Foundations of Integrative Medicine

Hal S Blatman, MD, DAAPM, ABIHM Past Chair, Integrative Medicine Consortium Past President, American Holistic Medical Association Author: Winners’ Guide to Pain Relief Medical Director: Blatman Health and Wellness Center Holistic Comprehensive Care Wellness and Rehabilitation Cincinnati OH and Manhattan NYC www.blatmanhealthandwellness.com

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Objectives

• Review reasons for why we are gathered to study at this conference; why we do and how did this path choose us for professional and personal life • Describe how integrative medicine is different from our allopathic training • Discuss how the integrative medicine patient encounter is different and more satisfying for both patient and physician • Review the philosophy of integrative medicine

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History

• Aristotle (384-322 BC) – Believed person was combination of physical and spiritual properties—no

separation between mind and body • René Decartes (1596-1650)

– Effort to separate mind and body to protect spirit from science • Mind and spirit for church • Left physical body to science • Philosophy led to Cartesian split of mind-body duality

• John Locke (1632-1704)/David Hume (1711-1776) – Influenced reductionistic movement—shaped our science and medical system

• If we could reduce natural phenomena to greater simplicity, better able to understand the larger whole

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Modern History

• Early 1900’s applied science and medical technologies began to transform medicine

• Flexner report (1910) impacted development of allopathic institutions – Emphasis research, education, clinical practice

• Scientific model—greater understanding of pathophysiology—development of combat tools (armamentarium) – Ability to ‘fix’ problems

• Repair a part without addressing underlying cause – Approach does not work well for chronic disease

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Cost of Medical Science Success

• Total healthcare expense $8086/resident 2009 • Drug spending ($250 billion in 2009) • Procedures • Patients led to believe tools are answer to physical

woes • Downplays interplay of mind, community, spirit • Dependence on technology widens communication

barrier patient/provider • Less use of rapport, gestalt, intuition, laying of hands

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Cost Control

• Managed care/capitation • Erosion of patient-provider relationships •  Increased time demands on physicians

with required objectives not involving patient care – Electronic medical records (+/-) – Prior authorizations

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Tipping Point

• Deterioration of provider-patient relationship • Overuse of technology/surgery

– Not that integrative/functional medicine doesn’t have it’s own technology

• Lack of efficacy for treating chronic illness • Adverse drug reactions 6th leading cause of

death in hospitalized patients1

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1. Lazarou J, et al., Incidence of adverse drug reactions in hospitalized patients. JAMA. 279:1200-1205, 1998.!

Public Influence

• Patients demanding less aggressive treatments • Botanicals were largest growth area of retail

pharmacy1

•  Interest toward – Complementary approaches

• Nutrition, botanicals, manipulation, meditation, massage

8 Brevoort P., The United States botanical market: an overview. Herbal Gram 36:49-57, 1996!

Federal Action

• 1993 Office of Alternative Medicine was started within NIH

• October 1998 upgraded to National Center for Complimentary and Alternative Medicine (NCCAM)

• August 1999 Chartered National Advisory Council on Complementary and Alternative Medicine (NACCAM)

• December 2014 name change to National Center for Complementary and Integrative Health (NCCIH)

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Academic Center Action

• 1997 Andrew Weil started first fellowship training program in integrative medicine

• July 1999 meeting of 8 medical institutions became Consortium of Academic Health Centers for Integrative Medicine —> Academic Consortium for Integrative Medicine & Health (The Consortium) 64 international members as of this writing 10

Integrative Medicine

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Integrative medicine is defined as healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. !It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.!

Rakel!

Holistic Medicine

Medical practice is oriented to the philosophy of knowing/recognizing that the body heals itself, our work is to teach our patients how to get out of their own way, and then facilitate their body’s healing mechanisms in whatever way we can, using any tool we know.

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Common CAM Therapies 10 Most Used in 2007

• Natural products • Deep breathing • Meditation • Chiropractic/osteopathic • Massage

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• Yoga • Diet-based therapies • Progressive relaxation • Guided imagery • Homeopathic treatment

From Barnes PM, Blook B, Nahn R, Complementary and Alternative Medicine Use among Adults and Children: United

States, 2007.!

Common CAM Therapies 10 Most Frequent Conditions in 2007

• Back pain** • Neck pain • Joint pain • Arthritis • Anxiety

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• Cholesterol • Head or chest cold • Other musculoskeletal • Severe headache or migraine •  Insomnia

From Barnes PM, Blook B, Nahn R, Complementary and Alternative Medicine Use among Adults and Children: United

States, 2007.!

