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31. Integrative Approach to Common Pediatric Conditions
Benjamin Kligler(Colic)
Sanford Newmark(Atopic Dermatitis)
Lewis Mehl-Madrona(Autism)
Jamal Islam(Acne)
Susan Gerik(Acne)
32. Integrative Approach to Pregnancy
Aviva Romm
33. Integrative Approach to Common Conditions in Women’s Health
Andrea Girman(PMS)
Roberta Lee(PMS)
Benjamin Kligler(PMS)
Susan Hadley(Vaginitis)
Ellen Tattelman(Fibroids) 34. Integrative Approach to
Monica J. Stokes
35. Integrative Approach to Geriatrics
Lewis Mehl-Madrona
Robert Schiller
Kenneth Mercer
Faculty of the Beth Israel Fellowship in Integrative Medicine
MaryBeth Augustine
Karen Erickson
Benjamin Kligler
Roberta Lee
Suzanne Little
Arya Nielsen
Aurora Ocampo
Edward Shalts
Lauren Vigna
WOODSON MERRELL, MD
Contributing Editors
Assistant Clinical Professor of Medicine
Columbia University College of Physicians & Surgeons
Executive Director
Center for Health & Healing
Beth Israel Medical Center
New York, New York
DAVID RILEY, MD
Clinical Associate Professor of Medicine
University of New Mexico Medical School
Albuquerque, New Mexico
Founder and Medical Director
Integrative Medicine Institute
Santa Fe, New Mexico
VICTORIA MAIZES, MD
Assistant Professor of Clinical Medicine College of Medicine
University of Arizona Health Sciences
Executive Director
Program in Integrative Medicine
University of Arizona Tucson, Arizona
VICTOR SIERPINA, MD
WD&Laura Nell Nicholson Professor in Integrative Medicine
Associate Professor and Clinical Medical Director
Department of Family Medicine
University of Texas Medical Branch Galveston, Texas
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Contributors
G. SRINIVASA ARCHARYA, MD (AYURVED)
Padma Ayurveda Clinic
Ambalpady, Udupitaluk, Karnataka India
JOHN A. ASTIN, PHD
Research Scientist
California Pacific Medical Center
Research Institute San Francisco, California
MARYBETH AUGUSTINE, RD, CDN
Registered Dietician
NYSCertified Dietician/Nutritionist
Integrative Medicine Nutritionist Center for Health & Healing
Beth Israel Medical Center
New York, New York
MARK BLUMENTHAL, BA
Adjunct Associate Professor of Medicinal Chemistry College of Pharmacy
University of Texas at Austin Austin, Texas
Founder and Executive Director American Botanical Council Austin, Texas
RAYMOND CHANG, MD, FACP
Clinical Assistant Professor of Medicine
Weill Medical College
Cornell University
President Institute of East-West Medicine
Medical Director
Meridian Medical Group New York, New York
JAMES N. DILLARD, MD, DC, LAC
Assistant Clinical Professor College of Physicians &Surgeons
Columbia University
New York, New York
ALAN DUMOFF, JD, MSW
Dumoff &Associates
President Life Tree Consulting Rockville, Maryland
DAGMAR EHLING, MAC, LAC, DOM
Oriental Health Source, Inc. Durham, North Carolina
KAREN ERICKSON, DC
Senior Chiropractor Center for Health &Healing
Beth Israel Medical Center New York, New York
KELLY FORYS, MA
Doctoral Candidate
Clinical Psychology/Behavioral Medicine Department of Psychology University of Maryland Baltimore, Maryland
LEO GALLAND, MD
Director
Foundation for Integrated Medicine New York, New York
SUSAN GERIK, MD
Assistant Professor of Pediatrics Department of Family Medicine Research Office University of Texas Medical Branch at Galveston Galveston, Texas
ANDREA GIRMAN, MD, MPH
Diplomate, Fellowship in Integrative Medicine
Beth Israel Medical Center New York, New York
SEZELLE GEREAU HADDON, MD
Assistant Professor
Otolaryngology, Head andNeck Surgery
Columbia University Medical Center
Attending Otolaryngologist Center for Health &Healing
Beth Israel Medical Center New York, New York
Associate Fellow, Program in Integrative Medicine
University of Arizona Tucson, Arizona
SUSAN HADLEY, MD
Faculty
Middlesex Family Practice Residency Program
Middletown, Connecticut
Assistant Professor
University of Connecticut, School of Medicine Farmington, Connecticut
RICHARD HAMMERSCHLAG, PHD
Research Director
Oregon College of Oriental Medicine
Adjunct Professor of Neurology Oregon Health &Science University Portland, Oregon
MARSHA J. HANDEL, MLS
Education &Information Co-ordinator
Center for Health &Healing
Beth Israel Medical Center New York, New York
RANDY J. HOROWITZ, MD, PHD
Medical Director
Program in Integrative Medicine
Clinical Assistant Professor of Medicine
University of Arizona College of Medicine Tucson, Arizona
STEVEN F. HOROWITZ, MD
Clinical Professor of Medicine and Nuclear Medicine
Albert Einstein College of Medicine Bronx, New York
Chief, Department of Cardiology Stamford Hospital Stamford, Connecticut
JAMAL ISLAM, MD, MS
Assistant Professor
Department of Family Medicine Research Office
University of Texas Medical Branch at Galveston Galveston, Texas
GEORGE KESSLER, DO
Clinical Instructor of Medicine
Albert Einstein College of Medicine Bronx, New York
Adjunct Assistant Professor
New York College of Osteopathic Medicine New York, New York
BENJAMIN KLIGLER, MD, MPH
Assistant Professor of Family Medicine
Albert Einstein College of Medicine Bronx, New York
Research Director andCo-Director
Integrative Medicine Fellowship
Center for Health &Healing
Beth Israel Medical Center
New York, New York
ROBERTA LEE, MD
Medical Director and Co-Director
Integrative Medicine Fellowship
Center for Health & Healing
Beth Israel Medical Center
New York, New York
Diplomate, Program in Integrative Medicine
University of Arizona Tucson, Arizona
ROBERT Y. LIN, MD
Professor of Medicine
New York Medical College
Valhalla, New York
Chief
Allergy/Immunology Section
Department of Medicine
St. Vincent’s Hospital New York, New York
SUZANNE LITTLE, PHD
Coordinator, Mind Body Program
Supervising Psychologist
Center for Health &Healing
Beth Israel Medical Center
New York, New York
Assistant Professor of Psychiatry
Albert Einstein College of Medicine
Bronx, New York
JAY LOMBARD, DO
Assistant Clinical Professor of Neurology
Weill Medical College
Cornell University
New York, New York
TIERAONA LOW DOG, MD
Clinical Lecturer
Department of Medicine
University of Arizona Tucson, Arizona
Clinical Assistant Professor, Family Medicine
