David Rakel

INTEGRATIVE MEDICINE AND PATIENT-CENTERED CARE

Integrative medicine has emerged as a potential solution to the American healthcare crisis. It provides care that is patient centered, healing oriented, emphasizes the therapeutic relationship, and uses therapeutic approaches originating from conventional and alternative medicine. Initially driven by consumer demand, the attention integrative medicine places on understanding whole persons and assisting with lifestyle change is now being recognized as a strategy to address the epidemic of chronic diseases bankrupting our economy. This paper defines integrative medicine and its principles, describes the history of complementary and alternative medicine (CAM) in American healthcare, and discusses the current state and desired future of integrative medical practice. The importance of patient-centered care, patient empowerment, behavior change, continuity of care, outcomes research, and the challenges to successful integration are discussed. The authors suggest a model for an integrative healthcare system grounded in team-based care. A primary health partner who knows the patient well, is able to addresses mind, body, and spiritual needs, and coordinates care with the help of a team of practitioners is at the centerpiece. Collectively, the team can meet all the health needs of the particular patient and forms the patient-centered medical home. The paper culminates with 10 recommendations directed to key actors to facilitate the systemic changes needed for a functional healthcare delivery system. Recommendations include creating financial incentives aligned with health promotion and prevention. Insurers are requested to consider the total costs of care, the potential cost effectiveness of lifestyle approaches and CAM modalities, and the value of longer office visits to develop a therapeutic relationship and stimulate behavioral change. Outcomes research to track the effectiveness of integrative models must be funded, as well as feedback and dissemination strategies. Additional competencies for primary health partners, including CAM and conventional medical providers, will need to be developed to foster successful integrative practices. Skills include learning to develop appropriate healthcare teams that function well in a medical home, developing an understanding of the diverse healing traditions, and enhancing communication skills. For integrative medicine to flourish in the United States, new providers, new provider models, and a realignment of incentives and a commitment to health promotion and disease management will be required.

Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study

PURPOSE Burnout, attrition, and low work satisfaction of primary care physicians are growing concerns and can have a negative influence on health care. Interventions for clinicians that improve work-life balance are few and poorly understood. We undertook this study as a first step in investigating whether an abbreviated mindfulness intervention could increase job satisfaction, quality of life, and compassion among primary care clinicians. METHODS A total of 30 primary care clinicians participated in an abbreviated mindfulness course. We used a single-sample, pre-post design. At 4 points in time (baseline, and 1 day, 8 weeks, and 9 months postintervention), participants completed a set of online measures assessing burnout, anxiety, stress, resilience, and compassion. We used a linear mixed-effects model analysis to assess changes in outcome measures. RESULTS Participants had improvements compared with baseline at all 3 follow-up time points. At 9 months postintervention, they had significantly better scores (1) on all Maslach Burnout Inventory burnout subscales—Emotional Exhaustion (P =.009), Depersonalization (P = .005), and Personal Accomplishment (P <.001); (2) on the Depression (P =.001), Anxiety (P =.006), and Stress (P = .002) subscales of the Depression Anxiety Stress Scales-21; and (3) for perceived stress (P = .002) assessed with the Perceived Stress Scale. There were no significant changes on the 14-item Resilience Scale and the Santa Clara Brief Compassion Scale. CONCLUSIONS In this uncontrolled pilot study, participating in an abbreviated mindfulness training course adapted for primary care clinicians was associated with reductions in indicators of job burnout, depression, anxiety, and stress. Modified mindfulness training may be a time-efficient tool to help support clinician health and well-being, which may have implications for patient care.

Placebo, Meaning, and Health

Placebos are boon and bane to medical theory and clinical practice. On the one hand, randomized controlled trials employ concealed allocations of placebo to control for effects not due to specific pharmacological mechanisms. As a result, nearly all of evidence-based medicine derives from principles and practices based on placebo. On the other hand, medical researchers and physicians have tended to ignore, minimize, or deride placebos and placebo effects, perhaps due to values emphasizing scientific understanding of mechanistic pathways. We argue that intention, expectation, culture, and meaning are central to placebo-effect phenomena and are substantive determinants of health. We introduce three dualities that are integral to placebo/meaning phenomena: body-mind, subconscious-conscious, and passive-active. These placebo-related dualities should be acknowledged, explored with research, and incorporated in theory. While we view consideration of placebo and meaning effects as essential to any adequate understanding of human health, we feel that lessons from this area of inquiry may already provide practical tools for astute clinicians. Toward this end, we list eight specific clinical actions: speak positively about treatments, provide encouragement, develop trust, provide reassurance, support relationships, respect uniqueness, explore values, and create ceremony. These clinical actions can empower patients to seek greater health and may provide a healthful sense of being cared for.