Titles Have Changed with Times

• 1970’s—Holistic medicine • 1980’s—Complementary and alternative

medicine • 1990’s—Integrative medicine • Present—Health and healing-oriented

medicine

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What is Your Practice?

• Why are you here • What was your path • What is your story • What will your practice evolve into • How will you integrate with others • How will you integrate this and future new

knowledge and ideas

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What is Your Practice Style?

• Who makes the medical decisions? – What is the doctor patient relationship you cultivate – How has your practice evolved from allopathic

care, what is different • Who directs medical care?

– What are the doctor patient expectations? – What is the patient level of education? – What is the level of patient participation?

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Patient Expectations— Will You Evolve to Patients with

Different Expectations? • What will be your evolution? • Evolve with intention with respect to patient expectations • What role to play

– You are the doctor, tell me what to do? – Partnership toward health and disease prevention – Guidance toward better life style choices

• Set example for optimal— – Nutrition – Exercise – Do your own work for personal growth

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Carefully Evaluate Treatment

• You may be recommending treatment different from community • Does the therapy work toward symptom suppression or

resolution? • How strong is the evidence? •  Is there potential harm? • What is the cost? • Does the therapy match the patient’s culture and belief

system? • Does the patient have information enough and also given

consent? 19

Medical Encounter

• Ceremony and Ritual in the encounter • White coat • Stethoscope • Waiting room • Dress, gown • Patients wait for us in the exam room • The “dance” we do

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Uniform and Ceremony in Medicine

• Wear a white coat – Says doctor, not nurse or MA

• Perceived credibility – Different uniforms-choose your costume – Patient expectations

• In the airplane—what if pilot was wearing cut off jeans, raggedy t-shirt?

• What if doctor is wearing more casual clothes? • The costume you choose is important

• Do you really need/want a white coat to do this? 21

Diagnostic Terms and Accuracy

• Ferocious liver – Cirrhosis of the liver

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Diagnostic Terms and Accuracy

• Diabetes: Insulin systemic pancreatic insufficiency disease (INSYPID)

•  Impotence: Definitely reduced orgasm or penetration (DROOP)

• Death: Disorder in which everything appears to be defunct (DEAD)

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Diagnostic Principles

• Each patient is a unique picture • Patient’s story is paramount • P’s of causation

– Predisposing — genetics – Precipitating — pathogens – Perpetuating — maladaptive stress response

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Healing Environment —Enhances Person’s Ability to Heal

• The environment can enhance the healing process, independent on the treatment chosen/utilized1 (not just the pill, but the practitioner)

• Optimal Healing Environments (Extension of Engel’s model)2

– Social, psychological, spiritual, physical, behavioral components of health care are oriented toward support and stimulation of innate healing capacities and the achievement of wholeness.

1.  Development of intention and awareness 2.  Experience of wholeness 3.  Relationship-centered care 4.  Health promotion with self-care and lifestyle skills 5.  Collaborative treatment 6.  Spiritual connection

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1. Jonas W., et al., Investigating the impact of optimal healing environments. Alter There Health Med. 2003 9:36-40.!2. Engel G., The need for a new medical model: a challenge for biomedicine. Science. 1977 196:129-136.!

Healing Encounter

• Term medical comes from Latin medẽrĩ – To Heal — shaped by our culture to be external treatment given to

patient • Medical Home concept from Rakel

– Healing intention of team that understands inner and outer environments are necessary for health

– Social connection can support life style behaviors while diagnosing and managing disease

• New models of care are being defined • Account for environment, epigenetic expression • Health as a continuum and our lives surrounded by mystery

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Salutogenesis

Term by Aaron Antonovsky, professor of medical sociology — describes approach focusing on factors that support human health and well-being, not cause of disease. Model concerned with the relationship between health, stress, and coping.

27 Successful Adaptation!

Healing Encounter

• Develop understanding of what person needs to self-heal

• Help person find balance to interact with environment

• Healing process is not one sided, both the patient and clinician are transformed.

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Trust - Empathy - Empowerment - Connection - Education!

