The Cure For The Common Medical Practice

On Good Friday in 2009, Mary Ann Harrison made a phone call that changed her life.

Harrison was suffering from fibromyalgia, high blood pressure, and an assortment of gastrointestinal issues. She was used to living with chronic pain—pain so constant and systemic that restful sleep was impossible and any physical exertion was exhausting. But on this particular afternoon, her abdominal discomfort was so severe that she called her primary-care physician in her hometown of New Bern, North Carolina, only to discover that his office had closed for the Easter weekend.

She remembered a brochure she’d received a few months earlier from Duke Integrative Medicine, touting its patient-centered approach to health and wellness. She didn’t really know much about integrative medicine beyond the fact that it combined Western medicine with holistic techniques. Health and wellness were foreign concepts to her at that point in her life; she just wanted relief. Desperate, she picked up her phone and dialed the number.

Within seventy-two hours, she had been seen by a Duke gastroenterologist to treat her acute GI symptoms and had spent an hour with physician Evangeline Lausier, director of clinical services at Duke Integrative Medicine. On a subsequent visit, she filled out a questionnaire that asked about her emotional, physical, and spiritual health—everything from past surgeries, current medications, and level of physical activity to job satisfaction, spiritual framework, joys and sorrows, social networks, and sources of stress. The form pressed her to look beyond her immediate health problems, including items such as “If time and money were not an issue, describe the things you long to do in your life.”

With Lausier’s guidance, Harrison mapped out a personalized health plan with specific goals that addressed all aspects of her health. She was assigned a personal healthcare team that included an integrative-health coach—a professional trained in behavior change—who would work with her between doctor visits and encourage her to take an active role in improving her health. Harrison’s coach talked to her about diet and exercise and helped her set a realistic plan for meeting her goals.

In the weeks and months that followed, Harrison started regaining control of her health. Although she was initially unsure about some of the complementary techniques her doctor suggested, she was pleased to discover that sessions of acupuncture and myokinesthetic treatments—massage-like exercises designed to stimulate the nervous system—relieved her fibromyalgia. She also completed an eight-week mindfulness program aimed at reducing stress.

Today, Harrison’s fibromyalgia is gone and her blood pressure is almost at the point where she can go off of her prescriptions for Norvasc and Losartan safely. She walks five miles a day, does an hour of Pilates every week, and focuses on strength training twice a week—plus some occasional tai chi and cardio dancing. She sleeps soundly. When she runs into acquaintances she hasn’t seen in months, they tell her she looks fantastic, like a different person.

“Three years ago, any physical activity was an effort,” says Harrison. “Today, I feel tremendously better. I have a lot more energy. I’ve learned how to set boundaries so that I don’t overcommit to things. I’m in control of my health. Integrative medicine has made all the difference.”

Harrison may have come to integrative medicine out of desperation, but she is now among the growing numbers of patients, physicians, health-care providers, and policy experts who see it as an effective and common-sense approach to improving health. Many patients, like Harrison, initially come to Duke Integrative Medicine because of health issues ranging from high blood pressure and diabetes to infertility and depression. Others are referred by physicians— oncologists who have seen the benefits of acupuncture and massage therapy on reducing cancer-related pain, for example, or primary-care doctors who endorse guided imagery or hypnosis, rather than another pharmaceutical prescription, to reduce anxiety. Some aren’t facing any medical crisis, but simply want health care that incorporates wellness practices such as yoga, homeopathy, and meditation.

And there’s mounting evidence that this approach works. With its focus on patient-centered, preventive care, integrative medicine has been shown to reduce emergency-room visits, hospital admission and return rates, surgical interventions, and the need for prescription medications. Advocates argue it may be the best hope for reining in the skyrocketing costs of health care in the U.S.

