the best of allopathic medicine and the best of CAM practices into comprehensive treatment plans, working with the body’s natural healing potential and based on the individual patient’s needs and preferences. Integrative healthcare is not just about procedures or substances. It is about a philosophy of living, helping to create optimum environments for good health.

This may sound like common sense but historically, and still today, there are impediments to achieving this balance in the health field in a way that focuses solely on the wellbeing of the patient.

Stories from our student days were valuable learning experiences for us. From Kerryn’s experience comes the following story:

I had just completed my surgery exams. During the exam, I was given a problem that involved a group of symptoms that made no sense to me. It was clear that this had not been in the syllabus for that term. Shortly after I left the exam, I encountered my surgery professor on the ward. He asked me how the exam had gone, and I told him how annoyed I had been that there was a question I could not answer because the condition described had not been taught to us. He nodded and smiled, then he gave me some advice I have carried with me throughout my clinical career. He said, ‘Any condition of the human body, any problem that could ever present itself to you in practice requiring diagnosis and management … that is the syllabus for medical training.’

Craig remembers being in a cardiology lecture at the beginning of his first clinical placement in fourth year:

The head of cardiology stood up at the beginning of the first lecture and commenced to tell us about all the foolish and naive things doctors used to believe 100 years ago about the causes and treatments for heart disease. We laughed. Then he said, ‘What do you think they will say about what I am about to teach you 100 years from now?’ I stopped laughing and reflected on how impermanent so-called ‘scientific knowledge’ is. Much of what we as students and doctors take to be fact is really just opinion, fiction or fashion. Times change and we learn from improved evidence and our mistakes, but always through the prism of our culture and upbringing.

And so it is with the story of everyday clinical practice. For most of us, medical training cannot prepare us for every possible clinical problem or for the expectations of today’s consumers or the consumers of the future. We are regularly presented with problems, some of which cannot be solved with the tools of our particular trade as we originally learnt it. This is no reflection on us as individual practitioners, or on our profession. Just as we do not have the training or the skills to remove a cerebral aneurysm or perform an anterior resection, we may not practise acupuncture or hypnotherapy, but we do see patients who will benefit from those treatments and happily refer them to skilled practitioners when it is appropriate.

Through expanding our own awareness and skill, we can expand the options available to our patients, by looking at the evidence for an integrative approach and by working in cooperation with other practitioners.

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