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Whole Person Health
Care
Jeni Lyttle, Duke Magazine September 2002
Used with permission
When talking about whole-person health care, the terminology
itself can be confusing, misleading, and laden with New-Age stigmas.
But use a different word--integrative. Integrative medicine combines
the best in traditional health care. It seeks to treat illness with
medication and/or medical procedures, with non-traditional research-
and outcome-based therapies that fall into a category commonly
called complementary/integrative medicine, or CAM.
The idea behind integrative medicine is not for people to forego the
appropriate traditional treatments in favor of CAM therapies, says
Tracy Gaudet, director of the Duke Center for Integrative Medicine
(DCIM), but to complement these treatments with techniques that
address the multiple components of whole-person care--including
body, mind, nutrition, movement, and spirit.
This philosophy clearly rings familiar with many Americans: Nearly
half have pursued CAM therapies at one time or another. And for
this, Gaudet cites two primary reasons: first, because there are
therapies and approaches that have been proven beneficial in helping
people prevent and fight illness, but have fallen outside mainstream
medicine; and second, because "a large cultural shift is afoot in
which people want to be seen as more than just diseased body
parts--they want to be understood and treated as the whole entities
they are."
Duke has long been known for its scientific and technological
advances in health care--as Duke Health System CEO Ralph Snyderman,
says, "The practice of medicine has benefited tremendously from its
marriage to science and technology over the last fifty years."
However, he adds, "the concern is that although that marriage is
vital--and will continue to drive Duke--it is insufficient, because
there are limitations, as well as benefits, to science and
technology. Unfortunately, much of today's delivery of health care
fails to acknowledge the components of health care that go beyond
science alone."
For example, although much of science-and-technology-driven medicine
is straightforward, a woman whose cancer results in the removal of a
breast "has needs beyond thinking of her own chances for a cure,"
Snyderman says. "In a way, she and all patients facing serious
illness become different people, with new questions, needs,
concerns, and priorities." In other words, cognitive and spiritual
issues.
The problem lies in the modern Western tradition of medical
education. While many health-care providers are trained to treat the
body, few are trained to address matters of the mind and
soul--components that are arguably as critical as the physical when
it comes to staying and getting well. And the fact that so many
consumers are now looking beyond body-only health care makes it even
more important for the medical community to be in the know about
integrative medicine.
"It's as though there are now two distinct health-care systems in
our country--conventional and 'alternative'--and because they're not
integrated, patients are stuck in the middle, getting mainstream
advice from their doctors and CAM advice from others," says Gaudet.
"Because many people aren't telling their doctors about their
interest in CAM therapies for fear the doctors won't be
knowledgeable and supportive, cancer patients are seeking medical
advice from health- food store clerks."
As a leading institution in the field of integrative medicine,
Gaudet says, Duke has a responsibility to educate both patients and
health-care professionals. "First and foremost, we at Duke are
advocates of the best medicine, and our knowledge of and receptivity
to CAM enables us to help patients separate what's safe and
legitimate from what's not--and then look at CAM therapies that
might benefit them."
Think of integrative medicine, which evolved centuries ago and began
appearing in health-care settings in the 1970s, as three overlapping
circles, says Jeff Brantley, director of Duke's mindfulness-based
stress reduction (MBSR) program. MBSR incorporates hatha yoga,
breathing techniques, and meditation to help reduce stress or
stress-related symptoms. "The left one represents traditional
Western medicine, the one in the middle symbolizes CAM therapies,
and the circle on the right are mind-body-spirit techniques--things
like mindfulness, that people can do themselves to promote health
and well-being."
While most of the techniques represented by the left and middle
circles require an expert to do something with or to us, Brantley
says, those represented by the right circle "are the internal
experiences that are vital to health and healing. There's growing
evidence that clarifies the link between how we experience stress
and how that stress affects our bodies' reactions to things. Our
immune systems in particular are greatly impacted by stress, which
can have serious health implications.
"Mindfulness is a quality we've already got. It's about paying
attention to what's here, inside and out, right now, and being
open-heartedly aware of what's going on in the present without
thinking or judging. Out of that undistracted awareness comes a
heightened appreciation for life and a strong recognition of habits,
choices, and options. It starts with being fully present--for good
things and bad."