Meditation or Exercise for Preventing Acute Respiratory Infection: A Randomized Controlled Trial

PURPOSE This study was designed to evaluate potential preventive effects of meditation or exercise on incidence, duration, and severity of acute respiratory infection (ARI) illness. METHODS Community-recruited adults aged 50 years and older were randomized to 1 of 3 study groups: 8-week training in mindfulness meditation, matched 8-week training in moderate-intensity sustained exercise, or observational control. The primary outcome was area-under-the-curve global illness severity during a single cold and influenza season, using the Wisconsin Upper Respiratory Symptom Survey (WURSS-24) to assess severity. Health care visits and days of missed work were counted. Nasal wash collected during ARI illness was assayed for neutrophils, interleukin-8, and viral nucleic acid. RESULTS Of 154 adults randomized into the study, 149 completed the trial (82% female, 94% white, mean age 59.3 ± 6.6 years). There were 27 ARI episodes and 257 days of ARI illness in the meditation group (n = 51), 26 episodes and 241 illness days in the exercise group (n = 47), and 40 episodes and 453 days in the control group (n = 51). Mean global severity was 144 for meditation, 248 for exercise, and 358 for control. Compared with control, global severity was significantly lower for meditation (P = .004). Both global severity and total days of illness (duration) trended toward being lower for the exercise group (P=.16 and P=.032, respectively), as did illness duration for the meditation group (P=.034). Adjusting for covariates using zero-inflated multivariate regression models gave similar results. There were 67 ARI-related days of-work missed in the control group, 32 in the exercise group (P = .041), and 16 in the meditation group (P <.001). Health care visits did not differ significantly. Viruses were identified in 54% of samples from meditation, 42% from exercise, and 54% from control groups. Neutrophil count and interleukin-8 levels were similar among intervention groups. CONCLUSIONS Training in meditation or exercise may be effective in reducing ARI illness burden.

Behavioral and Complementary Approaches for the Treatment of Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is one of the most common conditions seen in primary care settings. Despite this, there is no consensus as to the pathogenesis of this disorder or a consistently effective therapeutic regimen for many patients. This has encouraged the use of various alternative therapies from behavioral or complementary medicine. This review will address the evidence for alternative therapies, including the following: cognitive behavior therapy, hypnosis, elimination diets based on food antibody testing, nutrition supplements (such as fiber, probiotics, and prebiotics), and, finally, peppermint, l-glutamine, zinc, and cromolyn sodium. The review also explores the evidence for and the therapeutic ramifications of the hypothesis that increased intestinal permeability underlies the symptoms of IBS in many patients, and how a therapeutic plan that addresses nutrition, elimination diets, and nutrition supplements may be useful in restoring the integrity of the gut immune barrier.

Inflammation: nutritional, botanical, and mind-body influences.

Chronic inflammation is becoming an important risk factor to identify in regard to inhibiting disease onset and its progression. Nutritional science attempted to improve health by manipulating fats so that we could consume “healthy” nonsaturated fats while simultaneously allowing foods to have a longer shelf-life. However, despite our good intentions, trans-fats and partially hydrogenated oils have been found to promote inflammation and adversely affect health. This article reviews how essential fatty acids, the ratio of omega-3 to omega-6 fatty acids, glycemic load, the Mediterranean diet, specific foods and botanicals, and the mind-body relation influence the inflammatory cascade.

Healing the healer: A tool to encourage student reflection towards health

Background: Research has demonstrated that students’ health falters while in medical school with healthy behaviors continuing to deteriorate during residency. Medical education can be focused toward helping students find health for themselves. Physicians who are most likely to practice healthy lifestyles are more likely to encourage their patients to do so. Aims: Create a tool that encourages self-reflection, education and self-care for physicians-in-training. Method: Users completed a web-based tool that helped them create a personal health plan focusing on the themes of nutrition, lifestyle choices, family history, mind-body influences and spiritual connection. A six-question survey was completed by 500 users. Results: The results support the main objectives of the tool, which were to encourage self-reflection, positive lifestyle habits and education towards key aspects of health and well-being. Conclusion: Having medical students and residents develop their own health plans can be an efficient method towards encouraging self-care, understanding foundational health concepts and instilling skills to teach health promotion to their patients.

Value associated with mindfulness meditation and moderate exercise intervention in acute respiratory infection: The MEPARI Study

BACKGROUND AND OBJECTIVES Acute respiratory infection (ARI) is among the most common, debilitating and expensive human illnesses. The purpose of this study was to assess ARI-related costs and determine if mindfulness meditation or exercise can add value. METHODS One hundred and fifty-four adults ≥50 years from Madison, WI for the 2009-10 cold/flu season were randomized to (i) wait-list control (ii) meditation or (iii) moderate intensity exercise. ARI-related costs were assessed through self-reported medication use, number of missed work days and medical visits. Costs per subject were based on cost of generic medications, missed work days (

CAM Education: Promoting a Salutogenic Focus in Health Care

126.20) and clinic visits (

The Salutogenesis-Oriented Session: Creating Space and Time for Healing in Primary Care

78.70). Monte Carlo bootstrap methods evaluated reduced costs of ARI episodes. RESULTS The total cost per subject for the control group was