Integrative Medicine and Systemic Outcomes Research Issues in the Emergence of a New Model for Primary Health Care
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SPECIAL ARTICLE Integrative Medicine and Systemic Outcomes Research Issues in the Emergence of a New Model for Primary Health Care Iris R. Bell, MD, MD(H), PhD; Opher Caspi, MD; Gary E. R. Schwartz, PhD; Kathryn L. Grant, PharmD; Tracy W. Gaudet, MD; David Rychener, PhD; Victoria Maizes, MD; Andrew Weil, MD linicians and researchers are increasingly using the term integrative medicine to refer to the merging of complementary and alternative medicine (CAM) with conventional bio- medicine. However, combination medicine (CAM added to conventional) is not inte- grative. Integrative medicine represents a higher-order system of systems of care that Cemphasizes wellness and healing of the entire person (bio-psycho-socio-spiritual dimensions) as pri- mary goals, drawing on both conventional and CAM approaches in the context of a supportive and effective physician-patient relationship. Using the context of integrative medicine, this article out- lines the relevance of complex systems theory as an approach to health outcomes research. In this view, health is an emergent property of the person as a complex living system. Within this concep- tualization, the whole may exhibit properties that its separate parts do not possess. Thus, unlike bio- medical research that typically examines parts of health care and parts of the individual, one at a time, but not the complete system, integrative outcomes research advocates the study of the whole. The whole system includes the patient-provider relationship, multiple conventional and CAM treatments, and the philosophical context of care as the intervention. The systemic outcomes encompass the si- multaneous, interactive changes within the whole person. Arch Intern Med. 2002;162:133-140 Any intelligent person can study medical INTEGRATION VS ASSIMILATION literature and understand when or when not to use various treatments. What is so difficult, The term integrative medicine is often used even for a skilled physician, is to apply this to refer to blending the best of conven- knowledge in individual cases. For those who tional (allopathic) and complementary and know nothing about the fundamentals of alternative medicine (CAM). At face value, healing and treat it casually and talk a lot, nothing seems difficult. They don’t think there this goal seems straightforward and prom- is any illness that requires careful deliberation. ises an improved package of medical care The common run of people thinks medicine can for the consumer. However, a closer exami- be learned quite easily, whereas it is really nation of the process of this integration extremely difficult to master even for a raises a number of complex practical and conscientious physician. conceptual issues with which medicine as a field must grapple. This article deals with Maimonides (1135-1204) this process of integration and discusses im- The Regimen of Health Care; 4:7-8 plications for health care outcomes re- search. We suggest that by adopting a world- view derived from complex systems theory From the Program in Integrative Medicine, Departments of Medicine (Drs Bell, Caspi, in which the whole equals more than the Schwartz, Grant, Gaudet, Rychener, Maizes, and Weil), Psychiatry (Drs Bell and sum of its parts, a new perspective for medi- Schwartz), Psychology (Drs Bell, Caspi, and Schwartz), Neurology (Dr Schwartz), Family & Community Medicine (Drs Bell and Weil), Obstetrics and Gynecology cine and health care research emerges. 1 (Dr Gaudet), and Pharmacy Practice (Dr Grant), The University of Arizona Colleges The dictionary defines integrate as “to of Medicine and Pharmacy, and the Southern Arizona Veterans Affairs Health Care unite with something else,” “to incorpo- System (Dr Bell), Tucson. Dr Gaudet is now with Duke University Center rate into a larger unit.” Although the dic- for Integrative Medicine, Durham, NC. tionary definition of the noun integration (REPRINTED) ARCH INTERN MED/ VOL 162, JAN 28, 2002 WWW.ARCHINTERNMED.COM 133 ©2002 American Medical Association. All rights reserved. includes “the incorporation of Within conventional care, some nal contexts to fit a few of these equals into society,”1 it is evident multidisciplinary approaches to pa- smaller pieces into the dominant that the assumption implicit in the tient care have already laid a founda- model of conventional care and merger process for mainstream tion for the more fully integrative medical research. For example, nu- medicine is of an initial inequality medicine that could emerge: for ex- merous studies have investigated the in power and worthiness between ample, (1) in geriatrics, developing efficacy of acupuncture for various conventional and CAM approaches. multidisciplinary