New paradigm in healthcare needed

March 4, 2009 (Washington, DC) — The term integrative medicine "is a little like showing someone a Rorschach blot and asking, what do you see," said Harvey V. Fineberg, MD. The president of the Institute of Medicine (IOM) was speaking here at the opening of the 3-day IOM Summit on Integrative Medicine and the Health of the Public last week.

He focused on 5 primary dimensions of integrative medicine. "It is in a way the fulfillment of the old [World Health Organization] definition of health, which was clearly more than the absence of disease...the extension and comprehension of heath embodying its physical, mental, emotional, and spiritual dimensions altogether."

Integrative medicine extends across the whole spectrum of interventions, Dr. Fineberg said, keeping health and restoring health. It thinks about the coordination of care across the spectrum of services. At its most basic, integrative medicine "is the embodiment of patient-centered care."

"Finally, it conveys an openness to multiple modalities of care," both traditional and nontraditional, said Dr. Fineberg. The standard for evidence should be consistent, demanding no more or no less, "open to a variety of modalities, so long as they work."

Conference chairman Ralph Snyderman, MD, from Duke University in Durham, North Carolina, compared the $2.4 trillion US medical "industry" to the airline industry in that both hold the consumer in low regard; "both are built on technology and systems that assume that people will be there because they have no choice, but [they] pay little attention to the specific needs of the individual."

He said germ theory transformed American medicine in the early 1900s with "an incredible focus on the pathophysiology of disease." It resulted in "a find it and fix it" focus on the treatment of a single causal factor.

Genomics is ushering in a second transformation of medicine "where we can anticipate things before they occur...and transform it into personalized, predictive, preventative healthcare," Dr. Snyderman said.

"If you buy into the idea that health is your most precious possession," then these and other quickly evolving tools will give patients a roadmap of their health risks over the course of a lifetime. Dr. Snyderman pointed out that people could then invest in lifestyle changes that will optimize their long-term health.

The Science

One of the principal themes of the summit was the need to move from treating acute symptomatic disease to the earlier identification of risks for developing disease, as well as use of lifestyle and biomedical interventions to slow or preclude progression to disease.

Dean Ornish, MD, briefly reviewed literature demonstrating the negative impact of stress and depression on physiological factors such as blood flow, immune function, inflammation, brain volume, cardiovascular disease, and even gene expression. Changes in lifestyle activities can greatly ameliorate negative states.

"It really captures peoples' imagination to know that if you change your lifestyle, you can actually change your genes, at least to some degree," said the University of California San Francisco (UCSF) researcher. It can be a useful counter to the sense of "genetic nihilism, that there is nothing I can do."

"Pain can be a powerful catalyst to transformation," Dr. Ornish said. "Sustainable choices in lifestyle changes are based on joy and pleasure, not on risk factor reduction.... What is sustainable is pleasure, and joy, and fun."

He noted that illness begins with "I," wellness with "we." The core of integrative medicine gets the person out of the self and into the group, he said.

"The ability to make lifestyle changes and engage in healthy lifestyles is very much patterned by our social status," said his UCSF colleague Nancy Adler, PhD. There is almost a 5-fold difference in health status between the top and bottom quintiles of income; "this is a huge effect."

"Lower socioeconomic status accelerates the aging process," she said. "Things that change with aging — higher blood pressure, higher [body mass index], greater abdominal fat acquisition, a drop in cortisol — happen at earlier ages among those lower on the social ladder. We can see it even at the cellular level."

The National Institutes of Health's Esther Sternberg, MD, said that 10 to 15 years ago there was skepticism about stress as an illness. Today, "Nobody is questioning that chronic stress can make you ill." Researchers can trace how interventions can shift dopamine, endorphin, and immune function signaling pathways, she said.

"It is hard to do that with belief. We can stress an animal and stress a person and measure something. It is really hard to tell a person, believe and we are going to measure something; it is impossible to do that to a rat."

Dr. Sternberg is working to identify the complex mix of biomarkers that form "a signature, an individualized pattern of health or disease that tells us what this individual needs to do to help them maintain health or reverse disease."

Drawing blood to analyze these biomarkers can affect things such as levels of stress. Her research team has developed a patch that gathers sweat for analysis of markers. "There is a very, very tight correlation between what we could measure in sweat and in plasma," she said.

"Women who had a history of depression had an elevation of proinflammatory cytokines.... Their stress response shifted away from the vagally mediated relaxation response toward a sympathetic adrenaline-mediated response. These patients were asymptomatic." Dr. Sternberg hopes the patch approach might eventually be moved into the clinic so that patients might take the information and modify behavior before disease symptoms develop.

"I think the biggest challenge we have in organized medicine today is that we are not asking the right questions anymore," said Mehmet Oz, MD, the holder of joint positions with Oprah and Columbia University in New York City. "If you cannot fund the trial, you are not going to ask the question."

The level of evidence for making decisions is another concern. The randomized controlled trial is a superb tool for answering reductionist questions, but is less useful when trying to assess more complex, intermodal interventions.

"About 95% of heart disease is preventable today with diet and lifestyle," Dr. Ornish said. The evidence is that unless one is having a heart attack, angioplasty and bypass surgery don't prevent heart attacks or prolong life, yet the US continues to devote $100 billion a year to those procedures. The evidence suggests that the number of these procedures should decline, but they have not, he said.

Dr. Ornish concluded, "Let's take an evidence-based approach and apply it across the board, and not just to so-called integrative medicine."

Structural Issues

The body fixes itself, and the goal of the physician should be to abet this process, said Victor Sierpina, MD, from the University of Texas Medical Branch in Galveston. "We need to be out where people are, changing their lifestyles" so that the harm is stopped and healing can proceed.

But the current "find it and fix it" mentality has resulted in a reimbursement system that rewards more therapy, not spending time with patients to assist the body in healing itself, he said.

In most countries "the ratio of primary to specialty care [physicians] is roughly 3:1; in the United States, the pyramid is inverted, we have 60% specialists, 40% primary care doctors," Dr. Sierpina said. And the problem will get worse because fewer than 5% of medical school students choose primary care as their specialty.

Primary care also needs a major structural redesign, said Emory University's Kenneth Thorpe, PhD. Some "83% of primary care practices are in groups of 1 or 2, and they account for about 40% of primary care capacity." They also are the segment of providers least likely to have electronic medical records systems in place.

Dr. Thorpe said that the health system needs to find ways to better integrate these primary care physicians into the team approach to medicine and the continuity of care that the new health paradigm demands. Primary care physicians must gain the tools to better fulfill their role as coordinator of care. That is particularly true when one considers that 75% of current healthcare dollars go to treat chronic disease, not acute disease

Dr. Sierpina called for a change in reimbursement with some form of capitation, creation of time to spend with the patient, and creation of incentives for primary care. There was agreement that a resolution must address the burden of medical school debt and the status of primary care within the profession.

Dr. Snyderman said the model of physician-patient interaction will change. The physician-directed health team will serve more as a mentor to the patient, identifying the problem and offering guidance to turn it around.

A consensus seemed to emerge at the summit that the term "integrative medicine" may be a misnomer that mistakenly forces the issue into a clinical framework of disease. Rather the concept and language should be one of "integrative health," which embraces elements such as eating, exercise, and the built environment to foster health and allow the body to exercise its own healing functions.

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