But Brantley echoes the warnings of other Duke medical professionals
when it comes to CAM: "People must never stop taking their
prescribed medications or foregoing necessary procedures in favor of
CAM therapies like MBSR," he says. "If you have concerns about your
care, become a better partner with your physician and try to gain
skills that will make you more aware of what's going on inside. That
combination is very empowering--and is what really does help us to
be our own best healers."
Whether as part of MBSR or on its own, yoga is one component of
stress control and integrative medicine. A practice that evolved
some 5,000 years ago, whose name means to join or yoke together,
yoga "focuses on breathing techniques, physical postures, and
meditation to teach us to bring our bodies back into a state of
balance and quiet so that we're better able to deal with daily
stressors from a place of clarity," says Linda Smith, yoga expert
and DCIM director of programs. "A system of awareness and
rebalancing that's easy to learn and can be practiced at many
different levels, yoga is successfully used in the prevention and
treatment of many chronic conditions."
Because the goal of yoga is to tone, strengthen, and develop
flexibility and balance within one's body, Smith says it isn't only
for people in excellent physical condition. "Most everyone,
regardless of their state of health, can breathe, meditate, and move
their bodies. The key is to develop awareness and sensitivity to
what's going on in your body and learn to listen to its
limitations."
The reality, she says, is that stress in our lives is inevitable;
the goal is to learn to manage it. "When you have the tools to bring
yourself back into balance regardless of what's happening in your
life, it's very empowering."
 Touch
therapies provide another stress- and pain-management tool.
Practitioners use healing touch and massage to manipulate the tissue
of patients for therapeutic benefit, often while incorporating
relaxation techniques. Certified healing-touch practitioner Jon
Seskevich treats a variety of people at Duke, from transplant
recipients to cancer patients to women experiencing difficult
pregnancies. "We work with people who are living through some very
heavy stresses, and by teaching them touch and guided relaxation
strategies, we're teaching them to help themselves," he says.
"Science has shown not only a mind-body connection, but also that
touch and relaxation therapies are beneficial. So we can do these
things knowing we're on solid scientific ground."
For example, Seskevich says, a large body of research suggests great
therapeutic benefit from massage. Results of a study published in
1998 reveal that children with asthma who received only massage
therapy showed a 15 percent improvement--nearly equal to those who
received medication alone. And a University of Miami study to
examine the effects of human touch on cocaine-exposed premature
infants revealed that the infants who received touch therapies
gained significantly more weight than those who didn't.
As with many CAM techniques, touch therapies aren't just for people
suffering from disease or injury. "Because many people think of
stress as being brought on by problems, worry, or pressure, patients
will deny that they're experiencing stress--or feel that when they
are, they simply aren't coping well," says Seskevich. But stress is
actually caused by the adapting that comes with any type of
change--even when the change is good--and it creates powerful
chemicals that wear on our bodies and can cause tension, increased
pain, and sleep problems.
"It's hard to know where the mind stops and the body begins," says
Seskevich. "Everybody says, 'Relax. Don't worry.' But nobody teaches
patients how to do that. That's what we try to teach people with
tools like guided relaxation and touch therapies."
Another tool people can use is hypnosis, a process used to help
people access and control the trance state, says Duke consultant
Holly Forester-Miller. The trance state, an altered but naturally
occurring state of consciousness in which one can more readily
manipulate psychological and physiological abilities, is
successfully used in conjunction with traditional therapies to
address issues ranging from migraines and depression to weight loss
and chemotherapy side effects. "Accessing the trance state enables
people to suggest that parts of the body respond in certain ways, so
it can facilitate and assist with almost every health issue," she
says. "Hypnosis enables us to best use trance to accomplish a goal,
whether that's pain management, relaxation, psychological growth, or
physical healing."
The effects have been documented by medical research.
Forester-Miller cites a 1995 University of Connecticut study that
"examined cognitive behavioral therapies and compared them with the
same therapies coupled with hypnosis. The patients with hypnosis
showed greater improvement than at least 70 percent of those
receiving the same treatment without hypnosis."