University of New Mexico
Albuquerque, New Mexico
ROBERT B. LUTZ, MD, MPH
Research Assistant Professor
University of Arizona College of Medicine
Assistant Professor of Nutritional Sciences
Mel &Enid Zuckerman College of Public Health
University of Arizona Tucson, Arizona
VICTORIA MAIZES, MD
Assistant Professor of Clinical Medicine
College of Medicine
University of Arizona Health Sciences
Executive Director
Program in Integrative Medicine
University of Arizona Tucson, Arizona
LEWIS MEHL-MADRONA, MD, PHD
Coordinator for Integrative Psychiatry and System Medicine
Program in Integrative Medicine
University of Arizona College of Medicine
Director
Practitioner Core Center for Frontier Medicine in Biofield Science Tucson, Arizona
KENNETH MERCER, MD, MPH
Research Fellow
The Richard and Hinda Rosenthal Center for Complementary and Alternative Medicine
Columbia University New York, New York
WOODSON MERRELL, MD
Assistant Clinical Professor of Medicine
Columbia University College of Physicians & Surgeons
Executive Director
Center for Health & Healing, Beth Israel Medical Center New York, New York
DANIEL MULLER, MD, PHD
Associate Professor Departments of Medicine (Rheumatology) and Medical Microbiology &Immunology
Institute on Aging, Mind Body Center
University of Wisconsin–Madison Madison, Wisconsin
SANFORD NEWMARK, MD
Associate Faculty Member Department of Pediatrics University of Arizona College of Medicine
Faculty
Program in Integrative Medicine University of Arizona
Director
Center of Pediatric Integrative Medicine Tucson, Arizona
ARYA NIELSEN, MA, MS, LAC, FNAAOM
Faculty, Master Acupuncturist
Center for Health &Healing
Beth Israel Medical Center
Practitioner andProfessor of East Asian Medicine
Senior Faculty
Tristate College of Acupuncture
New York, New York
Guest Faculty
Anglo-Dutch Institute on Oriental Medicine
Netherlands
AURORA OCAMPO, MA, RN, CS
Adjunct Faculty
School of Nursing
Long Island University
Brooklyn, New York
Education Nurse Manager Nurse Specialist
Center for Health & Healing
Beth Israel Medical Center New York, New York
SUNIL PAI, MD
President and Medical Director
Sanjerani LLC
Santa Fe, New Mexico
Diplomate, Associate Fellow, Program in Integrative Medicine
University of Arizona Tucson, Arizona
FRANCINE RAINONE, DO, PHD, MS
Assistant Professor of Family and Social Medicine
Albert Einstein College of Medicine
Bronx, New York
Director of Community Palliative Care
Clinical Director of Inpatient Palliative Care
Department of Family Medicine
Montefiore Medical Center
Bronx, New York
DAVID RAKEL, MD
Director
University of Wisconsin Integrative Medicine Program
Assistant Professor Department of Family Medicine
University of Wisconsin Medical School Madison, Wisconsin
DAVID RILEY, MD
Clinical Associate Professor of Medicine
University of New Mexico Medical School
Albuquerque, New Mexico
Founder and Medical Director
Integrative Medicine Institute Santa Fe, New Mexico
AVIVA ROMM, AHG, CPM
Integrative Midwifery Carton, Georgia
ANTHONY ROSNER, PHD
Foundation for Chiropractic Education and Research Arlington, Virginia
KENNETH SANCIER, PHD
Qigong Institute
Menlo Park, California
ROBERT SCHILLER, MD
Assistant Professor of Family Medicine
Albert Einstein College of Medicine Bronx, New York Chairman
Department of Family Medicine
Beth Israel Medical Center New York, New York
EDWARD SHALTS, MD, DHT
Vice President
National Center for Homeopathy Trustee, Board of American Institute of Homeopathy Advisory Board Member
International Academy of Homeopathy Member, Council of Homeopathic Education Faculty
Center for Health &Healing Beth Israel Medical Center New York, New York
VIVEK SHANBHAG, MD (AYURVED), ND
Ayurvedic Academy &Natural Medicine Center Seattle, Washington
SAMUEL SHIFLETT, PHD
Assistant Professor of Family Medicine & Communiy Health
Albert Einstein College of Medicine Bronx, New York
Research Director
Center for Health &Healing Beth Israel Medical Center New York, New York
MICHELLE SIERPINA, MS
Adjunct Faculty
Institute for the Medical Humanities University of Texas Medical Branch Galveston, Texas
VICTOR S. SIERPINA, MD
WD&Laura Nell Nicholson Professor in Integrative Medicine
Associate Professor and Clinical Medical Director Department of Family Medicine University of Texas Medical Branch Galveston, Texas
BETSY B. SINGH, PHD
Professor and Dean of Research
Southern California University of Health Sciences Whittier, California
VIJAY J. SINGH, BA
Associate Professor Research Division
Southern California University of Health Sciences Whittier, California
MONICA J. STOKES, MD, FACOG, ABHM
Diplomate, Program in Integrative Medicine University of Arizona Tucson, Arizona
ELLEN TATTELMAN, MD
Assistant Professor of Family and Social Medicine
Albert Einstein College of Medicine Bronx, New York Director
Health in Medicine Project Residency Program in Social Medicine Montefiore Medical Center Bronx, New York
LAUREN VIGNA, MD
Attending Physician
Diplomate, Fellowship in Integrative Medicine Center for Health &Healing Beth Israel Medical Center New York, New York
SIVARA P. VINJAMURY, MD (AYURVEDA),MAON
Associate Professor and Research Projects Coordinator
Southern California University of Health Sciences Whittier, California
Foreword
A Harvard study recently reported that almost half of the American population is interested in using some form of complementary and alternative medicine (CAM) for the improvement of health.1 Without proper guidance from knowledgeable healthcare practitioners, however, the public’s enthusiastic embracing of CAM can be counterproductive. Patients need comprehensive treatment plans and guidance in selecting therapies and therapists in order to increase the chance of good therapeutic outcomes. This book illustrates the principles that physicians and other healthcare professionals can use in order to practice CAM in combination with mainstream medicine in a thoughtful manner. If it were simply a collection of protocols for the management of common conditions, it would be valuable, but it is more than that. Its content embodies the philosophy of the emerging field of integrative medicine.
