In 1998, Jeffrey Brantley, MD, was knocking on colleagues’ doors, trying to raise the visibility of a new project. He had just launched a Mindfulness-Based Stress Reduction program at Duke University Health System, the beginnings of what would become Duke Integrative Medicine. He laughs when he tells the story of the reception he got from some physicians. One prominent gastroenterologist eagerly agreed with Brantley about the importance of the mind–body connection, and described the role of stress in many of the cases he saw every day. “Let me show you something,” he told Brantley, pulling a book on holistic healing out of a filing cabinet. “I have to hide this book, because if my colleagues saw it, they’d think I was crazy.”
More than a decade later, fewer physicians feel the need to hide in the mind–body closet, and more medical centers around the country are embracing a holistic approach. Last year, more than six hundred health care professionals packed a standing-room only Summit on Integrative Medicine, held at the Institute of Medicine in Washington, D.C. The first of its kind, the summit brought together a range of experts to explore the practice of integrative medicine, its scientific basis, and its economic and policy implications.
To many, integrative medicine has become the one bright spot in a struggling health care system. It promises to control costs, prevent or reverse many chronic conditions, improve quality of life, and even return the idea of “health” to what is better described as a disease care system. But integrative medicine faces many challenges. Some conventional Western health care providers criticize integrative medicine for bringing what they view as unsupported and unscientific therapies into an evidence-based field. Others worry that its comprehensive approach to health and healing, while ideal, is too expensive to implement on a large scale. But the leaders in this emerging field are ready to tackle those challenges and prove that the U.S. is ready for a new kind of medicine.
What is Integrative Medicine Integrating?
The words “integrative medicine” may bring to mind holistic approaches such as acupuncture, massage therapy, and stress reduction. Although these can be important parts of an integrative approach, the field does more than merely integrate alternative and conventional medicine.
The Consortium of Academic Health Centers for Integrative Medicine defines integrative medicine as “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, health care professionals, and disciplines to achieve optimal health and healing.” Key to this definition is integrative medicine’s embrace of any therapy that supports health and healing, regardless of its origins. Treatment for cancer, for instance, might include everything from surgery and chemotherapy to diet, spiritual counseling, and yoga.
Integrative medicine also strives to integrate every aspect of the health care system, from self-care and primary care to urgent care and hospital care. This requires a level of communication and cooperation rare in modern health care. Integrative medicine also acknowledges the many resources a patient has outside of the medical system, including the body’s innate capacity for healing, the support of family and friends, cultural or religious beliefs, and the ability to find meaning within illness and suffering.
Finally, integrative medicine reflects a return to a core value of medicine—the power of the therapeutic relationship. This is easily overlooked in the modern, technology-driven culture of health care, but in integrative medicine, the time spent and the trust built between caregiver and patient is considered the foundation of effective health care.
Health Is More Than the Absence of Disease
Health, says Christiane Northrup, MD, is a vibrant thriving that includes pleasure, joy, and meaning. It is not simply the absence of disease.
Northrup is a leading advocate for women’s health and the winner of the 2010 Integrative Health Care Visionary Award. Part of Northrup’s vision is a world in which every individual recognizes his or her own capacity to create health. “True health care,” she says, “is often not found in hospitals—that is disease care,” she says. “They have a role, but your role in your own health is far more potent than hospitals, doctors, and insurance companies.”
Northrup says that even what medicine calls “health promotion” is usually just disease screening. “At a health fair, you can have your blood pressure taken, your cholesterol measured, and get a mammogram.” These tests can detect a problem, but they do little to create health, and by spending so much time and energy searching for what is wrong with the body, we miss opportunities to care for the body, mind, and spirit. Northrup recommends broadening our view of health care to include the things that create health and joy on a daily basis, whether it’s dancing the tango, reading a good book, or spending fifteen minutes a day in natural sunlight. “Begin to think about your health care as a program that you are in control of,” she says. “It includes your thoughts and beliefs and the people you spend time with. It includes turning off the news and getting massages regularly. Just being present with another human, being present in the moment, ramps up your circuitry of health.”
Moreover, Northrup says, true health care is possible even in the presence of pain, grief, or illness. Illness can provide the catalyst for learning how to be with yourself in a compassionate way, and focus your attention and energy on what matters most. “When you move toward that which is most fulfilling, pleasurable, and life-enhancing, healing follows, regardless of what your physical health is like in that moment.”
