Learning an integrated approach

 FIH: Can you tell us a bit about how the course is structured?
 
KN: The course has three one week residential courses, interspersed with distance learning. The residential component is fabulous, with a beautiful setting and high quality lectures. It was great to meet a like-minded and similarly interested peer group, with many secondary care doctors too.
 
CZ: Many different treatment modalities were introduced to give us an idea of the breadth and scope of the course. We were encouraged to try out self-help practices like tai chi and meditation so we could experience some of the therapies being discussed and learn how we might introduce them to our patients.

We also had a day on research in integrative medicine with speakers from NIH and from Stanford University.


KN: Our distance learning is fascinating and has so far covered phytotherapy and nutrition, then spirituality and mind body issues and then manual medicine and rheumatology. The work is punctuated by doing reflection on your own practice and your belief systems, which you share with others on the course.

CZ: At the end of a module, there's a videoed consultation with a patient - sometimes done in a very integrated way, sometimes not. You comment on how you'd handle the consultation, and then hear practitioners from a range of disciplines explaining how they see it - from herbalists, to people talking about how to motivate change. There's no right answer, but it really helps seeing the consultation in many different ways. 

FIH: Does the course look at the evidence base?
 
CZ: Yes, in all the modules there is a section reviewing the available evidence and discussing how this might influence practice.  

FIH: You both work in quite deprived areas. How easy is it to apply what you're learning on this course to your patients? 

CZ: It can often depend how ready your patient population is for it.  With something like depression, where there are so many routes you can take - you can mention exercise, you can give anti-depressants and it's important to find out what the patient would prefer. Sometimes patients will mention herbal alternatives like St John's Wort themselves. Doing the course has given me more confidence to discuss nutritional and other options with patients abd see what they feel interested in.

One big difference is that in the US complementary medicine is often cheaper than conventional care, because the patient may have to pay for medications themself.  Here in the UK, if you're suggesting over the counter supplements that may be just about affordable, but a six week course with a complementary therapist may be way beyond the budget of a patient when there's a free drug on the NHS.

 
KN: The bread and butter of general practice is often the condition that has no name but also diagnoses of exclusion such as fibromyalgia and irritable bowel syndrome. The NHS often has little to offer these patients but integrative medicine may well have some useful therapeutic options.   It takes time to address these with the patient and you often want to do more but just don't have the resources. 


CZ: You often see health problems building up - for example, someone comes in who is slightly demotivated and overweight with a family history of heart disease. There's an opportunity to catch it, if you can shift them towards taking more responsibility and creating the right conditions for the body to self-heal. With early onset arthritis too, you often only get the chance to prescribe painkillers when really you want to talk about lifestyle, diet and exercise.
 
FIH: What would you like to see doctors learning more about in this country?

KN: There should be a lot more taught in medical schools, including simple hands-on treatments. In osteopathy there's a simple strain-counterstrain technique which doctors can use in consultation for conditions such as neck pain. We could also use so much more acupuncture: the British Acupuncture Council have been encouraging doctors for years to use simple interventions that any GP can learn, for conditions such as tennis elbow.
 
CZ: The first module on nutrition was vital to understanding the building blocks of a healthy diet. Popular diet culture, and even well meaning information like encouraging eating margarine for a healthy heart are counter to the current science. Medics aren't at the forefront of knowledge on this information. It's not a costly thing for patients to do for themselves, but many doctors ignore it completely. 

KN: But when looking for behavioural change, it's not enough to say 'eat this, less of that', you then have to say 'come back and tell me how it went.'
 
FIH: How could integrated medicine be made to work on the NHS?
 
KN: There are big political questions about how we spend large sums of money on the NHS and the best way to deliver healthcare to the masses. Group work may be one way to deliver some of this healthcare - as the NHS already does for smoking cessation and slimming. 

CZ: There are already some interesting pilots, like group acupuncture for osteoarthritis of the knee. A problem is that networks are so loose it's difficult to build up a rapport with complementary practitioners. It would be great if PCTs were able to provide structures for providing evidence-based CAM on the NHS. For instance, the evidence supports the use of Alexander Technique for back pain, but I don't know of any PCT which pays for it.

We have big issues around continuity. Compared to others on the course, we've got some of the tightest consultation times. That used to be offset by continuity of care - As a GP, you'd keep seeing the same patient for several years. Now there's NHS Direct, Walk in centres, Darzi centres - and if your patient does return to your practice, they might not see you, and the whole conversation has to start from the beginning. 

You want to open doors in people's minds. You can't just open people up and then suddenly close them down again because the clock is ticking.

KN: And those doors being opened can have profound effects in terms of keeping patients well; an immediate investment but with potential huge benefits as well as saving for both patients, society and NHS resources.