Keywords: Integrative medicine, CAM, patient empowerment, therapeutic ritual.
Citation: Rakel D. Integrative medicine’s pragmatic mission. J Participat Med. 2013 Jun 26; 5:e26.
Published: June 26, 2013.
Competing Interests: The author has declared that no competing interests exist.
“By far the most frequent drug used in general practice was the doctor himself. It was not the bottle of medicine or the box of pills that mattered but the way the doctor gave them to his patient.”
–Michael Balint, Introduction to the Doctor, His Patient and the Illness.
Integrative medicine was not born from the medical establishment but from public interest. In the mid-1990s, there was a growing frustration with health care’s overdependence on the use of therapies to suppress symptoms while not recognizing self-healing mechanisms. Public surveys found that many viewed complementary and alternative medicine (CAM) to be more aligned with “their own values, beliefs and philosophical orientation towards health and life than traditional medicine.” This started a growing interest in CAM and encouraged the medical establishment to not only focus on what is wrong with the body, but to also recognize what is right with it.
Definition of Integrative Medicine:
Integrative medicine is defined as healing-oriented medicine that takes account of the whole person (body, mind and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.
This “salutogenic” (saluté=Italian word for health, genesis=creation of) approach  requires robust research models to look at the outcome we want to achieve. The traditional randomized placebo controlled trial (RCT) that controls for belief and expectation (placebo) is good for measuring the intrinsic effect of a drug, herb, or diet plan. But, if we want to know how to influence patient outcomes, we have to include the nonspecific variables that these trials try to remove. A nonspecific variable is the context from which the pill (specific effect) is prescribed. It includes the importance of relationship, expectation, and belief. The pragmatic controlled trial (PCT) looks at how all the variables (specific and nonspecific) affect the outcomes we want to achieve. This requires the participation of complex human beings and recognizes the parts of the therapeutic ritual. This is true for both CAM and conventional treatment.
Approximately 38% of Americans use CAM treatment. Low back pain is the most common condition for which CAM therapies are used. Low back pain is also the most expensive condition in primary care practices. Despite a significant increase in spending to treat this condition, there has been little improvement in outcomes over the past decade. We will use low back pain as an example of how a particular CAM therapy (eg, acupuncture) could be used to its fullest potential as we explore the contextual effects of the therapeutic ritual.
Ed is a 54-year-old construction worker who has had an exacerbation of his low back pain that has not responded well to physical therapy or to anti-inflammatory or pain medications. He has an interest in trying acupuncture since one of his buddies had a positive response.
Ed goes to a clinician whom he has never met. Due to limited time, the clinician quickly focuses on his pain and wants to try adding an antidepressant. He also refers him for an epidural steroid injection. When Ed says, “I was thinking about trying acupuncture,” the clinician quickly states, “There is little evidence CAM therapies provide any benefit and I wouldn’t waste your money.”
Ed goes to see his primary care clinician whom he has known for years. They exchange stories about their kids after which the focus transitions to Ed’s back pain. When the acupuncture idea arises, his clinician reports, “I have seen a few promising studies. I think it is worthwhile and the risk is very low.” She then recommends an acupuncturist who has helped a couple of her other patients. Ed feels empowered that someone he trusts agrees with what he is interested in trying. He leaves hopeful.
Comparing Models of Care
Clinician A, who does not know Ed and does not take his therapeutic interests into consideration, is relying on the specific or intrinsic value of the prescribed therapy. This approach significantly limits the potential of any treatment. For example, the use of serotonin reuptake inhibitors for mild to moderate depression has shown little to no benefit over placebo, but both have about a 58% benefit. The placebo, when used within the therapeutic ritual, works as well as the active drug. A common therapy used for low back pain in America, epidural steroid injections, also has limited benefit. For sciatica, a summary of many studies showed minimal short-term benefit and no long-term benefit. England’s National Institute of Clinical Excellence (NICE), an evidence-based guideline for therapeutic intervention, does not support the use of epidural steroids for low back pain.
Clinician B, who knows Ed well, is more strategic. She uses both the specific and nonspecific therapeutic influences that will add to the weight of the therapeutic benefit. (See figure.) She recommends a therapy (acupuncture) that has better data to support sustained benefit than epidural steroid injection for low back pain, and she gets the added advantage of choosing a therapy in which the patient has a positive expectation.
The expectation one has for a given therapy can have a significant therapeutic effect. When a caring nurse gave morphine with a positive expectation, compared to administration by a computer behind a curtain at a random time with no expectation, the positive nonspecific expectation equaled the specific effect of about 10 mg of morphine. Another study gave an opiate with a negative expectation, “This medicine will make your pain worse,” which completely negated the analgesic effect of the opiate. When the opiate was given after a positive expectation, “This medicine will significantly help your pain,” it doubled the positive effect. How Ed’s clinician creates expectation, positively or negatively, can make a difference in how he responds to any therapy.