Although some people are initially skeptical or fearful that
hypnosis will cause them to relinquish control, Forester-Miller says
most soon discover the opposite is true: "Because they learn to keep
their conscious and unconscious minds 'running' at the same time,
patients actually find they have more control than ever. Rather than
losing touch, they gain touch with the deepest parts of themselves."
Nutrition is also a critical component of overall health, says
nutrition educator Greg Hottinger. Nutrition therapy incorporates
diet and dietary supplements--"anything you put in your mouth that's
not food: vitamins, minerals, herbs, amino acids, enzymes, organ
tissues, extracts, or concentrates sold as leaves, powders,
capsules, oils, teas, or ointments."
While few would deny the preventive benefits of good nutrition, many
may be surprised to know that it can also be a powerful weapon in
fighting disease. The Ketonic diet, for example, dramatically
decreases the occurrence of several types of pediatric seizures. And
participants in the landmark DASH (Dietary Approaches to Stopping
Hypertension) study--in which Duke played a large role--saw
reductions in blood pressure comparable to patients taking
medication only.
Hottinger, whose consultations include cancer, heart, arthritis, and
Alzheimer's patients, says inflammation in particular can be
positively affected with dietary modifications. "There's been a
great deal of research about this," he says, "and the primary
approach is to reduce foods and substances--fats, for instance--that
promote the inflammatory response, while increasing anti-oxidants
and substances that promote an anti-inflammatory response--things
like flaxseed oil, ginger, black tea, and apples."
As with other integrative therapies, Hottinger says, the common
thread that runs through whole-person health care--regardless of
someone's health status--is increased awareness. "We emphasize
eating mindfully, by developing a relationship with your body, by
being aware of what and how much we eat, by recognizing the
emotional and cognitive states in which we eat, and by acknowledging
our beliefs about food and diet. We help people learn to listen to
the signals about what works or doesn't work for them."
Finally, there are intangible elements to integrative medicine, such
as those that are a part of noetic therapies. Noetic therapies, what
the National Institutes of Health call "frontier medicine," are
widely practiced medical therapeutics for which there are no
plausible explanations, including spiritual- or prayer-based
practices, says cardiologist Mitch Krucoff. "Every physician has had
a patient who physiologically should have died, but didn't. These
patients frequently appear to have a vital link that wouldn't 'let'
them die--and you usually don't have to look far to find a friend or
family member, religious verse, or photo of a new grandchild."
The opposite is true, as well, he notes: Patients without those
vital links often don't seem to do as well physically or
emotionally. "This phenomenon has led us to look at the human spirit
as it relates to cardiology," he says. "In addition to applying
Duke's world-class, high-tech cardiology theater, we're now
examining the role of internal resources patients may have to help
themselves when they have cardiac problems, undergo procedures,
heal, and recover."
"Because the human spirit is a potentially critical contributor to
their outcomes, we're very interested in the spiritual aspects of
intervention so that we can best care for our patients," Krucoff
says.
That's the rationale behind Duke's MANTRA (Monitoring and
Actualization of Noetic Training) studies. Launched with a 1995
pilot program at the Durham Veterans Administration Hospital by
Krucoff and nurse practitioner Suzanne Crater, MANTRA includes
patients who have or had blocked coronary arteries and who, like
many cardiac patients, are facing their own mortality. The results
of the 150-patient pilot study, which integrated noetic
(spirit-related) therapies like guided imagery, breath control,
touch therapy, and off-site prayer with traditional ones, were
promising. Patients receiving noetic therapies including off-site
prayer in addition to their standard treatment had 30 percent fewer
complications overall; those who were treated with the
double-blinded, off-site prayers from eight prayer groups around the
world had 50 percent fewer minor complications and 100 percent fewer
major complications.
Krucoff stresses, however, that while data consistently suggested
that noetic therapies are beneficial, the pilot study was too small
to be statistically definitive, and may not be generalizable to
other health-care settings. That's the reason for Phase 2 of the
study, launched in 1999 to examine the roles of music, imagery, and
touch therapy in cardiac care. Krucoff says Phase 2 already has more
than 500 participants and can include up to 1,000 more.
