Whole-Person Health Care

Long known for scientific and technological advances in treating patients, the Duke Health System is expanding its approach to healing through CAM, complementary and alternative medicine.

When talking about whole-person health care, the terminology itself can be confusing, misleading, and laden with New-Age stigmas. But use a different word--integrative. Integrative medicine combines the best in traditional health care. It seeks to treat illness with medication and/or medical procedures, with non-traditional research- and outcome-based therapies that fall into a category commonly called complementary/alternative medicine, or CAM.

The idea behind integrative medicine is not for people to forego the appropriate traditional treatments in favor of CAM therapies, says Tracy Gaudet, director of the Duke Center for Integrative Medicine (DCIM), but to complement these treatments with techniques that address the multiple components of whole-person care--including body, mind, nutrition, movement, and spirit.

This philosophy clearly rings familiar with many Americans: Nearly half have pursued CAM therapies at one time or another. And for this, Gaudet cites two primary reasons: first, because there are therapies and approaches that have been proven beneficial in helping people prevent and fight illness, but have fallen outside mainstream medicine; and second, because "a large cultural shift is afoot in which people want to be seen as more than just diseased body parts--they want to be understood and treated as the whole entities they are."

Duke has long been known for its scientific and technological advances in health care--as Duke Health System CEO Ralph Snyderman, says, "The practice of medicine has benefited tremendously from its marriage to science and technology over the last fifty years." However, he adds, "the concern is that although that marriage is vital--and will continue to drive Duke--it is insufficient, because there are limitations, as well as benefits, to science and technology. Unfortunately, much of today's delivery of health care fails to acknowledge the components of health care that go beyond science alone."

The problem lies in the modern Western tradition of medical education. While many health-care providers are trained to treat the body, few are trained to address matters of the mind and soul--components that are arguably as critical as the physical when it comes to staying and getting well. And the fact that so many consumers are now looking beyond body-only health care makes it even more important for the medical community to be in the know about integrative medicine.For example, although much of science-and-technology-driven medicine is straightforward, a woman whose cancer results in the removal of a breast "has needs beyond thinking of her own chances for a cure," Snyderman says. "In a way, she and all patients facing serious illness become different people, with new questions, needs, concerns, and priorities." In other words, cognitive and spiritual issues.

"It's as though there are now two distinct health-care systems in our country--conventional and 'alternative'--and because they're not integrated, patients are stuck in the middle, getting mainstream advice from their doctors and CAM advice from others," says Gaudet. "Because many people aren't telling their doctors about their interest in CAM therapies for fear the doctors won't be knowledgeable and supportive, cancer patients are seeking medical advice from health- food store clerks."

As a leading institution in the field of integrative medicine, Gaudet says, Duke has a responsibility to educate both patients and health-care professionals. "First and foremost, we at Duke are advocates of the best medicine, and our knowledge of and receptivity to CAM enables us to help patients separate what's safe and legitimate from what's not--and then look at CAM therapies that might benefit them."

Think of integrative medicine, which evolved centuries ago and began appearing in health-care settings in the 1970s, as three overlapping circles, says Jeff Brantley, director of Duke's mindfulness-based stress reduction (MBSR) program. MBSR incorporates hatha yoga, breathing techniques, and meditation to help reduce stress or stress-related symptoms. "The left one represents traditional Western medicine, the one in the middle symbolizes CAM therapies, and the circle on the right are mind-body-spirit techniques--things like mindfulness, that people can do themselves to promote health and well-being."

While most of the techniques represented by the left and middle circles require an expert to do something with or to us, Brantley says, those represented by the right circle "are the internal experiences that are vital to health and healing. There's growing evidence that clarifies the link between how we experience stress and how that stress affects our bodies' reactions to things. Our immune systems in particular are greatly impacted by stress, which can have serious health implications.

"Mindfulness is a quality we've already got. It's about paying attention to what's here, inside and out, right now, and being open-heartedly aware of what's going on in the present without thinking or judging. Out of that undistracted awareness comes a heightened appreciation for life and a strong recognition of habits, choices, and options. It starts with being fully present--for good things and bad."