The nonspecific effects with the best evidence in healing can be summarized using the “PEECE“ mnemonic
PEECE Mnemonic. Key nonspecific ingredients that positively influence healing through the clinician encounter:
These positive effects are enhanced through the therapeutic relationship that Ed has with his clinician. When psychiatrists treating depression with either placebo or an antidepressant (imipramine) were rated high in regard to a trusting relationship, they had better results with placebo than did psychiatrists treating patients with active drug who rated the relationships with their clinicians poorly. In summary, a strong therapeutic relationship trumped the effects of the pill prescribed. The strength of the therapeutic relationship is what gives the ingredients of PEECE their power. In fact, it is the desire of a more patient-centered and supportive relationship that draws many patients to choose CAM.
To study this relationship further, Kaptchuk and colleagues researched three different clinician styles for providing acupuncture for irritable bowel syndrome. The “augmented” group stacked the deck in regard to the nonspecific variables found to be of therapeutic benefit. The “limited” group placed the acupuncture needles with no time spent in forming a relationship, and the third group was a wait list control that was not seen by an acupuncturist. Six weeks after the intervention, symptom improvement was found in 62% of the augmented group, 44% in the limited group, and 28% in the control. In a similar study design, our research team looked at the severity and duration of the common cold in an “enhanced” group where each of the PEECE ingredients were applied compared to the “standard” visit type where they were not. Both were compared to a “no-visit” control. The main mental intent the clinician had before entering the exam room of the patient with a cold was either to connect with the patient (enhanced) or not connect (standard). Those patients who rated the clinician perfect in empathy had a shorter cold by 1.11 days with reduced severity compared to those visit types that were less than perfect in perceived empathy. The “enhanced” group also had a significant rise in nasal neutrophils and IL-8 compared to the other two groups. This correlation of immune markers supports how perception of empathy becomes physical and should carry as much weight in our therapeutic backpack as the specific effects of a drug or acupuncture needle.
Empowerment motivates people to take the necessary steps needed to activate their self-healing mechanisms and is a key quality that distinguishes CAM from conventional medicine. People rate CAM clinicians high in patient empowerment compared to traditional medical doctors and feel that CAM treatments give them a stronger sense of control over their health care. In a survey of patients who sought out CAM therapies, there was a correlation showing more symptom relief when they felt more empowered through a strong relationship with a CAM clinician.
Clinician B stacked the deck in favor of a therapeutic benefit from acupuncture. Stacking the deck, through a combination of relationship and PEECE ingredients, can increase the healing effects from whatever is prescribed. But ideally we should use those therapies with the best evidence for benefit with the least potential for harm. The NICE guidelines did this for low back pain and they included acupuncture, not epidural steroids in their evidence-based recommendation.
Who Is in Control?
If our clinical focus strives to create optimum health, we must understand the importance of giving patients a stronger sense of control in medical decision making. Primary care becomes much stronger when there is a continuous healing relationship with a provider who has broad insight about both disease and health. This requires that we shift some of the control from providers to individuals, their families and their communities. When health care in South-Central Alaska was transferred from the Indian Health Services to the people it served, they were asked what they wanted most from their health care delivery system. Their reply was an ongoing healing relationship with a community of clinicians that knows them well. Someone who “listens to them, takes time to explain things and who is able to effectively coordinate their overall care.” This health system formed with the goal of shifting control to the patient and providing both traditional and CAM services. This resulted in a 40% reduction in urgent care and emergency department utilization, a 50% reduction in specialist utilization and a 30% reduction in hospital days. Customer satisfaction surveys showed that 91% rated their overall care as “favorable.” We could add substantial value to health care delivery by recognizing the healing potential of these nonspecific variables that arise from relationship-centered care.
Creating Expertise in Health
Understanding how complex biopsychosocial living beings heal is much more complicated than treating a disease. It requires that we develop a unique understanding of the individual’s beliefs, lifestyle, and culture. Possibly even more challenging is for our medical system to put patients in charge of their health and shift our medical culture to a better balance between disease management and health creation. This shift in our intent requires that we take a more holistic and pragmatic view of achieving the outcomes we want for our patients within a dynamic and ever changing environment. This will be slow and difficult but, in the meantime, we should continue to invest in creating ongoing healing relationships. And for those who prefer to recommend epidural steroids over acupuncture, then prescribe the epidural steroid with enthusiasm and include all the PEECE ingredients.
Integrative medicine is not about simply studying therapeutic tools that are not traditionally used. It is about understanding how to use the most appropriate tools effectively to enhance health and healing. In doing so, we will evolve our research models to better understand this complexity (which includes the powerful nonspecific healing influences). When health is our common goal, we will become less fragmented as a health system because we will all be experts in understanding how complex systems heal. Health unites and disease segregates. This is true for our own medical culture as well for the patients we treat.
Gratitude to Charlene Luchterhand, MSSW for her review and support in preparation of this manuscript.
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