by Wayne Jonas
He awoke at 7 AM to his wife packing, getting him ready to be discharged back home. No call for a kidney had come in during the night. When he was fully awake he sat up and reached down to put on his socks—but something held him up.
“Ready?” his wife said, wondering why he was hesitating. It was long past the time they would have called him had the kidney been a match. But he was not ready. All the things that might happen should he leave now raced through this mind. He would have a dialysis treatment. He would go home and get back to work in his law firm and his community—a passion and purpose he would pursue it until the end. He would go on until it was his time to die, he thought.
“Let’s wait a bit,” he said to her. They sat in silence, waiting for the doctor to come in to discharge him. He just couldn’t bring himself to put his socks on.
When the doctor came in to the room he looked at them with an unusual smile. “Are you ready to go?” the doctor asked, in a strange tone.
“Sure, we are all packed up,” said Trevor’s wife, ignoring her husband’s still bare feet.
“Well, then.” The doctor could no longer contain himself; now he was smiling broadly. “You better unpack and get ready for the operating room. We found a kidney. It came in this morning—and it is a match!”
Trevor’s wife sat there, stunned. Trevor took a deep breath and broke into a smile to match the doctor’s. Finally, he simply said, “Okay then.”
He would be healed.
CHAPTER 10
Creating Healing
Your HOPE consultation.
Doctors don’t want frustrated, unhappy patients, and patients don’t want burnt-out, unhappy doctors. None of us wants to feel like we are victims of the health care system. But all too often, that is what we get. It does not have to be that way.
To understand why this happens and how to improve it, we need to look beyond the individual doctor, to the health care system and the environment. We then see there are many pressures on the health care system that push it away from the delivery of patient-centered and integrative health, especially for chronic and preventive care. When you as the patient are aware of these pressures, you can counteract them by creating healing relationships with health care professionals and your own healing environment. This chapter describes the forces that can help you and your health care team connect with the inherent healing power in you and in everyone. Let’s take a moment to summarize the forces operating on the current health care system.
UNDERSTANDING THE FORCES IN HEALTH CARE
Our modern medical system was originally set up to provide acute care. Problems that require immediate intervention, include injury, trauma, infection, heart attack, and stroke, are much better managed than chronic conditions.
Increasingly, most doctors are subspecialists. Except for those trained in primary care or family medicine, most doctors emerge from medical school well equipped to deal with only part of you—your cardiovascular system, or your bones and muscles, or your digestive organs, or your brain and central nervous system, or your endocrine system (glands and hormones). This is fine if your problems are restricted to these systems, but most health problems—especially those caused by stress and lifestyle—affect the whole person, including body, mind, and spirit. Specialists are not trained to look at health problems in this way.
We are fascinated by technology. Technology has produced tremendous advances in health care and will continue to do so. But there is a downside. The more inventive we get with diagnostic and surgical technology, the more we lose touch with the essential humanity of each patient. Patients are hooked up to blood pressure cuffs and monitors, injected with needles that withdraw blood, operated on through robotic arms attached to tiny cameras, and examined through ultrasound, MRI, and CT scans. Doctors can now peer into our brains, our organs, the very cells and genes of our body and obtain objective information about what is going on there. This is useful, of course, for diagnosis and treatment of disease, but the process tends to reduce people to objects, to depersonalize us. We are treated as if we too are machines, in need of repair, rather than living, breathing people with emotions, fears, and desires, in need of healing.
Doctors live with the potential for mistakes and lawsuits. Given the uncertainty in the science of medicine, the risk for error is high. Doctors don’t like this, and many overcompensate with unnecessary care in the hope of overcoming that uncertainty. However, that rarely works. More is not better. In fact, the overuse of medical technologies is one of the main causes of harm to patients. In addition, the risk of malpractice suits or discipline from oversight boards leads many doctors to practice so-called “defensive medicine”: ordering extra tests, waiting for specialists to “bless” a diagnosis, and focusing on extra paperwork, which also is often not in the best interest of the patient or based on good research evidence.
Doctors have information and work overload. Once, for my birthday, my father gave me a coffee mug inscribed with the words “Cognitive Overload.” The message was clear—slow down and relax. Take time to listen, especially with your heart, not just your brain. We are all flooded with waves of information daily, and it is impossible for any one person (or even a group of people) to extract, synthesize, and make good use of all the information that is now available. In addition, many doctors are overworked. They get paid by volume. Fee-for-service payment systems and reduced fees per patient mean less time per patient. In this system, patients do not always get the best care science has identified, because doctors either do not have time to distill important, evidence-based information; do not know about the latest research; or simply do not have enough time to deliver it. In previous chapters, I have described the consequent rising burnout rate of health professionals. Another consequence is medical error, such as prescribing or delivering the wrong dose of medicine or misreading a test result. The Institute of Medicine reports that preventable human errors in hospitals lead to the deaths of nearly one hundred thousand patients every year in the United States, making it nearly the third leading cause of death. Medical error kills more people than highway accidents, breast cancer, or AIDS. Overload is partly the cause of this.