A New Kind of Medical Practice
“What if a visit to the doctor left you feeling replenished, rejuvenated, and motivated to make changes in your life? What if you belonged to a health care practice that understood every aspect of your well-being—physical, emotional, and spiritual?”
That’s the invitation on the website of Duke Integrative Medicine, part of Duke University’s world-class medical system. This promise of integrated care draws more than five thousand patients to the Duke center each year. They come for help with chronic conditions such as high blood pressure, cardiovascular disease, and diabetes, or to seek a holistic approach to cancer recovery or pain management. Some come simply to invest in themselves and their health. A visit to the center is called a “health immersion,” and patients can choose to spend half a day, a full day, or a week at the center. For local patients, the center offers a flat-fee annual membership that provides unlimited consultation with an integrative physician, ongoing personal support, gym membership, cooking classes, stress reduction programs, and more.
Whatever the health challenge or goal, and no matter how short the visit, every patient at Duke Integrative Medicine has their own core team of health care providers, including a physician, nurse, and health coach, who will help the patient select the services and specialists that meet their needs. The patient’s health immersion begins with an intake that might last ninety minutes and assesses all areas of the patient’s life. The patient then has a series of appointments with other specialists, such as a nutritionist or a health psychologist, and receives complementary therapies like massage, acupuncture, or reiki.
What if a visit to the doctor left you feeling replenished, rejuvenated, and motivated to make changes in your life? What if you belonged to a health care practice that understood every aspect of your well-being—physical, emotional, and spiritual?
Every patient is also introduced to the concept of mindfulness and the body–mind relationship. “Mindfulness is at the core of everything we do,” Brantley says. “We believe that the more mindful people can be as they face health challenges, the healthier they will be.” The center also offers mindfulness-based stress reduction classes to health care professionals, and all of their care providers and health coaches are trained to bring mindfulness into their interactions with patients.
Before the end of the immersion, the full team of core and complementary care providers meets to chart a plan individually tailored for the patient. The patient walks away not only with a list of recommendations for supporting his or her own health, but with established relationships with a team of health professionals. Health coaches follow up with patients by phone on a monthly basis to support their progress. “It’s not just about experts giving information and advice,” Brantley says. “The power of the individual to shape the trajectory of their own health is one of the main principles at Duke. It’s a core shift in paradigm. We partner with patients to help them be the single most important element in their own health and healing.”
Can We Afford It? Ford Says Yes
Programs like Duke Integrative Medicine are incredibly appealing—who wouldn’t prefer a dedicated team of medical professionals, and a full spectrum of complementary care, instead of a ten-minute rushed appointment with an overworked physician that ends with a single prescription and a lot of unanswered questions? But in debates about the practicality of integrative medicine, one question always comes up: Is integrative medicine—which requires more time, more health care providers, and a broader scope of services—financially feasible in a health care system that is straining to contain costs?
Kenneth Pelletier, MD, is on a mission to answer that question. As director of the University of Arizona’s Corporate Health Improvement Program (CHIP), Pelletier helps companies evaluate and implement a range of integrative health interventions in the workplace. The CHIP program is designed to address two of the most common objections to integrative medicine: One, it’s too expensive, and two, there’s not enough evidence that it works better than standard care.
Pelletier started CHIP in 1980 as a small health promotion project with IBM. When that program was bought by Johnson & Johnson, a light bulb went off for Pelletier. “I realized corporations have a vested interest in health. They need high-performing, healthy people. Their products depend on it. If you want to demonstrate the clinical and cost-effectiveness of an approach, this is the place to do it.” Thirty years later, even in the midst of health care reform, large companies recognize they are still going to be on the hook for their employees’ health care. This, Pelletier says, makes them very open to preventive and integrative interventions. “It does not matter to them if something is conventional or alternative medicine. Once these companies see something that works, they act, very decisively.”
One such company is Ford Motor. A few years back, its medical director came to CHIP with a very specific problem. Ford was spending eighty to ninety million dollars a year managing back pain. In addition to the cost of covering employees on disability, Ford was running its own fully-staffed health clinics in plants across the U.S. The company estimated that the cost of employees’ back pain alone was adding $400 to the price of every car Ford sold; medical costs in total were adding $2300. Since this was far more than foreign competitors like Toyota were spending, back pain had become a major barrier to remaining competitive. So the medical director asked CHIP: Is there a way Ford could better manage back pain that would cost less?