special care teams9 Western disorders,22,23 but virtu- That is, the politically dominant and end-of-life programs to optimize ally no studies examine the effec- “larger unit” (ie, conventional quality of life in hospice care10; (2) in tiveness of the sum total of Chinese medicine in the Western world; see chronic pain treatment programs, medicine as practiced. In acupunc- Zollman and Vickers2) carries the applying multidisciplinary care to ture-only research, the effect sizes are values, culture, and conceptual improve individual self-efficacy and often modest.24,25 Yet, traditionally, framework into which it expects the quality of life11; (3) in psychiatry, Chinese medicine uses a coordi- smaller unit (ie, CAM) to assimi- blending social supports, psycho- nated and individualized program late. It operates from the assump- therapy, and medications12 as well that includes various combinations tion that each CAM intervention, as emphasizing the patient’s respon- of diet, botanicals, acupuncture, acu- once tested and proven effective, can sibility for his or her own recovery13; pressure, qi gong, and environmen- be incorporated into conventional (4) in family medicine, valuing good tal interventions to address the care as now practiced.2 physician-patient relationships14 and unique, systemic disturbance pat- preventive interventions15; and (5) in terns in a given patient.18 It is a test- INTEGRATIVE MEDICINE behavioral medicine/health psychol- able hypothesis that the effect sizes IS NOT CAM ogy, using behavioral interventions of the full treatment program could to foster self-care and self-efficacy in be much larger and more clinically However, much of the conventional patients with diabetes16 or arthritis.17 significant if the entire Chinese contemporary practice of physicians, Although these examples of care- medicine treatment program were especially for the treatment of patients beyond-the-lesion offer important studied as used.26 with chronic diseases, has continued models for a more ideal form of medi- Moreover, Western medical re- to focus on a specific somatic disease cine, even these models are not nec- search usually assumes that its ap- process at the end organ rather than essarily widely available and/or acces- proach to diagnosis is the preferred on healing the individual person. Dis- sible within the current health care way to label a patient. It requires ho- affection with how physicians provide system. mogeneous groups of patients with conventional care and rely on phar- As it evolves, truly integrative conventional diagnoses for study. maceutical medicine continues to medicine also depends for its philo- But each system of CAM has its own grow among consumers and physi- sophical foundation and patient- theory-driven method for categoriz- cians alike.3,4 Integrative medicine is centered approach on systems of ing patients. Within a group of pa- acomprehensive,primarycaresystem CAM that emphasize healing the per- tients with asthma, for example, each that emphasizes wellness and healing son as a whole (eg, traditional Chi- CAM system is likely to identify of the whole person5 (bio-psycho- nese medicine, Ayurvedic medi- several different subtypes, each re- socio-spiritual dimensions) as major cine, and classic homeopathy).18 quiring a unique set of interven- goals, above and beyond suppression These CAM systems diverge the most tions for optimal treatment re- of a specific somatic disease.6,7 In the in philosophy, diagnosis, and treat- sponse (Figure 1A). In classic ideal situation, the patient and the in- ment technique from conventional homeopathy, for instance, each of 4 tegrative practitioner are partners in medicine,18 and thus remain margin- different patients with chronic the effort to develop and implement alized. Using philosophy-driven asthma might respond to only 1 rem- a comprehensive treatment plan for frameworks that seek balance, har- edy type chosen on the basis of his issues that extend far beyond the im- mony, and proper flow throughout or her individualized symptom pat- mediate chief complaint and/or con- the patient, they diagnose and treat tern (eg, Arsenicum album or Kali ventional diagnostic category.6 Truly patterns of dysfunction within the en- carbonicum or Medorrhinum or Na- integrative medicine draws from con- tire person as an indivisible sys- trum sulphuricum). In other words, ventional and alternative techniques tem.19 From the perspective of West- homogeneity of sample selection to facilitate healing and to empower ern science, such CAM systems offer from a conventional medical per- the patient because healing is believed (1) virtually no commonly used, re- spective is likely to break down into to originate within the patient rather ductionist, scientific methods by heterogeneous diagnoses from each than from the physician.6 Thus, the which