Integrative medicine is not synonymous with CAM. Above all, it seeks to work with the body’s natural potential to heal. It recognizes that the body has innate mechanisms to maintain health and promote healing. The aim of integrative treatment is to activate those mechanisms and to address the patient’s emotional and spiritual well-being in addition to physical health. All aspects of lifestyle are evaluated in an integrative health assessment, and recommendations are made—about diet, exercise, and stress management, for example—that aim to foster healing. Great emphasis is placed on the therapeutic relationship that forms between practitioner and patient.
When I founded the Program in Integrative Medicine at the University of Arizona in
1997, many who were skeptical about this approach viewed it as unscientific or even antiscientific. But much of this concern seemed rooted in a lack of awareness of the scientific evidence that existed for the safety and efficacy of many CAM treatments. Now, seven years later that body of evidence has increased exponentially. Today, 22 medical institutions have joined the Consortium of Academic Health Centers for Integrative Medicine for the specific purpose of changing medical education, research, and practice in this direction. The deans and chancellors of these institutions recognize that medical education must include the principles of integrative medicine and specific information on CAM. This represents a profound paradigmatic shift within the medical profession and society at large.
Modern medicine has overlooked the body’s natural potential to heal. Conventional medical education emphasizes invasive procedures and the use of powerful medications that often produce significant adverse effects. Although the conventional system is able to treat many problems successfully, we must reconsider more carefully its potential for harm. In reality, the evidence base for many allopathic treatments is not as solid as is generally thought. Furthermore, most medical decision-making takes place in an arena where there is much scientific uncertainty. In the absence of a clear therapeutic path, physicians and patients should be partners in making decisions, using both knowledge and intuition.
Some years ago, I had a patient with metastatic breast cancer. Her oncologist persuaded her to opt for a bone marrow transplant, a very
1Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA 1998;280:1569–1575.
invasive and potentially lethal procedure that is now understood to be worthless. Did the oncologist really employ the strictest standard of evidence possible for a treatment that could jeopardize his patient's life? Did the patient demand adequate evidence from her physician for the efficacy and safety of this procedure?
Thankfully this situation is changing. I meet many medical educators and clinicians who realize that medicine, like all professions, must acknowledge that it is in a state of constant reevaluation in order to move forward. These are people open to change, and they are aware that they must be prepared to meet the needs of patients who desire more natural, less harmful ways of treating disease and supporting health.
This text is a valuable source of information for those interested in meeting this challenge. Many of the authors are graduates of the Program in Integrative (PIM) at the University of
Arizona. Others are graduates of the relatively new Integrative Medicine Fellowship at Beth Israel Medical Center–a program co-directed by one of my first students at PIM. I am pleased to see that it provides a base of scientific evidence where possible but also preserves the perspective of many of the alternative practitioners who have extensive experience in their respective disciplines.
It is a pleasure to introduce this book to what I hope will be a broad readership, interested in obtaining greater insight into the process of healing and how it can be maximized in the clinical setting.
Andrew T. Weil, MD Clinical Professor of Medicine Director, Program in Integrative Medicine
University of Arizona Tucson, Arizona
Preface
Integrative medicine is renewing the soul of medicine by combining the advances of science and technology in Western medical training with the whole person approach of traditional healing systems. While the practices and philosophy of complementary and alternative medicine (CAM) comprise an important component of the integrative approach, this new discipline is not synonymous with CAM. Integrative medicine seeks to blend the best of allopathic medicine with the best of CAM in its effort to assist medicine in returning to its original mission: preventing disease in a relationshipcentered approach that emphasizes the holistic nature of patient care and utilizes lifestyle components to improve health along with mental and spiritual well-being. These are fundamental values reflected in every ancient and traditional medical system. Although some feel that conventional medical approaches adequately embody these principles, many medical educators, physicians and patients today do not agree.
It is now estimated that as many as 30 to 40 percent of Americans seek some form of alternative therapies to support their conventional care. Although both conventional and CAM approaches can provide much clinical insight and effective tools for healing illness, their views of health and illness can be quite divergent, often leaving both types of practitioners wondering how they can effectively work together. This text seeks to strengthen the bridge between these rapidly converging worlds, augmenting the understanding of each in such a way as to improve the care of our patients. We hope that medical and CAM practitioners alike will find the information in this book a useful reference for effective integrative patient care.
A major challenge in editing this textbook has been to address the dual purpose of an integrative medicine reference: to be comprehensive in describing the spectrum of current clinical practice while being firmly anchored in scientifically based clinical research. At times these two goals are at odds, as much of the clinical practice of integrative medicine is not adequately supported by scientific evidence. For some therapies, scientific evidence may exist but has been produced in a less rigorous manner than we would like to see. Integration requires an open mindedness and willingness to explore the validity of alternative paradigms for health and illness, despite the lack of evidence from clinical trials. Therefore, although we have sought to maintain a perspective rooted in biomedical science, we have decided that a certain amount of material should be included which extends beyond what would be normally accepted in a referenced text.
