Blending in

A blended approach

Integrative medicine seeks to combine the best insights of both conventional and alternative medicine, while providing a unifying perspective to guide physicians in intelligently combining these heterogeneous systems of thought.

First, IM is healing oriented. A variety of alternative and traditional medical systems are premised on the “healing power of nature.” Conventional medicine is often criticized for “suppressing symptoms” and not getting at “root causes.” Integrative medicine embraces the notion that the body is innately self-healing and attempts where possible to either remove barriers to healing or assist the healing process, using suppressive therapies only when necessary.

Second, IM is relationship oriented. Family medicine has appropriately articulated a patient-centred model of care, replacing the traditional, more physician-centred approach. The relationship aspect of IM retains this patient-centred focus while more explicitly acknowledging the contribution of physicians to quality of care. Integrative medicine promotes physician well-being and self-reflection, and seeks to attract physicians who are on a healing path themselves. A growing literature suggests that physician credibility surrounding wellness promotion is enhanced when the physician is perceived to be personally “on the healing path.” In other words, IM proposes a transformational component, in addition to knowledge and skills acquisition, within medical education.

Third, IM takes into account all aspects of lifestyle, including nutrition, physical activity, stress, sleep, spirituality, and occupational functioning. There is much overlap here with how family medicine is already taught and practised. However, IM seeks to reinforce these aspects with enhanced teaching and detailed skill development in areas such as counseling on clinical nutrition, prescribing physical activity, assessing motivation, and creating behavioural change. Integrative medicine takes a decidedly “prevention and wellness” approach.

Fourth, IM makes appropriate use of all available therapies, both conventional and alternative. Often in conventional or alternative literature, the advantages of one approach are embellished while the problems with the other are emphasized. Integrative medicine seeks to acknowledge the critical contributions of both conventional medicine and CAM philosophies and treatments, while addressing the problems in each—the overreliance on medication and technology in conventional medicine and the frequent lack of scientific rigour in alternative medicine, for example. Fortunately there is growing evidence to guide physicians through issues such as nutritional recommendations, efficacy of herbal medicines, and use of mind-body therapies in specific conditions. Much of this knowledge lies in literature not read by conventional physicians and needs to be more prominently featured in mainstream medical literature and curricula.

Strategy

Landmark studies by Eisenberg et al6 and Astin7 in the 1990s documented the substantial rise in the use of CAM and expounded some of the reasons people seek and pay for these modalities of care. Users of CAM are frequently more educated and often have had “transformative” experiences. They want to be more involved in their care, seeking not so much to reject conventional medicine as to supplement it with a wellness and “holistic” orientation, and possibly less toxic therapies. Integrative medicine asserts that overall costs can be reduced by relying less on technology and drugs and investing more time with our patients by providing education in self-care of minor or chronic health problems and cultivating optimal health.

What would an IM-influenced curriculum look like? Medical education would include solid foundations in clinical nutrition, physical activity prescribing, behavioural change, working with spirituality, stress physiology, mind-body therapies, and herbs and supplements. Students would also learn about compelling and commonly sought alternative medical systems, such as traditional Chinese medicine, homeopathy, osteopathy, chiropractics, massage therapy, Ayurveda, naturopathy, and energy medicine. Students would explore the underlying philosophies, treatment approaches, and the strengths and weaknesses of each system, along with how to make appropriate referrals, how to choose reputable providers, and how to place such modalities into an overall plan of care. Finally, students would be encouraged, as a core component of their education, to undertake personal experiments in personal wellness, behavioural change, being a “patient” of alternative practitioners, and spiritual exploration.

Medicine is currently at a crossroads. The prevailing paradigm of scientific reductionism is being questioned and its limitations increasingly recognized. While reductionism has generated much useful knowledge about the mechanisms and treatments of diseases, it falls short of elucidating aspects of healing that a complex interplay of many factors involve.

A new generation of researchers is developing new methods for studying those dimensions of health and healing that cannot be explored with current research methods. As an example, the studies of cardiologist Dean Ornish in the 1980s, which looked at a combination of diet, group support, and yoga in reversing heart disease, demonstrated the powerful synergy at work in a multidimensional treatment program.8

Most physicians are aware of the dangers involved when patients pick and choose between conventional and alternative modalities without a trusted advisor to help weigh the options and decide on a combination treatment plan. Integrative medicine provides a supportive setting where patients can have substantial input into how their health is managed, exploring alternative and complementary therapies as desired, while at the same time ensuring that important and proven conventional treatments are not excluded. Family medicine is well placed to lead the way in integrative care. Weighing competing opinions while keeping patients’ interests in clear view has always been a defining dynamic of our work.

From theory to practice

Many difficulties remain to be worked out. Among them is the thorny issue of evidence. It is often implied—wrongly—that everything in conventional medicine is evidence-based and everything in CAM is not. It is becoming increasingly appreciated that the situation is much more complex. Furthermore, standard research methods are not adequate for generating evidence for many alternative treatments. Often individuals who have the same conventional diagnosis are treated differently within an alternative treatment system. Individualized care is difficult to study using conventional science. Many modalities, such as meditation, are difficult to standardize or to compare with a placebo arm. New methods of scientific evaluation, therefore, are being pioneered to study nondrug therapies in ways that are tailored to the operating characteristics of the therapies themselves.9 At the same time, it needs to be frankly acknowledged that many CAM therapies lack any firm basis and are not to be recommended. Family physicians trained in IM will be well placed to make such judgments in a manner that patients will find acceptable.

Practical aspects of IM, such as office management, must also be worked out. Organization of time, staff, and funds requires consideration. Likewise, changes in health care policy and health insurance will be required to reflect the evolving face of health care.

The changes proposed by IM, as it enters the medical mainstream, will do much to heal the unnecessary sense of conflict between conventional and comprehensive medicine, both in society, and in the minds of patients and clinicians. Integrative medicine holds the promise of restoring to medicine a more complete sense of its mission, and to its practitioners an enhanced sense of personal well-being and job satisfaction.