Elsevier

EXPLORE

Volume 5, Issue 5, September–October 2009, Pages 277-289
EXPLORE

Clinical article
Original article
Integrative Medicine and Patient-Centered Care

https://doi.org/10.1016/j.explore.2009.06.008Get rights and content

Integrative medicine has emerged as a potential solution to the American healthcare crisis. It provides care that is patient centered, healing oriented, emphasizes the therapeutic relationship, and uses therapeutic approaches originating from conventional and alternative medicine. Initially driven by consumer demand, the attention integrative medicine places on understanding whole persons and assisting with lifestyle change is now being recognized as a strategy to address the epidemic of chronic diseases bankrupting our economy. This paper defines integrative medicine and its principles, describes the history of complementary and alternative medicine (CAM) in American healthcare, and discusses the current state and desired future of integrative medical practice. The importance of patient-centered care, patient empowerment, behavior change, continuity of care, outcomes research, and the challenges to successful integration are discussed. The authors suggest a model for an integrative healthcare system grounded in team-based care. A primary health partner who knows the patient well, is able to addresses mind, body, and spiritual needs, and coordinates care with the help of a team of practitioners is at the centerpiece. Collectively, the team can meet all the health needs of the particular patient and forms the patient-centered medical home. The paper culminates with 10 recommendations directed to key actors to facilitate the systemic changes needed for a functional healthcare delivery system. Recommendations include creating financial incentives aligned with health promotion and prevention. Insurers are requested to consider the total costs of care, the potential cost effectiveness of lifestyle approaches and CAM modalities, and the value of longer office visits to develop a therapeutic relationship and stimulate behavioral change. Outcomes research to track the effectiveness of integrative models must be funded, as well as feedback and dissemination strategies. Additional competencies for primary health partners, including CAM and conventional medical providers, will need to be developed to foster successful integrative practices. Skills include learning to develop appropriate healthcare teams that function well in a medical home, developing an understanding of the diverse healing traditions, and enhancing communication skills. For integrative medicine to flourish in the United States, new providers, new provider models, and a realignment of incentives and a commitment to health promotion and disease management will be required.

Section snippets

Integrative Medicine: History and Definitions

A vision for a new kind of healthcare is emerging. It is patient centered, healing oriented, and embraces conventional and complementary therapies. This medicine has become known as integrative medicine. Driven initially by consumer demand, it is now increasingly being accepted by healthcare providers and institutions. Definitions abound, but the commonalities are a reaffirmation of the importance of the therapeutic relationship, a focus on the whole person and lifestyle—not just the physical

Integrative Medicine for a Young Man With Persistent Headaches

An 18-year-old high school student presented to the Arizona Center for Integrative Medicine clinic with a three-year history of severe headaches, neck pain, and a new onset tic disorder. He had previously been healthy and played on the varsity baseball team. He recalls the headache beginning after a violent sneeze. After a month of severe daily headaches, during which time he was unable to return to school, he was referred to a neurologist. New symptoms included poor sleep, poor energy, and a

History of Complementary and Alternative Medicine in the US Healthcare System

As a result of the Flexner report published in 1910, American medical schools were tasked to set higher admission and graduation standards and to adhere strictly to the protocols of mainstream science in their teaching and research.4 Over the next 25 years, close to 60% of medical schools were forced to close.4 Schools providing training in eclectic medicine, naturopathy, and homeopathy were even more adversely affected by the report, leading to closure of the majority. What is now called

Case Two

The patient was a 54-year-old man who recently had a myocardial infarction and had been treated with a stent placed in his left anterior descending coronary artery. He was hypertensive, overweight, stressed, and had elevated lipids with an LDL of 274. He came to the University of Wisconsin integrative medicine clinic wanting to find nonpharmaceutical options to prevent another heart attack. He was ethically against “big pharma” and did not want to take something that “may cause more harm than

Integrative Medicine in Practice

Currently some elements of integrative medicine are already being broadly practiced, and a few integrative medicine practice models have also emerged. This section will describe the roles of PCC, self-management and empowerment, communication and behavior change, continuity of care, new provider models, and group models in integrative medicine. It will also review the evidence supporting both the individual elements and the emerging models of care. These critical elements that support the

Self-Management and Patient Empowerment

The division of power between clinician and patient has significantly changed over the past three decades. With medical advances came more accurate diagnoses and effective treatments. Along with this positive evolution came a hierarchical relationship based on the belief that science and technology held the answers. This authoritarian approach has only recently been challenged, in part, by the internet that makes available the vast array of medical knowledge to any sophisticated searcher.