We used several criteria for deciding which healing traditions and modalities to include, given the paucity of quality clinical research on many of these therapies. Questions of what constitutes legitimate evidence, and the context of how knowledge is evaluated and judged within the medical profession form an important part of this discussion. We decided that additional criteria for inclusion of traditions or modalities within the text should include
•longevity of use within a complex medical system ( e.g., Chinese and Ayurvedic medicine);
•a plausible mechanism for effectiveness in treating a given condition, even in the absence of clinical trials; and
•expert opinion and clinical experience, particularly given the standing of many of our authors as leading clinicians in this field.
Understanding of a given condition from the perspective of a traditional medical system often will challenge the current pathophysiologic paradigms of conventional biomedical training. Our view is that this should be a welcome challenge that could open the door to potentially helpful new approaches.
A second challenge facing us as editors is seeking a balance between the systemsoriented, disease-focused approach to organizing information typically used in medical texts, and the whole person, wellness-oriented perspective that captures more accurately the philosophy of the integrative medicine approach. Thus, we begin the book by looking at wellness from the perspectives of physicians as well as practitioners of other healing arts. In subsequent chapters we examine the integrative approach to the treatment of specific conditions. Throughout the text we encouraged the authors to address how principles of healing and homeostasis can be applied in clinical practice. It is clear from these contributions that a whole-person, wellness-oriented approach can be applied even when discussing the treatment of a specific disease or condition. It is this commitment to simultaneously embracing both wellness-oriented and diseaseoriented perspectives that is the heart of integrative medicine.
Our experience at the Beth Israel Center for Health & Healing in New York over the past three years has provided the inspiration for approaching integration in this manner. The Center is a group of sixteen practitioners of diverse healing arts ranging from acupuncture to conventional medicine to homeopathy and chiropractic who are deeply committed to the development of this new paradigm. A great deal of effort has been required to forge a common language amongst ourselves to create effective communication and allow space for a diversity
of opinions regarding the origins of human health, illness and wellness. Our work with this group of practitioners—many of whom are authors in this text—over the past three years, and with our integrative medicine fellows over the past two years, has provided the intellectual framework for the outline of this new approach that we offer in this textbook. The text is divided into six sections.
•Part I, “Basic Principles,” outlines some of the distinctions between the conventional medical approach and the integrative approach, both in terms of principles and in terms of patient approach. The relevance of mind–body–spirit connections and of family, community, and social influences on health and illness are discussed in depth, with reference to specific patient case studies to illustration these basic principles.
•Part II of the text, “Therapeutic Modalities,”discusses in depth the major therapeutic approaches which, in addition to allopathic medicine, constitute the “toolbox” of the integrative practitioner. East Asian medicine, manipulative approaches, nutritional therapeutics, homeopathy, Ayurvedic medicine, movement therapies, botanical medicine, exercise, and spirituality are covered in this section. Each chapter is written by a practitioner of the discipline who was charged with balancing the “medical” perspective with that of the practitioners of the various healing arts. These chapters include a discussion of the history and philosophy of the modality, and a current review of the research literature regarding the impact of that particular approach on specific health outcomes. This commitment to find a balance between these two perspectives and a bridge between different healing paradigms is a central part of the philosophy of integrative medicine. It requires from all involved a commitment to appreciate the potential validity of a wide variety of paradigms in health, thus serving the equally
important mission to facilitate cross-cultural awareness. Informatics, which has become an indispensable tool for all health care practitioners, is also covered in this section with a specific emphasis on how to access reliable integrative medicine resources.
•In Part III, “Integrative Approaches to Specific Conditions,” we revisit the systemsoriented, disease-focused approach familiar to physicians and medical educators. These chapters, which cover a range of specialties and diagnoses focus on applications of the integrative approach to treatment of specific conditions. These chapters are all written by physicians and emphasize an evidence-based approach. In some areas where clinical research is not very extensive, we encouraged the authors of this section to include guidance for readers regarding some approaches which, although not yet adequately studied, are safe and potentially useful in clinical practice. This section of the text, written by physicians in active clinical practice of integrative medicine, should serve as an easy reference for practitioners looking for reliable information on how to help a patient with a specific illness or health condition using the integrative approach.
•Part IV of the text, “Integrative Approaches through the Life Cycle,” discusses the unique discusses the unique dimensions of the integrative medicine approach to the care of children, women (including pregnancy), and the elderly. This section takes a less “disease-oriented” perspective than Part III, and in particular emphasizes aspects of well-person care such as nutrition, exercise, and mind–body–spirit health which are often omitted from the conventional primary care approach to the care of healthy patients. The emphasis on preventive approaches and health-promotion which informs this section are central to the overall philosophy of integrative medicine.
•Part V, entitled “Legal and Ethical Issues,” covers a topic with which we feel every physician moving into the realm of integrative medicine should be familiar. This chapter provides illustrations of specific situations which may arise in the practice of integrative medicine and strategies which can help address the legal and ethical concerns which often emerge from those situations. In our teaching we find concerns regarding liability and ethics are often high on the list for physician audiences; this chapter offers concrete recommendations for physicians practicing in a new and unconventional approach.
•Part VI, “Selected Cases in Integrative Medicine” provides three case studies from the Fellowship Program in Integrative Medicine at Beth Israel Medical Center. These case discussions—one of a child with recurrent otitis and respiratory problems, one of a woman with fatigue and hormonal imbalance, and one of an elderly woman with heart disease and chronic pain— emerge from the weekly case conference we hold at the Center for Health and Healing as part of our postresidency clinical fellowship program. In these conferences, the fellows present cases from their practice to a rotating panel of faculty comprised of physicians, acupuncturists, nutritionists, psychotherapist and mind–body practitioners, homeo-paths, and representatives of various other healing arts. The cases in this chapter are offered as illustrations of how the diverse voices of the varied healing arts can come together to form a coherent treatment plan for many challenging problems.