But Brantley echoes the warnings of other Duke medical professionals when it comes to CAM: "People must never stop taking their prescribed medications or foregoing necessary procedures in favor of CAM therapies like MBSR," he says. "If you have concerns about your care, become a better partner with your physician and try to gain skills that will make you more aware of what's going on inside. That combination is very empowering--and is what really does help us to be our own best healers."

Whether as part of MBSR or on its own, yoga is one component of stress control and integrative medicine. A practice that evolved some 5,000 years ago, whose name means to join or yoke together, yoga "focuses on breathing techniques, physical postures, and meditation to teach us to bring our bodies back into a state of balance and quiet so that we're better able to deal with daily stressors from a place of clarity," says Linda Smith, yoga expert and DCIM director of programs. "A system of awareness and rebalancing that's easy to learn and can be practiced at many different levels, yoga is successfully used in the prevention and treatment of many chronic conditions."

Because the goal of yoga is to tone, strengthen, and develop flexibility and balance within one's body, Smith says it isn't only for people in excellent physical condition. "Most everyone, regardless of their state of health, can breathe, meditate, and move their bodies. The key is to develop awareness and sensitivity to what's going on in your body and learn to listen to its limitations."

The reality, she says, is that stress in our lives is inevitable; the goal is to learn to manage it. "When you have the tools to bring yourself back into balance regardless of what's happening in your life, it's very empowering."

Touch therapies provide another stress- and pain-management tool. Practitioners use healing touch and massage to manipulate the tissue of patients for therapeutic benefit, often while incorporating relaxation techniques. Certified healing-touch practitioner Jon Seskevich treats a variety of people at Duke, from transplant recipients to cancer patients to women experiencing difficult pregnancies. "We work with people who are living through some very heavy stresses, and by teaching them touch and guided relaxation strategies, we're teaching them to help themselves," he says. "Science has shown not only a mind-body connection, but also that touch and relaxation therapies are beneficial. So we can do these things knowing we're on solid scientific ground."


Healing from within and from without: yoga, opposite, and the power of touch

Healing from within and from without: yoga, opposite, and the power of touch


For example, Seskevich says, a large body of research suggests great therapeutic benefit from massage. Results of a study published in 1998 reveal that children with asthma who received only massage therapy showed a 15 percent improvement--nearly equal to those who received medication alone. And a University of Miami study to examine the effects of human touch on cocaine-exposed premature infants revealed that the infants who received touch therapies gained significantly more weight than those who didn't.

As with many CAM techniques, touch therapies aren't just for people suffering from disease or injury. "Because many people think of stress as being brought on by problems, worry, or pressure, patients will deny that they're experiencing stress--or feel that when they are, they simply aren't coping well," says Seskevich. But stress is actually caused by the adapting that comes with any type of change--even when the change is good--and it creates powerful chemicals that wear on our bodies and can cause tension, increased pain, and sleep problems.

"It's hard to know where the mind stops and the body begins," says Seskevich. "Everybody says, 'Relax. Don't worry.' But nobody teaches patients how to do that. That's what we try to teach people with tools like guided relaxation and touch therapies."

Another tool people can use is hypnosis, a process used to help people access and control the trance state, says Duke consultant Holly Forester-Miller. The trance state, an altered but naturally occurring state of consciousness in which one can more readily manipulate psychological and physiological abilities, is successfully used in conjunction with traditional therapies to address issues ranging from migraines and depression to weight loss and chemotherapy side effects. "Accessing the trance state enables people to suggest that parts of the body respond in certain ways, so it can facilitate and assist with almost every health issue," she says. "Hypnosis enables us to best use trance to accomplish a goal, whether that's pain management, relaxation, psychological growth, or physical healing."

The effects have been documented by medical research. Forester-Miller cites a 1995 University of Connecticut study that "examined cognitive behavioral therapies and compared them with the same therapies coupled with hypnosis. The patients with hypnosis showed greater improvement than at least 70 percent of those receiving the same treatment without hypnosis."