Potential New Provider Models

Our current healthcare system is actually a disease-centric medical model. We focus the majority of our attention on acute care (eg, treating heart attacks and cancer) followed by chronic disease management (eg, treating hypertension and diabetes), with minimal funding or attention paid to preventive care.

The shortage of primary care physicians contributes to the challenge of managing the healthcare needs of Americans. Between 1997 and 2005, the number of US graduates entering family medicine

Emerging Integrative Care Models

The development of integrative patient care models is progressing. Influential factors include recognition of the enormous numbers of patients using alternative medicine, their demand for integrative care, growing experience of providers referring to and using CAM, increased numbers of trained integrative medicine professionals, and the potential cost savings in these forms of treatment.

The most common form of integrative medicine is the patient-directed model, where the patient seeks out CAM

Integrative Medicine in a Cancer Patient

A 44-year-old woman with history of type 1 diabetes since age 12 presented to the Arizona Center for Integrative Medicine clinic for help with side effects from her chemotherapy. She had been diagnosed with stage IIB infiltrating ductal carcinoma of the breast. After lumpectomy and radiation, chemotherapy with Adriamycin and cytoxan had been recommended. With her first cycle of chemotherapy, she developed diabetic ketoacidosis, which placed her in the intensive care unit for a week. Despite

Outcome Research to Support Integrative Medicine

A large number of studies support lifestyle and increased time spent in consultations with patients. These include lower risk of the development of diabetes and reversal of cardiovascular disease.104, 105 Longer consultations resulted in fewer prescriptions, more lifestyle advice, better handling of psychosocial problems, and empowered patients.106

Several studies support cost savings with the use of CAM. For example, acupuncture treatments have been shown to reduce the need for knee surgery at

Integrative Medicine for Six-Year-Old Male With Otitis Media

A six-year-old male had a recurring history of otitis media since age 2. He had been treated with recurring courses of antibiotics, yet the ear infections recurred every two to three months; eustachian tube placement was also unsuccessful. His mother presented with him to the American Medical College of Homeopathy with a 24-hour history of fever to 102°, bilateral ear pain (worse on the right and described as sharp and cutting), enlarged painful lymph glands, and nocturnal salivation.

He was

The Integrative Medicine Model

Given the complexity of medicine, the wide range of therapeutic options, the need for preventive care, health promotion, acute disease care, chronic disease management, and palliative care, we will have to move toward team-based care. Already, teams have formed in complex areas of medicine, notably for children with disabilities, adults with renal failure, and hospice and palliative care. Teams will need training to work together effectively. Grumbach and Bodenheimer119 describe the five key

Case Five: The Future of Integrative Care

The patient presents for his semiannual health promotion check-up at his primary care clinic in New Mexico. He is a 46-year-old man who has been followed for two years with borderline elevated blood sugars, a low HDL, and elevated triglycerides, all hallmarks of metabolic syndrome. Despite discussion with his physician, he has gained 48 pounds over the past two years. He had been unable to make the recommended lifestyle changes as he was simply too busy. Today his labs confirm early diabetes,

Conclusion

For integrative medicine to flourish and provide solutions to our current healthcare crises will take systemic change. It will require a commitment to focus on prevention and health promotion, to embrace new providers, and new provider models. And to honor the therapeutic relationship and the bond that forms when a trained provider and patient will require a shift in focus. Technology, including electronic medical records that enhance interdisciplinary communication and teamwork, will be a

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