The worlds of alternative practitioners and physicians continue to converge as scientific knowledge advances and the demands of health care evolve. Some of the newest discoveries in genetics and molecular biology hold the promise of potentially reversing disease at
the most fundamental level. However, in far too many cases, all physicians can do is quell the symptoms of disease. In addition, physicians now have less time with patients—a brief ten minutes on average. Dissatisfaction by physicians and patients, for different reasons, has forced the re-examination of medicine’s
purpose. As its central theme, integrative medicine advocates the treatment of both the patient and the disease while seeking to redraft the definition of healing. Toward that end, our hope is that this text can add to the reshaping of current practices into a more humanistic, scientifically rooted body of medicine.
Benjamin Kligler Roberta Lee
Acknowledgments
FROM B.K.
I would like to thank the many friends and colleagues who have inspired me over my own personal and professional healing journey, including Jeanne Anselmo, John Falencki, Barbara Glickstein, Al Kuperman, Dorothy Larkin, Betsy Macgregor, Mark Miller, Red Schiller, Sir Abdulla Smith Ford, Charles Terry, and Gil Tunnel. My gratitude also to my patients and their families, who have taught me most of what I know.
My thanks to my mother, Deborah Krasnow and to my stepfather, Herbert Krasnow, for their love and support, and to my father, the late Dr. David Kligler, for my inspiration to become a physician.
Finally, my deepest thanks and appreciation to my wife, Susan, and to my children, Sophie, Michaela and Zachary, who bring joy and inspiration into my life every day and who are all very glad this project is completed!
FROM R.L.
There are a lot of people to whom I would like to express my gratitude. First, thanks to my former colleagues (Fellows and Associate Fellows) at the Program in Integrative Medicine at the University of Arizona for helping to shape some of the many ideas that are expressed in this book. Thanks to Wendy, Russ, Karen, Opher and Craig Schneider for your support throughout the years. Thanks to Victoria Maizes, Dave Rakel, Randy Horowitz, Sunil Pai, Sezelle GireauHaddon and Bob Lutz for contributing to the
book. Having mentors is always a gift; I am greatly appreciative of the ongoing support and guidance of Andrew Weil, who has always been a great inspiration to me.
I would like to acknowledge those who have been my teachers. Thank you to Dan Shapiro, Marty Hewlett, Tracy Gaudet, John Tarrant, Garchen Rinpoche, Steve Gurgevich, Sue Fleishman, Fredi Kronenberg, Harriet Beinfield, Efrem Korngold, Jon Kabat-Zinn, Saki Santorelli, Kate Worden, Rausa Clark, Jim Dalen, Joseph Alpert and Victor Yano.
A special thanks to my companion, Michael Balick, for his sense of humor, his advice and wisdom as a writer and editor. Thanks to my family for their eternal support especially my parents, Curtis, Millie and Cynthia, my sister Sabrina, brother Chris, as well as Tammy and Daniel Balick.
FROM B.K. AND R.L.
We are greatly appreciative of the time, effort, and expertise of all our contributing editors and authors; thank you for spending so much of your “extra time” to write on this project.
Also a big thank you to our wonderful editors at McGraw-Hill, Andrea Seils and Karen Davis, for their patience and guidance through this project, and to our editorial assistant, Margaret Price.
Lastly, there is one individual for whom any words we could think of to express our gratitude would not be enough:Mrs. Dorothy Mills. We are profoundly thankful for her support.
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Part I
Basic Principles
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Chapter 1 Integrative Medicine: Basic Principles
ROBERTA LEE, BENJAMIN KLIGLER, AND SAMUEL SHIFLETT
The doctor of the future will give no medicine, but will interest his patient in the care of the human frame, in diet, and in the cause and prevention of disease.
THOMAS EDISON
THE EVOLUTION OF MEDICINE
The physician’s goal has always been to alleviate suffering. This legacy, as passed from one generation of physicians to another, is encapsulated in the Hippocratic Oath taken by all medical students when they complete their medical training (see Figure 1–1).
Although the goal has remained constant, the means by which to achieve this goal have changed and evolved over time. In part, this change in the methodology of medicine has been shaped by a more complete understanding of anatomy and physiology, by the modern approach to treatment of infectious disease, and by the emergence of new areas in science such as genetics and molecular biology. In the twentieth century, rapid acquisition of knowledge in these areas has created a new paradigm for how disease can be influenced and treated.
During the time that the Hippocratic Oath was written, around 300 B.C., 1 the philosophy of medicine reflected an emphasis on observation of all aspects of the individual, from diet to the nature and content of dreams, as a means of understanding the malady suffered by that individual. Hippocratic physicians were strongly encouraged to resist classifying diseases solely according to the organs affected. Each patient was seen as an individual rather than as a “disease entity.” The notion of an individual as a combination of both material and spiritual properties was an accepted medical paradigm. In this era, explanations for ill health were ascribed to the imbalance of the four humors: phlegm, blood, yellow bile, and black bile. A constant thread throughout the writings of this time was a reliance on nature, and the main objective of treatment was to help patients achieve harmony so that the natural
A Modern Hippocratic Oath by Dr.Louis Lasagna
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow;
I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy and understanding may outweigh the surgeon’s knife or the chemist’s drug.
I will not be ashamed to say “I know not,”nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know.Most especially must I tread with care in matters of life and death.If it is given me to save a life, all thanks.But it may also be within my power to take a life;this awesome responsibility must be faced with great humbleness and awareness of my own frailty.Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability.My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body, as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection hereafter.May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
The Oath of Maimonides
The eternal providence has appointed me to watch over the life and health of Thy creatures.May the love for my art actuate me at all time[s];may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind;for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.
May I never see in the patient anything but a fellow creature in pain.
Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain;for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.
Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today.Oh, God, Thou has appointed me to watch over the life and death of Thy creatures;here am I ready for my vocation and now I turn unto my calling.