It’s a rallying cry that Ralph Snyderman HS ’67, Duke’s chancellor for health affairs from 1989 to 2004, has made the focus of his professional life. Ten years ago, he and co-author Andrew Weil, a Harvard-trained physician and integrative- medicine pioneer, wrote an essay for the Archives of Internal Medicine that advocated integrative medicine as a way to bring medicine back to its roots.

“The United States health system is in crisis,” they wrote. “Amidst unprecedented opportunities to transform health care for the better, American medicine faces threats from two directions. One is financial and cannot be solved by the profession alone. Health-care technologies are more expensive, more people want access to them, and reimbursement mechanisms neither provide universal coverage nor reward improved care or prospective planning. The second threat is intrinsic to our practice and must be solved from within. Facing the pressures of economic and bureaucratic strains as well as the seduction of technology, conventional medicine has become separated from its roots of caring, engaging with patients, and meeting their real needs.”

"...there's mounting evidence that this approach works."

Snyderman, also a James B. Duke Professor of medicine, speaks frequently to scientific and academic audiences about the benefits of integrative medicine. He also participates in the Mind & Life Institute’s conferences that feature the Dalai Lama in conversation with scholars and scientists around the nexus of contemplative traditions and contemporary scientific research. And he’s writing a book, a memoir of sorts, about the changes he implemented at Duke University Health System and the need for academic health centers to take the lead in creating a new medical model that emphasizes “personalization, prediction, prevention, and patient participation.”

It was under Snyderman’s leadership that integrative medicine took hold at Duke. A group of physicians, led by Martin Sullivan HS ’86, Larry Burk ’77, and Jeffrey Brantley, began exploring the range of scientific, cultural, and spiritual approaches to healing. In 1996, they sponsored the Duke Mind Body Spirit Conference, which attracted 400 healthcare practitioners—an additional 200 had to be turned away for lack of space. Snyderman was convinced that Duke could serve as a leader for the burgeoning integrative- medicine model, and oversaw the establishment of the Duke Center for Integrative Medicine in 1998. (Burk has just published Let Magic Happen: Adventures in Healing with a Holistic Radiologist, which chronicles his role as a former director of integrative-medicine education at Duke, among other themes.)

In 2006, supported by a grant from Christy Mack of the Christy and John Mack Foundation, the 27,000-squarefoot Duke Integrative Medicine facility opened on Duke’s Center for Living campus on Erwin Road. (Christy Mack is cofounder and president of the Bravewell Collaborative, a group of philanthropists dedicated to promoting integrative medicine. Her husband, John Mack ’68, is a Duke trustee.) The building was the first medical facility in North Carolina to receive LEED (Leadership in Energy and Environmental Design) certification for its stewardship of the environment, and it has won a National Design Award from the American Institute of Architects. People from all over the world come here to seek medical care or to train and earn certification as integrative-health coaches, yoga instructors, and mindfulness-meditation teachers.

The building reflects the ethos of integrative medicine, including design elements that integrate nature and heighten the senses. Hallways curve rather than follow straight angles. The paint colors reflect the four seasons, a subtle allusion to the four seasons of life. North Carolina river rock lines the interior and exterior edges of walls, creating a continuum between the indoors and outdoors. Consultation and treatment rooms have bamboo floors, wallpaper, and sliding shoji screens rather than cold steel fixtures and bright fluorescent lights. A floor-to-ceiling water wall in the waiting room trickles continuously. In a room where yoga and mindfulness meditation are taught, windows along the bottom of the wall remind supine participants of their connection to the Earth. An inner courtyard features skyward-reaching bamboo and stone pathways. Savory aromas emanate from a café/ nutrition center that overlooks an outdoor courtyard and stone labyrinth for walking meditation.

The environment serves to reinforce one of the main underpinnings of integrative medicine: that health transcends the presence or absence of disease. “Chronic conditions such as obesity, diabetes, and heart disease are often caused or compounded Perlman, executive director of Duke Integrative Medicine and associate vice president for health and wellness for Duke University Health System. “Of course, surgical interventions or prescriptions have their role. But we need to move in the direction of prevention and encouraging healthy lifestyle choices.”

