Integrated cancer care and The Seven Levels of Healing

FIH:  Can you describe your journey from directing your own cancer centre to becoming a writer and speaker on the integrated approach?

JG: During the ten years that I was directing my integrated cancer centre, I worked very hard to develop effective ways to help patients and families respond to their diagnosis on all levels - physically, mentally, emotionally, and spiritually.  This included discovering The Seven Levels of Healing, understanding how they really work, and figuring out how they can be implemented into mainstream care.  It also involved the laborious process of creating an entire cancer centre that was built around this philosophy, while maintaining the highest standards of conventional medical care at every step along the way.

Over this decade, thousands of patients and family members directly experienced our approach to integrated care.  During this time I also published the first edition of my book, The Journey Through Cancer: Healing and Transforming the Whole Person, in 2000.

The Journey Through Cancer was written as much from the heart as the mind.  It was the first book on integrated cancer care written by a practising medical oncologist.  After it came out I started getting calls to speak at conferences.  This was still in the early years of the 'integrative medicine' movement, as it called in the US, which began in earnest around that time.  The 1990s were the era of what was known as complementary and alternative medicine, or 'CAM'.  But in 2000 we began to transition to a more complete model of integrative, or 'integrated' medicine.  The Journey Through Cancer  was part of this new wave of change in the medical paradigm.  It contained a clear, credible description of how we can make this shift from a strictly conventional, biomechanical approach to a much broader, integrated model.  It also provided a very practical guide and resource for patients and loved-ones seeking a more holistic approach.

Soon thereafter, other cancer centres and hospitals began to ask me to come and talk with them about The Seven Levels of Healing.  Over time, it became clear that I was being called to let go of day-to-day clinical practice.  I was organically transitioning from an oncologist taking care of individual patients and families, to one who is working to help the healthcare system heal and evolve as a whole.

Most experts acknowledge that, in America at least, the healthcare system is facing grave challenges.  It has many areas of extreme dysfunction and imbalance which are clearly unsustainable.  As a metaphor, you could say that, in some respects, it has cancer, and won't survive without some serious interventions.  As an oncologist I'm called to try and make a positive impact - not only for patients and families, but also for physicians, nurses, and staff, and the system as a whole.

FIH:  Empathy is a gift that not everyone has - it's in short supply not just in the health service, but in all walks of life.  If you have a very bright doctor, great at understanding disease, it's quite a tall order to expect him or her to always be a great 'people person' as well, especially if they are constantly dealing with patients who are upset.  How can doctors get to a place where they can be that caring, empathic person without completely wearing themselves out?

JG:  That’s a great question, and an important one.  There’s a growing body of scientific literature that documents how an oncologist’s communication style can have either very positive or adverse impacts on the experience of patients and families.  Thankfully, medical schools and fellowships are now acknowledging this, and are beginning to offer training programmes to help physicians learn how to be more empathic listeners and more effective communicators.  That’s a huge step forward.  It is going to benefit patients and families, and ultimately, I believe, physicians as well, particularly oncologists.

Oncologists have a remarkably high degree of stress.  Surveys show that up to 60 percent have symptoms of what is called 'burnout' and even higher numbers report significant frustration and emotional exhaustion.  This comes from a multitude of factors, including the enormous challenges of dealing with people who are often emotionally on the edge, physically very sick, and facing real life and death issues.  This is compounded by trying to be an effective and caring physician within the context of a healthcare system that, historically, hasn’t really supported physicians to be the kind of empathic doctors that so many people really want.

Read more about Dr Jeremy Geffen's work on his website.Fortunately, these kinds of issues are now coming into significantly greater focus.  In 2007, the US National Cancer Institute published a remarkable monograph called Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering.  That’s quite a development for a healthcare system that has been primarily focused on the biology of disease and the 'bottom line'. In 2008, an equally impressive monograph was published by the US Institute of Medicine - one of America’s most prestigious medical institutions - called Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs …

FIH:  ... which sounds very integrated.

JG:  Yes, very much so.  They are emphasising how important it is for doctors to address all of these issues that we’re discussing.  The monograph is, in many respects, a resounding 'call to action' to incorporate these principles into the standard of care.

FIH:  And so the message to doctors is, that even if you’re a bit of a reserved individual, there are still things that you can learn that will help you reach your patients and not appear indifferent because you’re overwhelmed.