Figure 1–1. Modern Hippocratic Oath by Dr. Louis Lasagna (1923–2003). The Oath of Maimonides (1135–1204).
forces in the body (humors) could return to a state of balance. Relief of suffering from illness was primarily achieved by alterations in lifestyle, in diet, and in the life of the spirit. However, interventions such as botanical substances were sometimes incorporated in treatment as well. Even the writings of this time pertaining to surgery had the focus of restoration in balancing the “humors.” The mind and the body were seen as inseparable parts contained within each person, each person a combination of physical and spiritual properties.2
In the seventeenth century, René Descartes (1596–1650), a philosopher/scientist/mathematician, wrote a treatise on the relationship of the mind and the body—proposing that each was distinct from the other. This philosophy led to the mind–body duality or what is known as the “Cartesian split,”3 discussed in detail in Chapter 2 by John A. Astin. Descartes thought that the science of his time did not provide the proper tools or perspective for the study of mind and spirit. Descartes proposed that as science moved forward in its study of the physical body, the study of mind and spirit should be in the domain of the church. He believed that the application of empirical, scientific observation—as it was defined at the time—to the study of mind and spirit, would lead to an incorrect and inappropriate reductionism in the view of these central aspects of the human experience.
The notions of what was contained in the domain of science were influenced by other philosophers after Descartes. John Locke (1632–1704) and David Hume (1711–1776) philosopher/scientists of the seventeenth and eighteenth centuries produced influential writings that promoted reductionism4 and the use of “rational analysis” as the process of inquiry in science. During this time, great discoveries in physics by Sir Isaac Newton (1642–1727) and others in different areas of science enabled humans to gain mastery in explaining, predicting, and controlling many things in their environment—moving the world further and further into using this process of scientific inquiry
to evaluate any phenomena in nature that needed investigation.
Reductionists viewed the world from a mechanistic perspective, believing that all natural phenomena could be reduced to smaller, simpler pieces and the whole could be understood by studying the sum of its parts. According to this form of thought, in the equation A B C, A is defined as an identical state equal to the parts summated by B C. But is this really a true representation for A?
More recent thinking, as represented, for example, in quantum physics, holds that in more complex systems, although A is whole, B C does not entirely equal A. Rather, it is a close approximation of A. Therefore, the equal sign is somewhat of a misnomer. What is significant is that in the reductionistic thinking process, the whole is regarded only as the sum of its parts, whereas in the more modern model the whole can actually be more than the sum of those parts. In the eighteenth and nineteenth centuries, the subtlety of this distinction was lost because the reductionistic model was so effective in explaining many puzzling phenomena of nature.
Another analogy for understanding the distinction between reductionistic and “holistic” ways of understanding systems would be the process of baking a cake. The reductionistic view would assume that by studying the elements of a recipe comprising a cake (flour, water, eggs, and baking soda), we can understand what a cake is. However, this approach overlooks the process that actually transforms a collection of ingredients into a single entity.
EARLY AMERICAN MEDICAL PRACTICE: THE FLEXNER REPORT AND THE TRANSFORMATION OF MEDICAL EDUCATION (1800–1920)
In the early 1800s, “conventional” physicians, known as Heroic medical practitioners, included the use of purging, bleeding, large doses
of calomel (mercury chloride), and opiates as therapeutic interventions. In opposition to these practices were a substantial number of other medical professionals who believed these interventions to be toxic. On the basis of this conviction, many of these practitioners turned to systems of natural healing such as osteopathy, homeopathy, and naturopathy—all of which became popular in the United States during the nineteenth century. By the late 1800s, 20% of all practitioners in medicine in the United States were “alternative physicians.”5
Meanwhile, during this period, conventional physicians organized and lobbied to preserve economic and political dominance by setting up state medical societies to license physicians. “Irregular practitioners” not schooled and approved by orthodox institutions were aggressively pursued with the intent of depriving them of their ability to practice. Battle lines became drawn between the physicians and the alternative practitioners based on philosophical, political, and socioeconomic differences.6 The criteria for what constituted proper medical treatment and the content of medical education in the early years of this transformation became a heated topic of academic and political debate. At one point, the alternative practitioners, tired of the aggressive moves of the Heroic practitioners, lobbied to repeal all licensing laws that had been implemented, and won. This was known as the Popular Health Movement. By the end of the 1840s, almost all licensing laws had been repealed—creating great ire in the conventional medical community.7
Partially in response to this movement, in 1847, the American Medical Association (AMA) was founded to erect a barrier between orthodox medicine and “irregular practitioners.”8 By 1900, the AMA lobbied for state medical licensing laws to reclaim power from “irregular practitioners,” and eventually laws regulating practice were enacted in all the states. In 1910, Abraham Flexner, a medical educator, was employed by the Carnegie Foundation to evaluate the state of education in medical and healing
schools across North America. The report was initiated to help the leading philanthropists of the day decide where to focus their support. It evaluated most institutions very negatively. A major criticism cited was the weak entrance criteria for most schools; in some schools all that was required for admission was a “common school education.” In addition, Flexner dismissed homeopaths, osteopaths, and naturopaths as “unconscionable quacks.”9
The repercussions of the Flexner report resulted in the closing of more than half of the medical schools and many of the alternative medical schools in the United States. Only medical schools that were grounded in science survived the purge. Medical school curricula became steeped in biomedicine and science. As scientific thinking became more rigorous the toxic treatments of the past were discontinued and more efficacious drugs were used, increasing the public’s faith in the biomedical model and the power of science in taming disease. The Flexner report not only influenced allopathic schools to restructure their training but significantly challenged alternative practices to reevaluate their methods and educational curricula as well.10
AMERICAN MEDICINE IN THE TWENTIETH CENTURY
In the first half of the twentieth century, three advances produced a dramatic shift in methods of treatment: the discovery of microorganisms as a cause of disease, the development of antibiotics to combat those organisms, and the development of effective anesthesia.11 Other breakthroughs in the applied sciences created equally dramatic transformations in medicine. Advances in biochemistry, biophysics, physical chemistry, and immunology enabled escape from devastation by the scourges of smallpox, cholera, polio, and diphtheria, first through improved public hygiene and then through the development of vaccines. Henry Dale, the 1936 Nobel laureate in medicine, wrote this de-