"We can see the world of the tangible and the procedural, but when
it comes to the intangible--things whose mechanisms we may not fully
understand--the only thing we can do is measure clinical outcomes,"
he says. "An incomplete understanding of how or why the human spirit
works isn't a place to stop thinking or conducting research about
it."
This philosophy is widely shared throughout the medical center, he
adds. "At the highest levels, Duke's vision as an institution is to
re-define the optimal healing space for human beings by combining
the best in cutting-edge technology with awareness, cultivation, and
activation of the rest of the human being. We consider this the most
fertile ground for the next real advance in health care."
As with anything outside the borders of traditional medicine,
research, education, and mainstream support are crucial to the
continued growth of integrative medicine. A $1-million Centers for
Medicare and Medicaid Services grant awarded to Duke last year will
launch a two-year pilot study to better define whole-person health
care and examine ways people can strategically implement integrative
health planning into their lives for improved health.
Duke also offers students integrative-medicine curriculum options.
The School of Nursing offers a health and nursing ministries
master's degree designed to prepare nurses to serve as medical
professionals as well as promoters of whole-person care in specific
faith-based communities. And the medical school's integrative
medicine program includes monthly body-mind case correlation
dinners, CAM lectures, and courses that teach students to take an
integrative approach not only in caring for their patients, but in
caring for themselves.
"Education is critical if we're going to train the next generation
of health-care providers to think in this integrative model," says
DCIM education consultant Pali Delevitt. "It's not about replacing
one set of modalities for another; it's about exposing Duke medical
students to integrative-medicine practitioners who are successful
and teaching them to think holistically, to view illness and healing
from other paradigms.
"Traditional belief systems are not the final word. The history of
medicine shows that how we answer the question 'What is science?'
continuously evolves due to new knowledge. Integrative thinking is a
philosophy that's about looking inward and outward, and practicing
healing, not just practicing medicine--and this is what students are
clamoring for. They see integrative medicine as an opportunity to
grow, create community and personal wellness, and stay balanced as
they study and practice medicine."
Besides Duke's support of integrative medicine, interest from the
larger arena is growing. One example is the November 2001 launch of
a joint frontier medicine program by the National Institutes of
Health and the National Center for Complementary and Alternative
Medicine. "Public interest in integrative medicine is so intense,
and health-care issues so important, that the federal government, in
the absence of industry support, is now supporting integrative
medicine," says Krucoff. "That's a huge step forward."
But there are still many challenges to bringing integrative medicine
to the fore. Standardization in the practice and licensing of CAM
has yet to happen. And although some major insurers are beginning to
subsidize CAM services, most Americans must pay out of pocket for
them.
What can the average person--the average patient--do? "People must
vote with their feet about their health-care choices, by speaking to
their employers about the plans that are offered and by making sure
they relate to their physicians as partners in their health care,"
says Snyderman. "Involvement of the patient in their care is
absolutely key, and this is the type of health-care delivery we are
trying to make available at Duke.
"Seventy-five percent of health-care costs are spent treating
chronic diseases, often at a late stage. We have the ability to make
a big impact in the prevention and treatment of chronic
diseases--and therefore to improve the overall quality and cost of
health care--because so many of these diseases are impacted when
people modify their behaviors. We need to jump-start the solution to
the problem of effectively treating chronic disease. And that's why
Duke is involved in creating a national platform to find out what
really works in this field."
Will alternative therapies become a standard, accepted piece of
America's medical landscape? "My hope is that through Duke's
widespread support of and involvement in integrative medicine, we
can foster a mindset of wellness and involve patients in their own
health care," says Snyderman. "We must give patients the full range
of what they need to improve their health. We must do so by
recognizing each one as an individual in his or her own life setting
and by engaging them in their own health care. If we don't do this,
we're providing only a small segment of what patients expect and
deserve from a system that is supposed to be working with them to
improve their health."
--Lyttle is a Triangle-based freelance writer. |
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