CHIP helped Ford implement an integrative approach to back pain at a randomly selected engine assembly plant in Kentucky. The approach included the usual care offered at Ford’s clinics, plus onsite clinical acupuncture, mindfulness-based meditation and body mechanics training, and referral to chiropractic services when appropriate. Pelletier wasn’t sure how blue-collar assembly line workers would respond to the less conventional therapies. “When we first went to Louisville, we had to meet with the unions and Ford’s medical team. The very first person said, ‘What’s this acupuncture?’ And I thought, we’re in trouble. But the good news about companies is that they are agnostic. They want to get people healthy and back to work, so they can save money. They’re very practical, and they set aside bias. They’re not against any form of medicine as long as it is safe, effective, and cost-effective.”
The results of the study were impressive. Use of prescription opiates went down by nearly 60 percent among participants in the integrative program. This, Pelletier points out, has significant economic consequences. Employees cannot work on the assembly line if they are taking prescription opiates, even if their pain is controlled. A 60 percent reduction in use translates into a huge return to work and saved money on disability costs. The study has already had a big ripple effect at Ford. The approach is being replicated in all of their health clinics, and Ford’s insurance companies are covering the costs, thanks to the power of Ford’s demands.
Pelletier was surprised to find that the single best predictor of improvement was participants’ use of a guided meditation CD, the component they thought might be the least appealing to the plant workers. Use of the CD predicted significant improvements in back pain-related disability, job performance, and physical and mental well-being. “We went back six months later, and twice as many workers were using the meditation CD than any other modality for back pain.” Findings like this demonstrate the feasibility of bringing less conventional modalities into communities that may not currently have access to or familiarity with them.
Programs like CHIP are also building the evidence base required to demonstrate the economic feasibility of integrative medicine. At the 2009 IOM Summit on Integrative Medicine, Pelletier presented an analysis of the cost effectiveness of integrative medicine interventions in the workplace. He found 153 relevant reports of worksite interventions, all of which showed positive health outcomes and related benefits in short-term disability, long-term disability, absenteeism, employee retention, productivity, and performance. Sixty-three studies addressed financial outcomes, and all but one reported positive cost-effectiveness, cost-benefit ratio, or return on investment. Pelletier estimates that the typical return on investment is actually between 3.5 and 4.9, but that it takes about three years to fully realize the financial payoff. At a minimum, integrative medicine programs break even, despite the upfront costs, but convincing employers and insurers to adopt such programs will require both vision on the part of those footing the bill, and more hard data confirming the long-term economic rewards.
The Power of Lifestyle
On February 26, 2009, Dean Ornish, MD, went to Washington to testify before the Senate Committee on Health, Education, Labor, and Pensions, chaired by the late Senator Edward M. Kennedy. Ornish is the founder and president of the non-profit Preventive Medicine Research Institute in Sausalito, California, and the bestselling author of books such as Dr. Dean Ornish’s Program for Reversing Heart Disease. He made ten key recommendations to the committee for health care reform, including funding more scientific studies in integrative medicine, changing farm subsidies, incentivizing food companies to make and market healthier foods, putting mandatory physical education back in schools, and incentivizing a focus on wellness rather than illness in health plans and at corporate worksites.
Ornish’s own studies over the last thirty years have shown that when people make major lifestyle changes, extraordinary benefits are possible, including reversing or slowing the progression of cardiovascular disease and cancer. His program, laid out in bestsellers like The Spectrum, includes a wide range of health-supporting behaviors, such as moderate exercise and a low-fat, plant-based diet. It also emphasizes stress reduction, through yoga and meditation, and social support. “Part of what I’ve learned is the need for connection,” Ornish says. “It’s a primal human need. People who are lonely and depressed die sooner. This is the real epidemic, the breakdown of social networks. We create environments that feel safe for people to talk about what’s going on in their lives. When you can meet an unmet need, this is very powerful. Intimacy is healing.”
“Part of what I’ve learned is the need for connection,” Ornish says. “It’s a primal human need. People who are lonely and depressed die sooner. This is the real epidemic, the breakdown of social networks.”
Many studies have demonstrated both the clinical success and cost savings of Ornish’s program. For example, a trial using patients at eight hospitals found that almost 80 percent of individuals with cardiovascular disease who were eligible for bypass surgery or angioplasty could avoid these surgeries through lifestyle changes. The estimated savings per patient was $30,000.
