The Best of Both Worlds
Can Integrative Medicine Transform
the U.S. Health-Care System?

While complementary medicine is used alongside conventional medicine, and alternative medicine is used in place of conventional medicine, integrative medicine holds a broader view: At the heart of integrative-medicine programs is a conviction that good medical care combines conventional practices with complementary and alternative medicine (CAM) therapies that have been proven effective and safe.

assage therapist Doreen Lafferty is staying late at work to help a 95-year-old client get dressed following her first massage. The client admits the treatment left her a bit sore, even though Lafferty’s skilled touch relieved her low-back pain.

Lafferty’s cozy massage room, adorned with a fountain and an altar, and buffered by soft music, could be inside a home office or small-business suite, so personal is its ambience. But this massage practitioner is employed by the Jefferson-Myrna Brind Center of Integrative Medicine located on the vast, urban campus of Thomas Jefferson University Hospital in Philadelphia, Pennsylvania. The center, which opened in 1997, was one of the first integrative-medicine programs in the United States.

Lafferty has been a member of the center’s integrative-medicine team almost from the start. Her practice is a demanding one: she sees four to six clients for one-hour sessions, four days a week, with 15 minutes between appointments. Hectic as it is, Lafferty calls her work very rewarding, because she sees people in distress “get their functioning back.”

This is especially true for those in chronic pain, who have found little in mainstream medicine that helps, says Lafferty, who is also a licensed occupational therapist.

“When they use acupuncture, massage, yoga, nutritional counseling and mindfulness-based stress reduction—all that together really helps some get out of chronic pain and into a healthier lifestyle,” she says.

A team approach

The practitioners in her clinic—doctors of Chinese and integrated medicine, massage therapists, acupuncturists and mind-body practitioners—meet once each month for clinical-care conferences, and take turns giving informal educational presentations related to their disciplines. Also during these meetings, the team might discuss patients with particularly complex medical conditions, and refer them to others on the team. These sessions are so useful, Lafferty says, “I wish we had the time and funding to have a clinical-care conference every week.”

Doreen Lafferty is employed as a massage therapist at the Jefferson-Myrna Brind Center of Integrative Medicine at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania.

Lafferty also wishes she could provide massage to patients in the hospital. Right now, she and her colleagues mainly treat outpatients, who have already been discharged from the hospital and want to explore other therapies.

“The (inpatient) staff at the hospital [doesn’t] know we exist,” says Lafferty, who gets most of her referrals from integrative-medicine physicians, general practitioners and pain-management specialists. “There is a still a great deal of research to be done to increase the evidence base of this medicine.”

Her sentiment is echoed within the larger context of integrative medicine.

“Our research over the past 14 years has shown a consistent level of usage by adult Americans,” says David Eisenberg, M.D., director of the Division for Research and Education in Complementary and Integrative Medical Therapies and the Osher Institute at Harvard Medical School. “While there have been a few notable changes in which CAM therapies people are using [between 1997 and 2002, for example, the number of U.S. adults using herbal supplements jumped from 12.1 percent to 18.6 percent; the practice of yoga increased 40 percent over the same period], the overall number of adults employing some type of CAM has remained remarkably consistent since we began our surveys in 1990.”

Studies by Harvard Medical School show that in 1997, 36.5 percent of U.S. adults used at least one form of CAM, and that 35 percent of U.S. adults used at least one form of CAM in 2005.

“This says to us that these therapies are part of the fabric of modern day health care, and that we need to do more research on their safety and effectiveness—just as we would with any other therapeutic options,” Eisenberg says.

The realm of acceptance

In 1994 Andrew Weil, M.D., launched the first university-based integrative-medicine program in the nation, at the University of Arizona. Now, about 75 percent of U.S. medical schools offer CAM-related coursework, typically representing one or two elective courses. However, a recent study found that medical students and residents still consider their exposure to CAM insufficient to answer patients’ questions and appropriately refer them to CAM practitioners.

The integrative-medicine programs described in this story are members of the 31-member Consortium of Academic Health Centers for Integrative Medicine, a group of programs participating in teaching, evidence-based research and clinical care that fosters the development of integrative-medicine practices.

Daniel Monti, M.D., director of the Jefferson-Myrna Brind Center, says he has believed in an integrative approach to medicine since the early days of his career, which began in 1992.