Perlman, who has a master’s degree in public health with a focus on epidemiology and biostatistics, says there is growing acceptance in the medical community and among consumers of integrative medicine and non-Western approaches to health and wellness. “I think we’ve moved beyond much of the resistance or skepticism because we’ve amassed a body of evidence that supports the integrative approach,” he says. For example, multiple studies have shown that acupuncture helps reduce chemotherapy-induced nausea for cancer patients, that hypnosis prior to breast-cancer surgery reduces pain and speeds recovery, and that meditation can reduce acute respiratory infections and even have a positive effect on cardiovascular disease.

Duke Integrative Medicine is one of fifty-one academic health centers that belong to the Consortium of Academic Health Centers for Integrative Medicine, a network that includes Johns Hopkins, Yale, Harvard, Northwestern, and Mayo Clinic. (Perlman was chair of the consortium in 2010, a year before he came to Duke.) In addition to providing patient care, these academic centers conduct a host of clinical-research studies to assess the impact of certain integrative-medicine tools. At Duke, Perlman is conducting NIH-funded studies on the benefits of massage therapy for osteoarthritis of the knee. There are studies exploring mindfulness meditation as a therapy for conditions such as tinnitus and maintaining weight loss. And there’s a pilot study with Duke undergraduates, conducted in conjunction with student affairs and student health, to examine how individual or group sessions with health coaches might address issues such as stress and anxiety.

Research already has shown that healthcare coaches are effective at getting patients to take a more-active role in their own health. In a ten-month study of noncompliant diabetic patients conducted at Duke eight years ago, those assigned a health-care coach saw their health improve significantly over a control group. When interviewed after the study about why they were able to adopt and maintain healthy habits when they’d been unable to do so in the past, the reasons were entirely personal: To play football with a grandson. To be able to bend over and tie a shoe. To travel to Machu Picchu with a spouse. None mentioned a medical goal such as lowering glucose levels, losing weight, or spending less money on prescription medications.

In the decade since his Archives of Internal Medicine essay, Snyderman says there has been movement toward what he calls “the transformation of American medicine.” But it’s not happening as fast as he’d hoped. “Despite notable areas where we’ve made progress, most of the progress is still in front of us,” he says.

Kevin Schulman, the Gregory Mario and Jeremy Mario Professor of business administration and the director of the Fuqua School of Business’ Health Sector Management Program, says that is partly due to the fact that the integrative-medicine model is a multipronged approach that can be interpreted and practiced in a variety of ways. “When we look at new concepts of health care, we want to see evidence that supports the benefits of those concepts and then explore ways that can be translated into clinical practice. So rather than saying that integrative medicine is the solution to current problems in the health-care system, health-policy analysts need to look at which discrete components are effective and what economic barriers need to be overcome in order to disseminate those components into the existing system,” he says.

One place where that’s already happening is at the Department of Veterans Affairs, which operates the largest health-care system in the country. Tracy Gaudet ’84, M.D. ’91, former executive director at Duke Integrative Medicine, heads the VA’s recently founded Office of Patient-Centered Care and Cultural Transformation. (She first learned of the VA’s interest in integrative medicine during a VA task force site visit to Duke.) She says she is excited about the prospect of scaling a successful, academically based model of integrative medicine into a system that serves 6 million veterans who are seen at the VA’s more than 1,000 facilities.

"When we look at new concepts of health care, we want to see evidence that supports the benefits of those concepts and then explore ways that can be translated into clincal practice."

“Our goals at Duke Integrative Medicine and at the VA are exactly aligned— both places want to create a paradigm shift in how we think about health in this country, and in doing so, improve the healthcare system in a fundamental way,” says Gaudet. “Our number-one goal at the VA is to provide veterans with personalized, proactive, patient-driven health care.”