Although some people are initially skeptical or fearful that hypnosis will cause them to relinquish control, Forester-Miller says most soon discover the opposite is true: "Because they learn to keep their conscious and unconscious minds 'running' at the same time, patients actually find they have more control than ever. Rather than losing touch, they gain touch with the deepest parts of themselves."

Nutrition is also a critical component of overall health, says nutrition educator Greg Hottinger. Nutrition therapy incorporates diet and dietary supplements--"anything you put in your mouth that's not food: vitamins, minerals, herbs, amino acids, enzymes, organ tissues, extracts, or concentrates sold as leaves, powders, capsules, oils, teas, or ointments."

While few would deny the preventive benefits of good nutrition, many may be surprised to know that it can also be a powerful weapon in fighting disease. The Ketonic diet, for example, dramatically decreases the occurrence of several types of pediatric seizures. And participants in the landmark DASH (Dietary Approaches to Stopping Hypertension) study--in which Duke played a large role--saw reductions in blood pressure comparable to patients taking medication only.

Hottinger, whose consultations include cancer, heart, arthritis, and Alzheimer's patients, says inflammation in particular can be positively affected with dietary modifications. "There's been a great deal of research about this," he says, "and the primary approach is to reduce foods and substances--fats, for instance--that promote the inflammatory response, while increasing anti-oxidants and substances that promote an anti-inflammatory response--things like flaxseed oil, ginger, black tea, and apples."

As with other integrative therapies, Hottinger says, the common thread that runs through whole-person health care--regardless of someone's health status--is increased awareness. "We emphasize eating mindfully, by developing a relationship with your body, by being aware of what and how much we eat, by recognizing the emotional and cognitive states in which we eat, and by acknowledging our beliefs about food and diet. We help people learn to listen to the signals about what works or doesn't work for them."

Finally, there are intangible elements to integrative medicine, such as those that are a part of noetic therapies. Noetic therapies, what the National Institutes of Health call "frontier medicine," are widely practiced medical therapeutics for which there are no plausible explanations, including spiritual- or prayer-based practices, says cardiologist Mitch Krucoff. "Every physician has had a patient who physiologically should have died, but didn't. These patients frequently appear to have a vital link that wouldn't 'let' them die--and you usually don't have to look far to find a friend or family member, religious verse, or photo of a new grandchild."


Hand-to-hand harmony: stretching is essential in yoga


Hand-to-hand harmony: stretching is essential in yoga.


The opposite is true, as well, he notes: Patients without those vital links often don't seem to do as well physically or emotionally. "This phenomenon has led us to look at the human spirit as it relates to cardiology," he says. "In addition to applying Duke's world-class, high-tech cardiology theater, we're now examining the role of internal resources patients may have to help themselves when they have cardiac problems, undergo procedures, heal, and recover."

"Because the human spirit is a potentially critical contributor to their outcomes, we're very interested in the spiritual aspects of intervention so that we can best care for our patients," Krucoff says.

That's the rationale behind Duke's MANTRA (Monitoring and Actualization of Noetic Training) studies. Launched with a 1995 pilot program at the Durham Veterans Administration Hospital by Krucoff and nurse practitioner Suzanne Crater, MANTRA includes patients who have or had blocked coronary arteries and who, like many cardiac patients, are facing their own mortality. The results of the 150-patient pilot study, which integrated noetic (spirit-related) therapies like guided imagery, breath control, touch therapy, and off-site prayer with traditional ones, were promising. Patients receiving noetic therapies including off-site prayer in addition to their standard treatment had 30 percent fewer complications overall; those who were treated with the double-blinded, off-site prayers from eight prayer groups around the world had 50 percent fewer minor complications and 100 percent fewer major complications.