“When I thought of complicated problems, I was aware of other modalities that would be useful,” Monti says.

He has been widely published in scientific journals on the topics of mind-body medicine, complementary-healing approaches for cancer patients, and integrated management of chronic pain. He has also completed the first phase of a National Institutes of Health-funded clinical trial on the effects of an intervention he and his team developed for cancer patients that incorporates mindfulness meditation and artistic expression.

Monti notes that integrative medicine is not synonymous with CAM. The driving force behind integrative-medicine programs is the collaborative relationship between the patient and the physician, who work as a team to optimize the patient’s health and well-being.

“We are trying to provide an alternative [and] integrate all aspects of the person,” Monti explains. “Sometimes in the integration, we use complementary modalities. For example, for chronic pain, our acupuncturist, or both massage therapist and acupuncturist, can make all the difference in the world.”

Many consumers are exploring alternatives to conventional health care. In May 2004 the Centers for Disease Control and Prevention (CDC) released the results of the National Health Interview Survey, which included a section on CAM usage developed by the National Center for Complementary and Alternative Medicine (NCCAM) and the CDC National Center for Health Statistics. Among the survey results: 36 percent of American adults use some form of CAM, with that figure rising to 63 percent when prayer is included; a growing number of people believe that CAM helps with health problems not addressed by Western medicine; and massage—used by 5 percent of survey respondents—ranks among the top 10 preferred therapies.

Meanwhile, the number of hospitals offering massage therapy has increased by more than one third over the past two years, according to a May 2006 American Hospital Association survey.

An increasing number of medical schools now offer courses on CAM, and also require students to take classes in integrative medicine. In the university system where Lafferty works, medical students learn the rationale for integrating CAM within mainstream settings. What’s more, medical students rotate through the integrative-medicine clinic and observe the acupuncturist, the nutritionist and Lafferty, who demonstrates the therapeutic value of massage.

Monti says that integrative medicine is moving into “the realm of acceptance” in regard to mainstream medical practitioners.

“We’re in the middle of some sort of a paradigm shift. I have physicians approach me and ask, ‘How do I bring this modality into my practice? Which have scientific evidence, and which don’t?’” he says. “We are continually looking at ways to quantify what we do so medical staff are more and more convinced about the efficacy of less-conventional treatment options.”

Listening to the patient

“I think that all of us resist change,” says registered nurse, yoga teacher and massage/acupressure practitioner Jnani (pronounced yani) Chapman, who works at the Osher Center for Integrative Medicine at the University of California, San Francisco School of Medicine. “It is wise to expect that resistance and to be ready to meet it with science and an evidence-based understanding” of CAM, she adds.

Chapman specializes in working with people who have cancer, heart disease and chronic illness. At the Osher Center, she offers acupressure and massage, and teaches gentle yoga for cancer patients and therapeutic yoga for medical and stress-related conditions. She is also the massage coordinator at the Commonweal Cancer Help Program, a residential retreat program for cancer patients in Bolinas, California.

The best physicians will listen to what the patient wants, says Chapman. “Once a physician hears from the patient the difference in how they feel after receiving a complementary treatment, the physician will most likely say, ‘If you resonate with it, then try it.’”

Chapman says most physicians will tell patients they can’t recommend CAM modalities when the hard science isn’t available to support their safety and efficacy, but that response, Chapman observes, “is different than saying, ‘This treatment is bad.’ When patients understand that distinction, they can go out and do their own research.”

Chapman’s belief in alternatives to Western medicine began 42 years ago, when she was in the seventh grade. Her mother required almost around-the-clock dialysis and began spending more time at the hospital than at home. Then, when she was freshman in college, her father died of a heart attack three months before her mother’s death. The staff at the 94-bed community hospital where her mother was treated became Chapman’s surrogate family, but she says she still believed that hospitals were “places of death.”

“I became totally alternative, not integrated,” she recalls. “I thought, ‘Western medicine could not help either of my parents.’”

But later, as a massage therapist, the hospital frequently requested that Chapman work at a patient’s bedside.

“It was this experience that helped me overcome my aversion to Western medicine and allowed me to enter nursing school,” she recalls. “I saw how valued I was by the nurses for helping reduce stress and relieve suffering for their patients. It was the family of the patient who was asking me to come in and give a massage, but the nurses would be delighted.

