Integrative health in an ideal world?

It's about as far from staggering into your GP's surgery in the rain as you can get.  No sterile interior, NHS health posters and fraying magazines; instead there's uplifting state-of-the-art architecture, personally tailored care, a huge range of medical choices, a garden and - oh - an entire forest out the back. 

Duke Integrative Health Center is one of the flagship venues bringing together orthodox medicine with complementary approaches and lifestyle interventions. Built with money from a private donor, it is based at Duke University, North Carolina in the United States. 

We spoke to the Director, Dr Tracy Gaudet about the growth of 'integrative' health in the US, the work at Duke and how she hopes that the health nirvana they offer won't just be a resource for the few.
 
FIH: Can you tell me what integrative health means on your side of the Atlantic?

TG:  Integrative health for us is a broader approach to health care.  Rather than limiting our focus to a disease process or a body part, it’s an emphasis on really engaging the whole person, physically, mentally, emotionally, spiritually, as well as using a full array of approaches that can be of benefit, including things that would be considered complementary therapies here.

FIH: You have close links with a group of health philanthropists, the Bravewell Collaborative and are a part of their clinical network. Is the success of integrative health in the US down to them, or have there been other voices in its favour?

TG:  There have been a number of factors: one is the public.  More than ten years ago the first study was published that focussed on how many people in the States were using complementary and alternative medicine and it got a lot of attention. Then a series of studies that came out looking at why people were doing this and they weren’t necessarily dissatisfied with conventional medicine, but they were wanting a broader approach that more aligned with their values around life and health.

Then the gasoline on the fire, if you will, has been the work of philanthropists, like the Bravewell Collaborative who have really enabled this to take off in a way that it wouldn’t have if it didn’t have that funding.  We are the co-ordinating centre for 'BraveNet' which is their practice-based research network. 

FIH: When a patient comes to you how do you find a way of steering them towards a combination of things that will be useful and away from things that you might feel are beyond the pale or unhelpful within the complementary stream?

TG:  We’re trying to train physicians to understand the full spectrum of health care, so they can partner to be inclusive of things they may not otherwise be as familiar with, whether that’s acupuncture or hypnosis for example, and also to help them weed out any approaches or therapies that might be harmful or not beneficial.  In our system it’s the role of the physician to work with the patient to sort  through all of that.

FIH: From the physician’s point of view what kind of extra knowledge do they need to have to be able to sit with the patient and authoritatively say, 'Look, these are your set of choices, have you considered this?'

TG:  At a minimal level the most important thing seems to be just having an open mind, in other words many of the patients understand that we don’t necessarily have all the answers and very often there hasn’t been enough research done.  So they are often working together with patients much more in a partnership model where we’re understanding what we know, what we don’t know and then how to make decisions.

One of the great things that Bravewell has done is allowed us to pretty extensively educate physicians who really want to focus their practice on integrative medicine through a two year associate fellowship training programme.

So the spectrum covers everything from physicians who don’t have any particularly focussed training but are open-minded and willing to look at all approaches, to somebody who has focussed more attention on their education in that area.
 
FIH: You base your approach on a wheel of health.  Can you explain roughly what it looks like and what it includes?
 
TG : Yes.  At the centre of the wheel is mindfulness - knowing your own state and being able to spot a shift.  Around it sit all the ingredients of good health: movement and exercise, nutrition, physical environment, relationships, personal growth and spirituality and the mind-body connection.  On the outside rim of the wheel we consider three overlapping approaches to staying healthy - preventative medicine, conventional and CAM treatments, and pharmaceuticals and supplements.  In treating a patient we look at which areas they need to work on to address their health concerns.

FIH: Can you describe the sorts of people who might come to you and the kinds of responses you might give to them?

TG:  Patients tend to group into three basic types: one is a group of patients who are very health conscious who want to do whatever they can to optimise their health and their vitality.  They don’t necessarily have a specific medical issue or problem. 

Then we see people who have had what I would call a major medical event,  like a cancer diagnosis, or they’re headed into surgery or they’ve had a heart attack. 

We work hand-in-hand with them to create an integrative health plan built around the wheel of health.  For example, there’s some very interesting evidence, looking at patients who prepare for surgery by using hypnosis and acupuncture.  It shows they really have much better outcomes in terms of how much anaesthesia they need and how many side effects like nausea and vomiting they have.

The last group of patients that we see are people who have chronic conditions.  Conditions where the existing medical system isn’t so great at curing or fixing, and they again want to look at this from ‘well, I know what medicine or surgery can and cannot do for me, but can I get a better result and live a healthier life if I use a broader array of therapies and learn self-care techniques?’

FIH:  Looking at the Duke brochures with those gorgeous pictures of architecture and the level of care that you obviously provide, it does look like a service for the rich, or at least the very comfortably off. Is that your demographic at the moment?

TG:  One of the goals of the center is to model a new approach to health care.  So the question was ‘if you could build a facility from the ground up, what would that look like?’  So it is  more high-end, because it's not typically covered by insurance.