Managed care increasingly dominates our health care system. Attempts to contain the escalating cost of health care puts treatment decisions into the hands of insurance administrators or government regulators rather than doctors and patients. Both patients and their doctors are frustrated that therapies they consider important or useful are not covered by insurance, or covered only minimally—even when there is sound scientific evidence for their use. This further restricts doctor-patient time together, as reimbursements depend on how many patients are seen and how many procedures are performed. When physicians have only fifteen minutes—or sometimes just five—to devote to a patient, conversations are rushed and patient-doctor relationships don’t develop. Patients more often leave with a prescription for a drug rather than a recommendation for lifestyle change, let alone delving into the deeper dimensions of healing. This is not a good environment for prevention, the management of chronic illness, or optimal healing.
The hierarchy in health care puts patients last. The standard medical hierarchy goes like this: doctor, nurse, medical assistant, patient. When you enter the hospital or outpatient system, if you are like most patients, you are dis-eased, dis-robed, dis-empowered, and eventually dis-charged. Such a system prevents a collaborative partnership with your doctor and prevents your doctor from being your advocate within the system.
There is an increasing diversity of patients and practitioners. Patients come into the system from a variety of cultural backgrounds and with personal preferences and beliefs about their health. Too often, doctors and other health professionals are not prepared to provide care that is sensitive to their patients’ culture, ethnicity, or belief differences. Witness what happened to Trevor because of this disconnect. In many cases, language may also be a barrier to communication. Even in the alternative medicine world, patients should
be wary of “turf” battles among different alternative practitioner groups, each claiming, for example, that their approach—be it naturopathy, chiropractic, or acupuncture—is the best for everyone. No single approach works for everyone or even for the same condition in different people.
SYSTEMS WORKING TOWARD INTEGRATIVE HEALTH
That is the bad news. The good news is that health care systems around the world now implement more integrative health care and are seeking to build a more balanced approach to healing chronic illness. I invite you to seek out these practices, ask for them from your physician, health care system, government, and insurance provider, and bring them into your life. What patients like Trevor could not get twenty years ago is increasingly available today—if you look and ask for it. Integrative health care comes in a variety of forms and names.
In the previous chapter, I provided an overview of policy guidelines and health systems seeking to optimize a patient-centered medical home and other integrated or pay-for-value approaches to health care. I gave several examples, such as the Nuka and Iora systems and the work from the Institute for Healthcare Improvement and Stanford evaluations of the top 5% of primary care in the United States. The Commonwealth Fund reports on such exemplars in integrated care on a regular basis. What most of these systems did not do, however, is integrate complementary and alternative medicine (CAM) approaches into their delivery. Thus, many of them are missing one of the three legs of fully integrative health care: conventional care, complementary care, and self-care. Let me give you a brief overview of groups that are integrating this second leg of integrative health—the Integrative Medicine and Health, traditional, and CAM efforts—around the world.
INTEGRATIVE MEDICINE AND HEALTH
The best global overview of the rise in complementary and alternative approaches to healing is being done by the WHO, whose office of Traditional & Complementary Medicine (T&CM) tracks and advances information, research, and access to non-Western (nonconventional) practices. The use of these practices by patients and physicians is extensive—ranging from between 30% to nearly 90% of the general public in some places. Countries such as Singapore, Japan, China, and Korea provide some or even full coverage of T&CM practices for their populations. Eighty percent of the 129 member countries in the WHO assessment provide acupuncture (originally an approach only in traditional Chinese medicine), including eighteen (14%) with insurance coverage. As of 2012, thirty-nine member countries (30%) had doctoral-level training programs in T&CM, and seventy-three (56%) had government-funded research institutes. The economic output per year in herbal and natural products alone is over $83 billion in China, $7.4 billion in Korea, and $14.8 billion in the United States.
Around the world, the reasons patients give for their use of T&CM are similar to the reasons many of my patients give for seeking complementary and alternative medicine: easier access, dissatisfaction with exclusively conventional care, and a desire for safer and more natural or whole person care. Cost savings were also cited, and there is some data to support this. Reports from WHO and the RAND Corporation (an independent international research group) show lower costs with equal outcomes with some types of T&CM for chronic pain. When integrated into primary care, practices that include T&CM report lower costs for hospitalization and drug use.
The WHO Strategy report and others have found that, as illustrated in Trevor’s experience, the two systems of T&CM and conventional medicine often do not integrate with each other—in any country. Usually, T&CM and conventional hospitals and clinics operate separately. A review by RAND researcher Ian Coulter of over seventeen thousand studies on what is called “integrative medicine” around the world showed that only five studies explored full integration between the systems. This means that patients are, unfortunately, caught between these systems and therefore need to become their own integrators. This is challenging, given that the quality of training and products in CAM is often neither regulated nor oriented toward scientific evidence as much as conventional medicine. While some countries, such as Australia, Canada, and certain European countries, closely regulate the quality and use of natural substances such as herbs and supplements, many other countries do not. Supplement and herbal companies can market and sell such products with dubious or inadequate science. The WHO report notes the wide variety and quality of regulations on T&CM compared to conventional medicine worldwide.