“(Eventually), we at [the Osher Center] were funded to bring acupressure and acupuncture into the hospital,” Chapman adds. “We are thrilled that patients can be referred to have both acupuncture and massage.”

Educate medical students

In 2000 NCCAM awarded Mary Jo Kreitzer, R.N., Ph.D., and colleagues a five-year, $1.6 million grant to investigate attitudes toward CAM in the University of Minnesota’s schools of medicine, nursing and pharmacy. Kreitzer is the director for the university’s Center for Spirituality and Healing. She hypothesized that giving medical students knowledge and experience about CAM would help shape more favorable attitudes about unconventional modalities. “We have found out that it does,” she says. “Knowledge shapes attitudes, and experiences also shape attitudes.”

Kreitzer, who is also an associate professor in the nursing school, teaches a complementary-therapies program, which offers a graduate minor in complementary therapies and healing practices, or a graduate certificate for those who already have advanced degrees.

“We are the first and the largest university to offer a program like this,” Kreitzer says. “More and more students are seeing complementary therapies as an ideal complement to their primary field of interest.”

Of the medical schools in the United States that now have integrative-medicine programs, Kreitzer says, “A lot my colleagues have faced barriers in implementing these programs, [but] we had tremendous support from faculty,”

The University of Minnesota faculty is also collaborating on a study on the impact of an integrated residential-treatment program for women with eating disorders. Anecdotally, the residential-treatment staff believes that therapies such as massage are making a difference, Kreitzer says. From the beginning, “our center was not just about researching. We are also interested in helping to design integrated systems of care.”

But there aren’t enough research dollars to go around, Kreitzer says. She points out that the United States spends “a fraction” of the total National Institutes of Health budget on CAM research, even as NCCAM increased research funding from $2 million in 1992 to $122.7 million in 2006.

Transforming health care

In Baltimore, the Center for Integrative Medicine at the University of Maryland School of Medicine employs two physicians, two acupuncturists and a yoga instructor, and contracts for massage, shiatsu, qigong, tai chi, nutritional counseling, stress-reduction

The integrative medicine program at Hartford Hospital in Hartford, Connecticut, includes (from top to bottom): reflexology, reiki and acupuncture.

classes and reflexology. As is true of other integrative-medicine centers, this one treats more self-referrals than physician referrals.

But that is slowly changing. Through one-on-one education, more integrative health-care practitioners are making contact with primary-care doctors.

The Baltimore center publishes a brochure that describes its integrative approach and the roles of patient and specialist. “The patient has to be committed to being part of the team,” says Jeanette M. Cronise, the clinic’s practice director.

Each patient completes an extensive intake form that forces him to think carefully about his lifestyle and health behaviors, and gives the physician “a good idea of the kind of patient we are dealing with,” she adds. During the initial intake, the patient and the physician discuss what the patient is willing to commit to in terms of time and money.

Cronise says reimbursement for integrative-medicine services will likely remain a barrier in the years to come. Most patients pay out-of-pocket for services, although traditional insurance plans generally cover acupuncture and office visits with the integrative-medicine physician. Some insurance companies that don’t cover CAM therapies offer discounts to health providers who agree to participate in their networks. However, Cronise says that, as yet, practitioner reimbursement has not been significant enough to warrant much participation.

Optimistic, Cronise believes that as more employers offer flexible spending accounts allowing subscribers to make decisions about how they spend their health-care dollars, insurance payments will increase.

And despite the barriers that still limit access to integrative-medicine practices, Lafferty also foresees an ongoing transformation of the U.S. health-care system.

“When I first started working as an occupational therapist in 1988, I thought there should be a team of people who used complementary and alternative-medicine interventions, as well as traditional Western approaches to care for patients,” she says. “I waited nine years for this to happen. Every day I walk into work, and I’m very thankful.”

Chris Cunningham is a freelance writer for a variety of health, business and higher-education trade magazines. A former hospital and long-term care administrator, she is a regular contributor to Fibromyalgia AWARE, and has written for MASSAGE Magazine on topics including “For Fibromyalgia Clients, Very Easy Does It” (January/February 2005), and “Hepatitis: What You Need to Know” (November/December 2005).