The most recent studies of Ornish’s program have used some high-tech, cutting-edge measures to demonstrate the power of these low-tech, common-sense lifestyle changes. A 2008 paper in the Proceedings of the National Academy of Sciencesanalyzed the expression of over 500 genes in the prostate cells of men with prostate cancer. After patients followed Ornish’s program for three months, many genes that promote cancer, heart disease, and inflammation were downregulated, while many health-promoting genes were upregulated. This suggests that lifestyle changes, social support, and stress reduction have a measurable impact on something as concrete as our genes. A 2008 study published in The Lancet Oncologyreported that the same participants showed an increase in telomerase, an enzyme that helps preserve telomeres, the bits of DNA at the end of chromosomes. Previous research has shown that shortened telomeres is a significant predictor of disease and mortality. The Ornish study is the first to demonstrate that any intervention has a positive effect on telomerase, and, by extension, may increase lifespan.
Many in the medical profession applaud Ornish’s findings but question whether patients will really make these kinds of comprehensive changes. After all, it’s easier to take a pill than change your diet and make time for exercise and meditation. To these skeptics, Ornish argues that compliance rates for drugs like Lipitor are actually abysmally low. “People don’t want to take a pill to prevent something so horrible they don’t want think about it,” he told me. “But our data shows that most people are able to make and maintain these lifestyle changes because they feel so much better so quickly. Feeling better is sustainable. Joy of living is a much better motivator than fear of dying.”
Follow the (Insurance) Money
Ornish believes that one of the most critical aspects of health care reform is the reimbursement of integrative medicine practices that have been demonstrated to be safe and effective. Insurers are currently much more likely to reimburse costly surgical procedures and medications—the American Heart Association puts the price of coronary bypass surgery at $99,743—than inexpensive lifestyle changes that could, according to Ornish, prevent ninety percent of cardiovascular disease. At places like Duke Integrative Medicine, the vast majority of patients pay out-of-pocket for services. Brantley compares the cost of a health immersion or annual membership ($2,995) to a vacation—a reasonable expense for many but an unaffordable luxury to others. Having to pay out of pocket will keep many people from investing in their health, leading to higher personal and societal costs in the long run.
Reimbursement also drives physicians’ medical decisions, Ornish says, even more than evidence. “We could do a thousand studies, but until something is reimbursed, the practice of medicine won’t change.” He points to a large study published in 2007 in The NewEngland Journal of Medicinewhich found that the most common surgical procedures for heart disease—angioplasties, stents, and coronary bypasses—do not prolong life or prevent future heart attacks for 95 percent of patients who receive them. “You’d expect that once that study came out, the number of angioplasties and stents would go down. Instead, it’s increased—because it’s paid for.”
Ornish has spent sixteen years working to get his lifestyle intervention for cardiovascular disease reimbursed by Medicare. At times, he met what seemed like illogical resistance to the common sense and evidence-backed recommendations of his program. “In 1995, the Administrator of Medicare told me, ‘Before I’ll consider doing a Medicare demonstration project, you need to get a letter from the director of the National Heart, Lung, and Blood Institute of the National Institutes of Health stating that your program is safe.’ I asked him, ‘You want me to get a letter saying that it’s safe for older Americans to walk, meditate, quit smoking, and eat fruits and vegetables?’ He said yes.”
Ornish secured the letter, and Medicare now covershis program of lifestyle intervention for heart health. He hopes reimbursement for this and other integrative medicine programs will change not only medical practice, but also medical education. This is a critical step, because one of the biggest challenges facing integrative medicine is the medical culture. Today’s health care providers haven’t been trained in the kind of wellness-focused interventions and collaborative care—especially between conventional and complementary providers—demanded by integrative medicine. Incorporating these principles into medical education could eventually transform health care by creating a generation of doctors who value and know how to deliver an integrative approach.
Those working to promote the field of integrative medicine agree on one thing: they would be thrilled to see the word “integrative” disappear completely. “Even in the beginning,” says Jeffrey Brantley, “we weren’t trying to be at odds with conventional medicine. We’re not trying to be renegades and rebels. We think we’re part of medicine. Now the paradigm is shifting.” He recognizes that integrative medicine is viewed by many as a challenge to conventional medicine, and there are some who have a vested interest in not changing the current system. But he hopes that in time, the distinction between integrative and conventional will dissolve.
“At Duke, our dream is that one day there won’t be integrative medicine,” he says, “because all medicine will be practiced the way we practice it. Treating the whole person, using an evidence-based approach, and bringing mindfulness into every aspect of health care—this will be standard medicine.”