Healing Encounter

• Community • Shared purpose with patient

– In Life and in Death • Looking for best of health along the way • Looking for a best life and death experiences • Focus on helping present and last wishes come true

• Community support 29

Healing Encounter

• Self reflection on your bias, state of mind, minimize judgement

•  Insight and Intuition – How do you know which choice to

recommend? • Encourage and motivate to action

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Healing Encounter

• Pause before entering, breathe, ground • Presence — be present, alert, authentic

– Create the space for meaningful conversation – Empathy and understanding provide comfort – Even if you otherwise can’t change the

process of illness you can always comfort • Proceed — insight, develop a plan

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Healing Encounter

• Create patient expectations • Protect time in your schedule • Offer support and collaboration with others on the

team • Code appropriately for billing

– 99244 for 60 min appointment – 99245 for 80 min appointment

• Document 32

Importance of Continued Learning

• What is your path? • What have you learned? • Do you ever stop learning? • Do you search your contacts and literature for what might

help your patients? • Do we ever really know enough?

– Yes, never feel inadequate as you do your best, just know you continue your search for what will help your patients

– Be grateful for what you have learned that can help people, and be ever curious to learn more

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Does Learning Ever Stop?

• NO • Not in this field • There is always someone who can teach you more

– Patients – Students – Peers

•  Is your work yours?

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Is Your Work Yours?

• Spirituality – Not about religion

• Spirituality is not defined by religious writing and following – Does your work come from you?

• Mine does not — and I appreciate the gifts I have been given • We all have our gifts — where do they come from

– Are you grateful for your gifts? – Do you appreciate the gift of trust given to you by your patients?

• Where do your gifts come from? – Why did you choose to go to that conference? – How did your path connect with the people that have been your mentors?

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Some Rules

• Never let a patient leave your office and say that the doctor never touched me

• You absolutely need to touch the patient’s problem and make the patient hurt more by your touch – Not to be masochistic – Be educational and gentle – The patient needs to remember you touched where they hurt – This is the PRIME DIRECTIVE of a medical exam!

• Just as important as listening – This is the best clue as to where the problem/pain comes from

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What is Chronic Pain? Curing the Incurables…

• Two schools of thought across the globe

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ACUTE

PAIN

CHRONIC PAIN

NO HOPE

KILL NERVES INTERRUPT

SIGNAL EPIDURAL STEROIDS

MAKE NERVOUS SYSTEM NOT

WORK PAIN

CONTINUES UNTIL BODY HEALS FROM

INJURY

THEN PAIN GOES AWAY

How Much of the Rest of What You Were Taught Does Not Work

or Ring True with Experience? • Blood pressure • Lipids •  Infectious disease •  Inflammation from injury and chronic illness/pain • Herbal medicine • Acupuncture (magic, why does it work?) • Nutrition—how important is it?

– In this field of medicine it is much of the “bottom line” • Cancer and terminal illness • Death

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What Turns You On?

• Helping people • Appreciating the level of trust patients have for your

– Living up to that trust – Honoring that trust

• Knowing that you never know everything • Knowing that you can always learn more • Connection to experts that can help you in your quest to help people • What credentials do you need?

– You are here to prepare for the Board exam • What is your path and interest?

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Ceremony and Ritual

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Healers!Art—

Science!

Art—Ceremony!

Search for

Meaning!

Science!Physical

Aspects of Disease!

Administrative Financial

Legal Pressures!

Our Patients Seek Communication and

Partnership!

Ceremony and Ritual

• Ceremony allows us to bring meaning, control, and connection into patient’s lives – Create a space where the uncomfortable becomes safe to

share – Act as powerful glue to initiate/renew functional communities

• Rituals allow pause, downtime, suspend pressures of the day

• Scents and music with massage or acupuncture • Soft environment

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Ceremony/Ritual • Office visit is full of ceremony and ritual

– Time and your schedule are suspended – Sign in – Check out magazines – See other people taken back first – Pass your insurance card — determines your level of upcoming ritual

• Shared purpose and preparation as you are escorted to a private room — ritual of BP, Wt, interim history, current concern

• Opening to the ceremony when doctor enters room • Sacraments — essential oils, smells, music, syringes, otoscope • Ceremonial dress — some patients dress up a little, what do you wear • Sharing — doctor and patient, sometimes deeply personal in both directions • Closure — plan, goals for next visit, homework, settle payment on the way

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Why?

• How is this different? • Being with people • Personal connection • Heart • Efficacy of treatment

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What Does it Take?

• Being in the world in a different way • Personal healing and doing our own work • Helping people heal • Helping people die • Creating a healing environment • Creating ceremony and ritual in the medical

encounter

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Being Meaningful Living Meaningful

Authentic in Life and Practice

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Thank You

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