Gaudet says that the integrative-medicine approach resonates with veterans. “They understand that in order for a mission to be successful, you need to have a battle plan, training and skill building, and support from and trust in your fellow team members. Those are the exact same values we are building on in our approach to health care. Veterans come up with a personalized plan for their own health, get the training they need to make it work, and have a health-care team that includes their health-care providers that is dedicated to making sure they succeed. This is about helping them become missionready for their lives.”

But while the VA makes strides to replicate the integrative model across its system, the rest of the country is lagging far behind. Despite the cost-effectiveness of preventive medicine, the current reimbursement model rarely covers integrativemedicine therapies, says Snyderman. “Physicians and other providers are reimbursed for providing interventions around specific episodes of high-intensity care, rather than for preventive measures that improve patient health and save money in the long run. It’s a reactive model rather than a proactive one.”

At places like Duke, that’s starting to change. Duke Integrative Medicine opened its first primary-care practice in July 2012, and the insurance plans that cover most Duke employees now allow for an annual primary-care visit to an integrative- medicine physician and follow-up visits. “We are increasing access to our model of patient care,” explains Perlman. “Now patients can see an integrative physician for a consult and have it covered by their insurance. In our primary-care practice, we spend more time with each patient, take a whole-person approach that considers physical, emotional, and even spiritual well-being, and provide ongoing support for some of the toughest challenges people have in the way they live their lives day to day. This is how we are going to have a lasting impact on patient health.”

But insurance still doesn’t cover many aspects at the heart of integrative care, including 24/7 access to an integratedhealth team that includes a physician, nurse, and health coach. For those services, primary-care patients at Duke Integrative Medicine pay an annual fee of $1,500, which also gives them access to classes and educational workshops.

Organizations such as the American Public Health Association, the Robert Wood Johnson Foundation, and the Consortium on Academic Health Centers for Integrative Medicine are expecting that implementation of the Affordable Care Act (ACA) may open up new opportunities to expand integrative medicine. The ACA’s Community Transformation Grants, for example, encourage cost-efficient initiatives that focus on nutrition, physical activity, emotional well-being, and overall mental health.

Health-care analysts also point to a national shortage of physicians—the American Association of Medical Colleges projects a shortfall of more than 100,000 doctors by 2025—as another impetus to reform the system. Fuqua’s Kevin Schulman, director of the Health Sector Management program, notes that reimbursement models that favor invasive procedures are creating an economic incentive for medical students to eschew primary care for specialty fields. “The business of medicine is getting in the way of the practice of medicine,” he says.

An integrative-medicine model could shift the focus back to helping patients live healthily. And, as Adam Perlman notes, it could ease pressure on physicians by surrounding them with teams of health-care providers working to sustain patients’ progress between trips to the doctor. “The hope is that physicians will be able to spend more time with patients, but that a lot of the health support between physician visits will be handled by other healthcare providers such as nurse practitioners, physician assistants, integrative-health coaches, nutritionists, and others trained in complementary and preventive care,” he says.

Can a patient-centered approach that emphasizes health, wellness, and prevention become the standard of care? Can integrative medicine drop the adjective and become simply medicine?

“When we look at the future of health care in this country, the best thing one can say is that despite the inadequacies and enormous cost of the current unsustainable system, we know how to do it far better,” says Ralph Snyderman. “Most of the people who are concerned about health policy and delivery systems fear the possibility of a major health crisis as we try to increase access while managing the high costs of health care. The current approach is so expensive and ineffective in improving health that major change must occur. So the question is, as change occurs, will there be a soft landing or a hard landing?

“I’m an optimist, so I think we can create a soft landing. Which means that while we can’t continue the way we are doing things now, we can transition to a more rational, integrated, and personalized approach to delivering care. Integrative-medicine approaches involving the individual in his or her care can make health care not only cheaper, but also make it more effective and compassionate. And that’s something everyone wants.”