An interesting parallel is mammography, when it first came out it was hugely expensive and not covered by insurance.  It's like that with any kind of any innovation.  So our signature programme is health immersion across several days followed by an ongoing relationship across the year, which of course is more high-end.

The danger of modelling that way is that integrative medicine can be perceived as only for the well-to-do, as you’re saying, which is a very legitimate concern. The issue of how we translate that into the broader system is a really important one.  We do have offerings across the spectrum, we have free offerings and we have a financial aid service, so that access is not a barrier. 
 
More importantly I think we’re creating strategies that allow us to bring this into the mainstream.  This summer we’re launching integrative health coaching, a training programme to teach people to be health coaches in any environment.  That could be in a clinic, a church, a barber shop.  Those are ways that we can help bring this approach to the mainstream and not have it be an elite medicine, because that’s the last thing we want to do.

FIH:  What kinds of people do you want to bring into health training?

TG:  We want to attract people who have already worked in health fields - such as medicine, nursing, physical therapy or health education, ideally for 3 - 5 years.
 
FIH:  What’s your relationship with Duke University - do you work with their medical students?

TG:  Yes - students and residents

FIH:  So do they interact with you depending whether they are open to this approach or not,  or is it innate in the course that any Duke medical student might take?

TG:  Some of both is the short answer.  We have integrated it into the four year medical school curriculum, so some of it is core to the curriculum for every medical student.  Then for people who have a greater interest, we also have the opportunity for more in-depth study with us as well.

FIH:   In the UK at the moment there's a sense of polarisation between orthodox medicine on one side and complementary on the other - with the latter being portrayed by its detractors as always voodoo-ish and anti-Enlightenment. Is this conversation also playing out in the US, and if so, where do you stand in that debate?

TG:  I think that that divide was greater ten years ago than it is now.  I think we’ve made progress in that way, not to say that there isn’t still opposition, but I think ten or even 12 years ago when there was that initial recognition that complementary approaches were being used commonly in the States, there was a reaction of conventional medicine against it  - in my opinion out of fear and misunderstanding. When I was starting my work in Arizona for example, the head of the cancer centre said, you know, 'Well, you know, I know what you guys are going to do here, you’re going to take everybody off their chemotherapy and give them herbs'.

But no, actually that’s not what we’re going to do.  But there was that concern and the fear that this was much more alternative and anti-medicine than it was integrative.

Now I think we’ve come a long way in that regard, not like it’s perfect or there’s never any conflict. But the mainstream medical physicians, for example, now see us as a resource to them and their patients because they know we’re not being fanatical, that we’re grounded and that we can give them advice and recommendations in areas where they are not knowledgeable. 

FIH: Do you carry out any research?  

TG:  Yes.  Since our mission is to create a new models of care, most of our research is focussed more on those models rather than in individual therapy like acupuncture and how it works, although we do some of that research. 

So we are asking 'do we actually get better results for people, do they really make changes in their life, are their medical outcomes better?'  We’ve done everything from a randomised control trial a few years ago, looking at the integrated approach across ten months to see if it makes a difference in reducing people’s risk of heart attack and stroke and it did. 

We also looked at the concept of teaching people mindfulness and awareness as it applies to their relationship with food, to see if we can impact on binge eating disorders or over-eating and weight loss maintenance.  We have other research looking at the concept of health coaching with diabetic patients. 

FIH: So it’s more pragmatic testing in the real world rather than double blind RCT ?

TG:  Well, it’s a little bit of both.  We're also working with  Bravewell on a practice based research network which they call BraveNet, and that is definitely more of the real world.  A practice based research network, is set up to look at how clinicians are using this in the real world, in practice, and see what impact it’s making.  So some research is set up much more in that way, and then we do have trials that are set up as an RCT as well. 

FIH: You've got a third estate in the US who aren't so significant over here, which is the insurance companies.  Most people in the US won’t be able to get help unless their insurance companies says, 'Yes, that’s a sensible idea.'  Do you feel like you’ve got a job to educate them that it’s worthwhile?

TG: That’s a huge piece of it, and for us in the States one of the good strategies is to affect change first through Medicare and Medicaid, which are the Government funded programmes, because most of the other insurance companies follow suit. So yes, this is a huge issue in terms of whether or not this will become mainstream medicine.  It'll be a sign of progress when there's no difference in terms of insurance coverage between acupuncture or hypnosis or injections with steroids. 

FIH: You’ve come so far in ten years, if things carry on as they are, where could you realistically hope to be another ten years from now?

TG: Given the pace at which things are changing, you know, I hope we'll be in a place where perhaps we’re not even talking about integrative medicine anymore.  You know, where  these approaches are just integrated into the hospitals and into clinics and it is standard care,  not something people have to seek outside of their conventional medicine or even necessarily pay for out of pocket.  And we'd like to see it as standard in the education of health professionals too.