April/May 2000

Straight Talk

By Richard S. Materson, MD

The future is not a result of choices among alternative paths offered by the present, but a place that is created, first in the mind, next in will, then in activity. The future is not some place where we are going to, but a place we are creating. The paths are not to be discovered, but made, and the activity of making the future changes both the maker and the destination.”—John Schaar

This quote is prominently displayed on Lee Kaiser’s Integrated Medicine Virtual Institute Web site. It summarizes the mind-set of being “Kaiserized” as a fellow in the program. I had the pleasure of serving as a fellow last year and the honor of being on the faculty this year. What I learned ought to be magic to the ears of forward-thinking, creative Rehab Management readers.

In Kaiser’s future world, the great traditional wisdom from the past is integrated into today’s best scientific medicine. We no longer are simply a sickness-treating medical machine, but rather a system of prevention and healing. If disease does occur, our goal is to work toward each individual reaching his or her maximum potential. This accomplishment relies on individual uniqueness, inherited traits and talents, and understanding customs and traditions and appreciating the marvels of spirituality and ecology.

Integrated medicine’s focus is not on diagnosis alone, but on tuning into the whole person, assuring personal insight into health- and wellness-promoting behaviors and minimizing stress-induced or aggravated body ravages. It emphasizes the use of safe and effective herbals, nutraceuticals and botanicals, prudent dietary habits, elimination of substance abuse, and rational exercise. It includes modalities such as Oriental medicine, acupuncture, centering meditation, energy techniques such as yoga, tai chi, healing music, plants, and animals. In this system, the patients are fellow travelers and in charge of their own destination. Practitioners are mentors who are available to assess, coach, educate, and reason.

Finding a Balance

Is the skill of the diagnostician not necessary? Are the marvels of imaging, laboratories, genetics, medicine, and surgery ignored when needed? Not to worry, integrative medicine is not flaky. It does not eschew evidence-based medicine or the science-based wonders of the new millennium, but rather, it enriches them. The effect of the relaxation response on the immune system, the healing power of direct and intercessory prayer, the power of personal mythology are all included in the medicine bag of this system.

The naysayers may find reason to quarrel. But the many published studies in reputable journals documenting the public’s fascination with complementary and alternative medicine are not to be ignored. The growing field of neuroimmunology has embraced a new look at the biological substrate beyond the placebo effect of these substances and modalities and combinations thereof. The number of journals, including the New England Journal of Medicine, JAMA, and a host of field-initiated publications with responsible articles, increases daily. Harvard, Stanford, and other prestigious institutions now devote significant resources to these programs. The United States government has substantially increased funding for research including a center at the prestigious National Institutes of Health.

None of this is new to rehabilitation practitioners who have long championed a nonpaternalistic system and patient autonomy. We were early advocates of patient education. No rehab program can ignore proper nutrition and effective exercise, and we were the pro- genitors of interdisciplinary teams. Rehab is a natural.

Indeed, some rehabilitation programs have discovered the effectiveness of complementary medicine when added to regimens for patients with pain syndromes and chronic illnesses. Some have established wellness centers where both fitness and wellness are stressed. Attention in these centers must be paid to the four pillars of wellness—physical, social, psychological, and spiritual—in order to be effective.

Herb Benson’s remarkable work with his Mind Body Medical Institute at Harvard has proven the benefit of his programs in disorders that are caused or aggravated by stress. Real lifestyle changes are evidenced in his cardiac prevention and rehabilitation programs. Benefits extend to patients suffering from AIDS, cancer, infertility, chronic pain, asthma, and allergies.

Then there is the remarkable work of Larry Dossey. This is a bona fide medical scientist looking carefully at the benefits of direct and intercessory prayer. In a world of persons struggling for their spiritual—not necessarily religious—senses, what a powerful tool to bring to the table. No, we should not forsake our clinician’s garb for priestly vestments, but we must be willing to take a spiritual history and assess the patient’s beliefs, their importance, and the support system’s and the patient’s preferences as to how we deal with spiritual issues.

The hazards

The alternative and complementary system is not without hazards. Sadly, there are sharks in these waters as in other endeavors willing to take unfair advantage of patients. The business is mostly a cottage industry with few certifications or standards. Outcome analysis is: if cash is willingly paid by recipients and they come again, that is good outcome.

Institutional bureaucracy can kill these practitioners. Yet Western evidence-based medicine requires an accepted nomenclature and standards for purity of ingredients and content of procedures and programs. We must do this without eliminating the autonomy patients find in these programs, or making them cost-prohibitive.

The variations of how to organize the relationships and integration is a beginning science. Can the programs pay for themselves or be profitable? How does one assess a community’s readiness for such programs? How are they best marketed? Should they be affiliated with hospitals, ambulatory centers, or wellness centers? Is it a cash-only business? Will the trend toward increased insurance coverage hold up?

Where to begin

In my opinion, this is a golden opportunity for the rehabilitation community. We should embrace this integration in our clinical programs. We should ally with consumers and complementary and alternative medicine practitioners and their organizations to agree on nomenclature, to understand practices and define standards, and to mutually support each other as this area develops.

Similarly, we should meet with hospital and insurance industry representatives so that all parties may contribute. We must pay attention to benchmark programs. And as Kaiser suggests, we must allow ourselves to dream a bit. We must let loose the world as we know it with its rules, formats, and regulations, and dream of the world as it should be. We then must come back to this pragmatic world and set our sights on achievable goals to help our dream become reality. Both we and the reality will change through the process. The gift is ours to grasp if we wish. We must not lose the opportunity.

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