JG:  Exactly.  In fact, this is one of the benefits of implementing The Seven Levels of Healing programme in a cancer centre.    Non-physician staff members can be trained to offer the programme and skilfully address and respond to these needs.  This is extremely helpful when the physicians are unable to do so, for whatever reason.  For example, some oncologists, just by their nature, may not have the interest, skill, or time, to provide the kind of emotional support that many people want or need.  Or they may not know a lot about which complementary therapies can be safely and effectively integrated into a conventional cancer treatment plan.  But they can offer a well-established 'body, mind, heart, spirit programme' knowing that it is sound and has been vetted by a medical oncologist. 

This can help the whole organisation be more efficient in coherently addressing patients’ and families’ myriad needs and concerns, and relieve anxiety not only for patients and loved ones, but also for physicians and other staff members.

FIH:  How does the experience of doctors and staff change in an integrated system?

Doctors and staff are often overlooked in this whole equation.  We often forget that they are also human beings.  Most are very sincere, hard working, devoted, and self-sacrificing professionals.  At the same time, I believe that if we’re ever going to have the kind of healthcare system that so many people are longing for, we have to teach physicians and staff how to more fully honour and care for themselves, and their colleagues, as well as their patients.  The Seven Levels of Healing can help greatly in this regard, in both their personal as well as their professional lives.  Ultimately we need to transform the culture of medicine - from what is often a fairly aggressive, competitive environment into one that is more caring and collaborative.

When staff people genuinely feel that their own needs are being addressed at work, they become healthier human beings, more compassionate to themselves, more self-aware, and therefore more effective and skillful in interacting with their colleagues and their patients.

Our cancer centre had negligible staff turnover because people felt truly honoured by their work.  Through training in The Seven Levels of Healing approach our staff evolved from seeing themselves simply as technicians doing a specific job to highly-functioning team members using their knowledge and skills to help patients navigate their journey.  This is an important, added benefit of a genuine integrated approach: doctors and staff can become healthier, happier, and more productive. There will be less absenteeism, less turnover, and higher work satisfaction.  With a healthier staff, the whole system will benefit over the long term.

FIH:  Who can get access to this approach at the moment?

It is presently offered at the Rocky Mountain Cancer Centre (RMCC) in Boulder, Colorado, but it's available for licensing to other centres.  And, of course, anyone can read my book as they go through cancer treatment, wherever they are.

The programme in Colorado is facilitated by RMCC staff members whom my staff and I specially trained.  We recently completed a first-year pilot project, during which 94 people participated in the programme.  The feedback was resoundingly positive, and on that basis the programme was extended into its second year.  Data from the pilot project will be presented at the 5th International Conference of the Society of Integrative Oncology meeting in Atlanta, Georgia, in November 2008.

We’re now actively exploring ways of bringing the programme to more cancer centres throughout the country.

FIH:  So you can implement your programme in an existing, independent cancer centre?  It’s not necessary to start from scratch as you did with your own centre?

JG:  Yes, precisely.  One of the great features of this programme is that it can indeed fit into other cancer centres - either as the primary focal point for integrated care, or in conjunction with other psychosocial, educational, or integrated programmes or services.  It could easily be implemented at any NHS cancer centre.  One of my goals is to bring the programme to the UK and work with oncologists and other healthcare professionals who are inspired to implement this kind of leading-edge approach to integrated care.

FIH:  What are the Seven Levels?

Briefly, they are: Level One: Education and Information, Level Two: Connection with Others, Level Three: The Body as Garden, Level Four: Emotional Healing, Level Five: The Nature of Mind, Level Six: Life Assessment, Level Seven: The Nature of Spirit.  (Read more about the Seven Levels.)

FIH:  Level Three of the programme is about integrating complementary therapies into conventional cancer care.  How do you sift through the options and find out which ones will be helpful?

Yes, Level Three: The Body as Garden addresses these questions directly.  It explores the large and growing world of complementary therapies - including the roles of diet, nutrition, exercise, yoga, acupuncture, massage, reiki, and many other modalities - and teaches patients and families how to make wise choices about using them.  My book lists a great deal of scientific data about all these modalities.  It clarifies which are known to be beneficial, and distinguishes them from a variety of therapies which may potentially be harmful.  In the programme, we address what is safe for patients to use along with their conventional care, and what should be avoided or, at the very least, discussed openly with their oncologist.  This is a big part of Level Three in the programme.

Whenever new data is published in the medical literature that can support the benefits of existing or newly emerging complementary therapies, we immediately present this information to the programme participants - as well as to the cancer centre’s physicians and staff.  So, in this way, the information offered by the programme is always up-to-date.  We want to recommend modalities that are evidence-based, and known to be safe and effective.