scription of the therapeutic advances in medicine that had occurred by mid-century:
Our successors, viewing the times in which we live from the longer perspective of history are likely to recognize the first half of the twentieth century as the period in which civilization first began to feel, for good or ill, the first impact of progress in the natural sciences.12
The explosion of the scientific and medical information of this time provided a much different understanding of the pathophysiologic basis of disease and the tools required to combat it. The birth of subspecialization in medical care evolved to accommodate this expansion of knowledge and technology. The focus in training and practice in medicine continued to shift physicians toward a disease-oriented model, as it was so effective in taming disease with the new tools of technology and discoveries in science. This trend continues today in medical education as well as in the clinical arena. As David Rakel and Andrew Weil suggest, physicians have become a body of practitioners who “focus on pieces”13 of medical care, and our society one that believes in the power of medical technology to conquer all medical ills.14
At the beginning of the twentieth century, the life expectancy in the United States was approximately 50 years of age. It has risen steadily since that time and now stands at 76.9 years.15 The rise in life expectancy has increased the prevalence of chronic disease. And although the life expectancy has continued to rise, the ability of technological medical advances to keep pace in their ability to alleviate suffering from these chronic diseases has been limited in comparison to the impact of the advances on more acute illness.16 The basis for this gap in success between the treatment of acute and chronic conditions using conventional methods lies in the current approach to both diagnostics and therapeutics. Conventional approaches focus on specific diseases, repairing only a part without addressing the underlying causes.17
This method ignores the interconnectedness of all organ systems and the role of mind and spirit in the restoration of health. Although temporary relief may be attained from this organ-specific approach, it may also impart a “sense of false security.”18 For example, cyclooxygenase-2 (COX-2) inhibitors may provide adequate relief from pain for a runner with chronic lower extremity pain from an overuse injury. However, this relief may merely allow the runner to further damage his joints because he has relief from his pain—yet his lifestyle and the reasons for the development of the pain have not been addressed.
TECHNOLOGY AND THE HEALTH CARE CRISIS
The triumphs of medical science have carried with them a great financial burden for our society. Medical advances during and after World War II were primarily in pharmaceuticals, which were relatively inexpensive. After 1960, advances in medical treatment increasingly involved new and complex equipment or procedures that, in contrast, were quite expensive. This created a tremendous rise in medical expenditures. From 1965 to 1975, the share of national health care expenditures paid by the federal government jumped from 26% to 37%19 and the $10 billion spent by the government in 1965 became $27.8 billion by 1970.20 In 1999, national health care expenditures as a percentage of gross domestic product was 13%, and in 2000 the overall cost of health care was $1.29 trillion.21
By 1969, the awareness of growing health care expenditures was labeled as a “crisis in health care,”22 even though costs had been steadily rising at that point for almost a decade. Analysis revealed that the crisis was derived from more than just the cost of delivering new technology and procedures; in fact, the system of health care had built-in incentives encouraging use for those providing services. If more procedures were done for the treatment of a
disease, financial rewards increased for the physician and/or hospital involved.23 Furthermore, the system encouraged patients to believe that these tools were the answer to their ill health. In the 1980s, managed care and capitation began to emerge as cost-control strategies. These models of health care, however, had their own costs, as they reduced some excessive expenditures but created more erosion in the patient–provider relationship. As physicians became enmeshed in this system, they acquired new demands on their professional time unrelated to patient care, and began spending less time with their patients as a consequence. A great dissatisfaction developed in both patients and doctors; patients have mourned the loss of medical attention and felt unheard and poorly served, and physicians have experienced a loss of autonomy. Moreover, physicians have lost much of the satisfaction that comes from establishing a genuine connection with the patient.
This situation continues in American medical care to this day. The complexity of achieving successful treatment in chronic illness remains a challenge for both doctor and patient because it must be addressed in an existing medical system that sustains a narrow focus. The “healing tools” of time, touch, and rapport that constituted a major part of how physicians traditionally cared for chronically ill patients remain undervalued and uncompensated in our current system. Meanwhile a growing number of people who are acutely aware of their unmet medical needs have turned to other medical systems—alternative health care and older traditional health systems—for relief from suffering in chronic illness.
PUBLIC DEMAND AND THE RESURGENCE OF TRADITIONAL MEDICAL SYSTEMS
The 1960s were a pivotal time in American culture, and the ideas that were introduced in American society created a new subculture of
people whose values embraced ethnic diversity, environmental awareness, and a reexamination of traditional family and professional roles. Paul Ray, a sociologist, and Sherry Ruth Anderson, a clinical psychologist, have identified these people as “Cultural Creatives.” After surveying over 100,000 Americans during a 13year period, they estimated that there may be as many as 50 million people who have intentionally chosen a style of life that reflects personal authenticity. The authors define authenticity as follows:
...that your actions are consistent with what you believe and what you say. The people in this subculture prefer to learn new information and to get involved in ways that feel most authentic to them. Almost always it involves direct personal experience in addition to intellectual ways of knowing.24
One example of this shift toward a different awareness and its effect is in attitudes toward environmentalism: “When Rachel Carson’s Silent Spring appeared in 1962, the environment was a serious concern for no more than 20% of Americans. Now at least 85% of Americans are concerned about it.”25
What is the relevance of these facts to medical professionals? These Cultural Creatives seek a more holistic form of health care, including an interest in traditional medical systems such as Chinese medicine and Ayurveda, as well as other modalities that focus on the importance of mind–body awareness. These more holistic approaches, it seems, address more directly the need of this population for a more authentic form of health care.