Krucoff stresses, however, that while data consistently suggested that noetic therapies are beneficial, the pilot study was too small to be statistically definitive, and may not be generalizable to other health-care settings. That's the reason for Phase 2 of the study, launched in 1999 to examine the roles of music, imagery, and touch therapy in cardiac care. Krucoff says Phase 2 already has more than 500 participants and can include up to 1,000 more.

"We can see the world of the tangible and the procedural, but when it comes to the intangible--things whose mechanisms we may not fully understand--the only thing we can do is measure clinical outcomes," he says. "An incomplete understanding of how or why the human spirit works isn't a place to stop thinking or conducting research about it."

This philosophy is widely shared throughout the medical center, he adds. "At the highest levels, Duke's vision as an institution is to re-define the optimal healing space for human beings by combining the best in cutting-edge technology with awareness, cultivation, and activation of the rest of the human being. We consider this the most fertile ground for the next real advance in health care."

As with anything outside the borders of traditional medicine, research, education, and mainstream support are crucial to the continued growth of integrative medicine. A $1-million Centers for Medicare and Medicaid Services grant awarded to Duke last year will launch a two-year pilot study to better define whole-person health care and examine ways people can strategically implement integrative health planning into their lives for improved health.

Duke also offers students integrative-medicine curriculum options. The School of Nursing offers a health and nursing ministries master's degree designed to prepare nurses to serve as medical professionals as well as promoters of whole-person care in specific faith-based communities. And the medical school's integrative medicine program includes monthly body-mind case correlation dinners, CAM lectures, and courses that teach students to take an integrative approach not only in caring for their patients, but in caring for themselves.

"Education is critical if we're going to train the next generation of health-care providers to think in this integrative model," says DCIM education consultant Pali Delevitt. "It's not about replacing one set of modalities for another; it's about exposing Duke medical students to integrative-medicine practitioners who are successful and teaching them to think holistically, to view illness and healing from other paradigms.

"Traditional belief systems are not the final word. The history of medicine shows that how we answer the question 'What is science?' continuously evolves due to new knowledge. Integrative thinking is a philosophy that's about looking inward and outward, and practicing healing, not just practicing medicine--and this is what students are clamoring for. They see integrative medicine as an opportunity to grow, create community and personal wellness, and stay balanced as they study and practice medicine."

Besides Duke's support of integrative medicine, interest from the larger arena is growing. One example is the November 2001 launch of a joint frontier medicine program by the National Institutes of Health and the National Center for Complementary and Alternative Medicine. "Public interest in integrative medicine is so intense, and health-care issues so important, that the federal government, in the absence of industry support, is now supporting integrative medicine," says Krucoff. "That's a huge step forward."

But there are still many challenges to bringing integrative medicine to the fore. Standardization in the practice and licensing of CAM has yet to happen. And although some major insurers are beginning to subsidize CAM services, most Americans must pay out of pocket for them.

What can the average person--the average patient--do? "People must vote with their feet about their health-care choices, by speaking to their employers about the plans that are offered and by making sure they relate to their physicians as partners in their health care," says Snyderman. "Involvement of the patient in their care is absolutely key, and this is the type of health-care delivery we are trying to make available at Duke.

"Seventy-five percent of health-care costs are spent treating chronic diseases, often at a late stage. We have the ability to make a big impact in the prevention and treatment of chronic diseases--and therefore to improve the overall quality and cost of health care--because so many of these diseases are impacted when people modify their behaviors. We need to jump-start the solution to the problem of effectively treating chronic disease. And that's why Duke is involved in creating a national platform to find out what really works in this field."

Will alternative therapies become a standard, accepted piece of America's medical landscape? "My hope is that through Duke's widespread support of and involvement in integrative medicine, we can foster a mindset of wellness and involve patients in their own health care," says Snyderman. "We must give patients the full range of what they need to improve their health. We must do so by recognizing each one as an individual in his or her own life setting and by engaging them in their own health care. If we don't do this, we're providing only a small segment of what patients expect and deserve from a system that is supposed to be working with them to improve their health."

--Lyttle is a Triangle-based freelance writer.

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