While it is not the purpose of this chapter to give a comprehensive summary of global T&CM practices, special mention of a few regions may help readers understand better how to use these systems to achieve their own integrative health. More information is regularly posted on my website at DrWayneJonas.com.
The United States has made outstanding progress in developing integrative medicine in recent years, catalyzed by the NIH, the Office of Alternative Medicine (OAM, which I directed from 1995 to 1999), and then the National Center for Complementary and Integrative Health, which replaced the OAM. This effort facilitated the development of several academic health centers. For those who get their care at academic health centers in the United States, there is a growing group providing integrative medicine and health. The Academic Consortium for Integrative Medicine and Health is made up of over seventy academic health centers and teaching hospitals that provide integrative medicine. In the United States, these include schools such as Harvard, Stanford, Johns Hopkins, Duke, and others, such as the universities of Arizona, Minnesota, Maryland, and California. This effort was supported for several years by a group of private philanthropists, the Bravewell Collaborative. Bravewell, which has since closed, supported not only the academic development of integrative medicine, but also a research network, a movie, and a National Academy of Medicine summit in 2009 called Integrative Medicine and the Health of the Public. That summit called for adding the principles of integrative health into health care for more holistic care by incorporating nutrition, mind-body practices, the use of more natural substances, and other complementary treatments into mainstream medical care.
There are many other groups leading the integration of nonconventional medicine into the mainstream. These include the European Society of Integrative Medicine (ESIM) and the International Society for Complementary Medicine Research (ISCMR), which held their tenth and twelfth international congresses, respectively, in 2017. Having followed this field for over three decades, I am struck by how often the philosophies and approaches that begin in these groups get taken up (with or without the same labeling) by mainstream medicine. These groups represent the “stay tuned for what may become the future of prevention and healing.” They are the canaries in the coal mine that, instead of alerting to danger in health care, alert to innovations in healing. Most of these organizations seek to better integrate what they do into conventional biomedical health care systems.
One of the pioneers and continued leaders in the area of integrative medical education is Dr. Andrew Weil. His University of Arizona Center for Integrative Medicine has medical education programs and fellowship training—led by Dr. Victoria Maizes—that has taught over 1,500 physicians in the foundations of integrative health, developing a cadre of young doctors with the knowledge and skills for healing. Look up their graduates for a doctor near you. Dr. Weil is a best-selling author whose multiple books describe how you can incorporate integrative medicine in your life. His most recent title, Mind Over Meds, is a well-researched book full of practical suggestions for using lifestyle approaches and natural substances to treat many of the conditions, for which most doctors prescribe drugs. This is an especially timely topic as we try to tackle the epidemic of opioid drug overuse and its damaging effects.
Recently, a remarkable experiment in integrative health was launched at the University of California, Irvine (UCI). An entire health sciences college encompassing the schools of medicine, nursing, pharmacy, and public health was formed under the principles of integrative health. The college was launched through a joint partnership of UCI and Susan and Henry Samueli (who also fund
the Samueli Integrative Health Programs that I run). The goal of this new college is to “educate the next generation of health science professionals to transcend current boundaries; foster clinical programs with an increased focus on lifestyle, prevention, wellness and optimal health; and promote discovery of an expanded set of tools and platforms that fosters a systems approach to health, inclusive of all forms of evidenced-based healing—conventional and complementary.” This will indeed be a new way for health care professionals to learn how to balance curing and healing—and a way to attend to those factors that make healing work.
Other examples include the Cleveland Clinic, one of the top medical centers in the United States. It has started a program in what is called “functional medicine”—a term coined by Dr. Jeffrey Bland over thirty years ago. It seeks to integrate science-based nutritional and lifestyle modifications with mainstream science for delivery in health care. In his recent book The Disease Delusion, Dr. Bland describes how the merger of nutrition with genomic medicine is creating a paradigm shift in healing that uses whole systems science and the ancient concept of food as medicine. The Cleveland Clinic program, directed by Dr. Mark Hyman—author of multiple best-selling books on prevention and health promotion—plans to test this approach for its effectiveness in healing several major diseases. Cleveland Clinic also operates an Institute for Integrative Health and Wellness that provides a team approach of CAM and mainstream practitioners. Physicians are gaining greater access to training in nutrition and lifestyle change. The Institute for Functional Medicine (IFM) now offers regular seminars and a certification in functional medicine for physicians. When I last visited the IFM training course, I noticed that they were no longer just preaching to the believers in alternative approaches to medicine. Most of the physicians attending the training were from mainstream organizations like the Veterans Health Administration, Kaiser Permanente, and Providence Health. They were looking for the kind of education in nutrition they did not get in medical school or residency.