Much of this shift toward healing arts other than conventional medicine went undetected by the medical community until a landmark publication by David Eisenberg and colleagues, in 1993, revealed that the public was spending $13 billion dollars out of pocket for complementary and alternative care medicine (CAM).26 A subsequent study, published 5 years later showed a similar trend, with an even higher percentage (42%) of Americans using CAM in
1997, and out-of-pocket expenditures for CAM increasing by 27% over the earlier study.27 Astin, in 1998, was able to document that this interest was not entirely a result of dissatisfaction with the current medical milieu. His research revealed that the most powerful motivator for patients in choosing therapies other than conventional medicine was the desire for an approach to health and illness more closely aligned with “their own values, beliefs, and philosophical orientations toward health and life.”28 These values, as they are often expressed in healing arts other than medicine, include a commitment to a healing-oriented approach to health; an attempt to choose natural remedies when possible; an emphasis on therapeutic interventions using diet and lifestyle rather than aggressive medical procedures; and an understanding of the centrality of the mind–body connection in the healing process. These are all values very consistent with those of the Cultural Creatives as defined by Ray and Anderson.
THE DEVELOPMENT OF THE NATIONAL CENTER FOR COMPLEMENTARY AND ALTERNATIVE MEDICINE
The public demand for CAM therapies created a need for research in these areas. Physicians largely unfamiliar with these practices were limited in their ability to answer questions that patients might ask about CAM. Huge information gaps were evident in the scientific literature concerning safety and efficacy. In 1993, in answer to this need, an Office of Alternative Medicine was started within the National Institutes of Health (NIH), with an initial budget of $2 million. The office later was expanded and renamed the National Center for Complementary and Alternative Medicine (NCCAM); its budget has been greatly expanded, and, as of 2002, it was $104.6 million per year.29 The continued expansion of this office has allowed important research in areas that were previously studied either not at all or only with very small groups of patients.
As research in this area has matured, however, it has become clear that the clinical practice of integrative medicine, relying as it typically does on multiple therapeutic interventions applied in an individualized treatment plan for a given patient, poses a great challenge for conventional research methodology. Our “gold standard”—the reductionistic, randomized, controlled, double-blind study—may not be the most effective tool for studying individualized treatments or complicated remedies that act in combination and are not amenable to reduction. The phenomenon of synergy, in which the whole is actually equal to more than the sum of the individual parts, is felt by many integrative medicine practitioners to play a critical role in this model. Randomized controlled trials (RCTs) and the reductionistic model in general—at least as they are widely used today—are not entirely applicable tools for measuring or describing the phenomenon of synergy.
Equally challenging to conventional science is the question of what constitutes sufficient evidence as a source of knowledge. We have been entrained by our scientific education to value the randomized, controlled, double-blind study as the highest process by which to study and evaluate efficacy in medicine and in science at large. However, at the root of its development as an evaluative process, this method approaches whatever is studied by dissection of the component parts while ignoring the concept that the whole has some value beyond the summation of these components.30 In a realm where personal perception, belief, cultural influence, or even the community has significant influence, this reductionistic perspective may be too narrow to be of value as an evaluative tool. That is not to say that it is not useful: we have gained and will continue to gain great insight from studies using this methodology. But the complexity of converging systems, some with distinctly less material aspects, should be acknowledged and accommodated as we pursue a greater understanding of how and why things work. More specific issues, challenges, and new
developments pertaining to research are discussed later in this chapter in the section “General Research Issues.”
WHAT IS INTEGRATIVE MEDICINE?
According to Rakel and Weil,
Integrative medicine is about changing the focus in medicine to one of healing rather than disease. This involves an understanding of the influences of mind, spirit, and community as well as of the body. It entails developing insight into the patient’s culture, beliefs, and lifestyle that will help the provider understand how best to trigger the necessary changes in behavior that will result in improved health. This cannot be done without a sound commitment to the doctor–patient relationship.31
Integrative medicine is a medical practice that is healing-oriented. It is a practice that is oriented toward prevention of illness and toward the active pursuit of an optimum state of health. It is the marriage of conventional biomedicine, other healing modalities, and traditional medical systems (Chinese medicine, Ayurveda, homeopathy, and Western herbalism, among others.). An integrative practice neither rejects conventional medicine nor uncritically embraces alternative practices.32 It is an approach that belongs to no specific specialty and describes a state of dynamic health. Therapeutic choices in integrative medicine are prioritized according to the level of benefit, risk, potential toxicity, and cost. The relationship between the physician and patient is central to the practice of integrative medicine, and involves the art of relationship as much as it does the knowledge of science. Finally, the integrative approach is a perspective that acknowledges the full spectrum of being in health in all realms: the mind, the body, and the spirit. A major objective is a life that is lived from a stance of enjoyment as wellness is maintained rather than a focus on regimens that make up
an obligatory “checklist” of health prescriptions to extend longevity. Community and environment are seen as integral components to wellness. Implicit in this process is the patient’s responsibility in maintaining health.
Definitions in Integrative Medicine
Many terms have been used to describe medical practices outside of the biomedical model. Many of these have been pejorative, such as “fringe medicine” and “unorthodox.” “Nontraditional medicine” has been used to describe ancient traditional medical systems like Ayurveda or Chinese medicine; this choice of terminology seems somewhat paradoxical given that these systems have been used for several thousand years longer than has modern “traditional” medicine. “Alternative medicine,” a term that appeared in the 1970s, implies the use of other healing practices in place of allopathic/biomedical medical treatments, and thus does not reflect the synthesis defined by the integrative approach. “Complementary” medicine suggests the addition of other healing practices to conventional biomedicine but relegates these therapies to a secondary role.
“Holistic” and “integrative” medicine are the commonly used terms closest in definition to integrative medicine, in that both imply a balanced, whole-person–centered approach and involve a synthesis of conventional medicine, CAM modalities, and/or other traditional medical systems, with the aim of prevention and healing as a basic foundation.
Integrative Medicine: An Approach with Many Tools
The integrative medicine practitioner is fortunate in having at his or her disposal a much wider variety of tools than are generally available to the conventional practitioner. Virtually any technique or intervention that is safe and effective—from both biomedicine/allopathic