As part of this process, we caution patients about the potential risks of interactions between a variety of herbs and other supplements that could adversely affect the efficacy of their chemotherapy and/or radiation.  We also help them deal with underlying emotional issues that can often be a part of the motivation for seeking CAM therapies, such as feelings of anger, anxiety, depression, or loss of control - or pressure from family or friends.

We’ve found that if we can help people effectively address some of the important underlying emotional issues they are dealing with, they can relax a bit, and rest more fully and deeply.  This can greatly ease the sense of urgency many people feel about swallowing a lot vitamins and supplements, or pursuing radical diets or other interventions that may or may not be helpful.

A second major focus in Level Three is teaching people how to honour the body as a precious garden, rather than regarding it strictly as a 'machine' to be fixed by drugs, surgery or radiation.  Using the garden metaphor, we discuss how to eat well and nourish oneself, as one would 'fertilize' a garden.  We also talk about the importance of watering the garden (staying well hydrated), oxygenating the soil (breathing and exercise), getting plenty of sunshine (spending time outside, in nature), and learning the art of patience and compassion for one’s self.

The idea is to approach complementary therapies as a way of nurturing and strengthening one’s physical being - as opposed to an attempt to help cure one’s disease with unproven modalities.  In the other Levels of the programme, we address the medical, psychosocial, mental, emotional, and spiritual dimensions of healing.

FIH:  Can I ask you how you’ve found the journey, politically speaking?  Have there ever been moments where you’ve been characterised as a little ‘fringey’?

JG:  When I first opened my centre in 1994, the mainstream medical community still viewed this kind of integrated approach as 'fringey'.  But the public definitely wanted this kind of care - even back then - and we were swamped. 

Since then, my experience has been quite positive, for a number of reasons.  To begin, The Seven Levels of Healing  programme is based on a sound, scientific platform.  I don’t make outlandish claims about the benefits of the programme, or the approach to whole-person care that I and many others am advocating.  It explicitly builds on a rock-solid foundation of conventional medical care, while addressing the multi-dimensional needs and concerns of patients in a coherent, effective way. 

I’ve been extremely blessed with a top-notch medical education, which I acknowledge and greatly value.  Physicians who might disregard or even criticise a book or programme like mine, a priori, are often more open-minded because I am an experienced oncologist.  I know what it’s really like to work in this field and bear the tremendous burdens and responsibilities that oncologists carry every day.  I actually did this, for many years, in a real cancer centre, treating people from all walks of life.  More recently, it’s been exciting to demonstrate that the programme can be effectively implemented in other cancer centres, with very positive benefits.  So all of this lends credibility to what I am offering.

FIH:  There are lots of examples of excellence already out there - your own work and Bravewell's in the States, and many of the entrants for our Integrated health awards.  The difficulty is no longer finding good paradigms, but getting to the tipping point where everybody thinks 'this is the gold standard for treating disease'.  What do you think it will take to get to that tipping point?

JG: I think it will require a combination of more research, and more time.  However, there’s no doubt that the proverbial genie is 'out of the bottle' and this movement is not going to stop.  There are numerous factors driving this wave of transformation - not only from a biomedical perspective, but also from significant cultural, historical, and demographic perspectives. 

To begin, medical advances are helping people live longer today than ever before.  People are also more health conscious today than ever before, and are spending billions of dollars out of pocket for CAM services.  Also, in the US, there are 77 million 'baby boomers' who began turning 60 in 2006.  They are heading into the years when the incidence of cancer rapidly escalates, and the data clearly shows how much they want, and are already pursuing, a more holistic approach to care.  Additionally, a growing body of scientific evidence is documenting the benefits of an integrated approach, and numerous mainstream cancer centres are now exploring how to do this.  So one could say that, in some respects, we already are at the tipping point, and it’s now just a matter of time before this becomes the established, new paradigm of healthcare. 

I’m thrilled to be a part of this movement.  It’s an honour to help facilitate this transformation through my work in this field and see the difference in the lives of physicians and staff, as well as patients and families.

Jeremy Geffen, MD, FACP is a board-certified medical oncologist and a pioneer in integrated medicine and oncology.  He is president of Geffen Visions International and director of Integrative Oncology for P4 Healthcare and Caring4Cancer.com. 

Read more about Dr Jeremy Geffen's work on his website