by Lauray MacElhern
The U.S. medical system, although referred to as “health care” is largely one of disease care, a status quo that threatens our country’s economic and societal well-being. An inside-out transformation of this system, that teaches and encourages prevention and wellness, not just disease management, is desperately needed. According to the latest World Health Organization data1, the United States ranks 46 out of 48 countries in terms of “health care efficiency” – a calculation derived from life expectancy and health care cost per capita. We spend 18 percent of GDP per capita on health care – the highest percentage of any nation. In fact, 20 percent of all U.S. government spending goes to health care – more than double the total amount of any other country. Despite this enormous cost, our health outcomes are among the poorest. In 2013, the National Institutes of Health (NIH) ranked the U.S. as having the lowest life expectancy of the 17 highest-income countries. We are the most obese nation of any Organization for Economic Co-operation and Development (OECD)2country3, and tied with France as the most depressed population in the world.4 We seem to be sick on so many levels-mind, body and spirit-and this sickness takes a devastating toll on our health, our society, and our economy. The issues are complex and systemic. Yet, an emerging field called integrative medicine is offering hopeful, multifaceted solutions to the health care crisis and it just may actually work to save our system in time. More than 60 of our top-ranked Academic Health Centers (AHCs)5 and health systems in North America, including UC San Diego, have opened doors and minds to this new paradigm, with promising results.
Integrative medicine is a growing trend that has the potential to become the new gold standard that will define the “medicine” of the future. There are approximately 60 AHCs across the country that have created a Center for Integrative Medicine within their institutions and have become members of an organization called the Consortium of Academic Health Centers for Integrative Medicine. Members include many of the nation’s oldest and most prestigious universities, the Ivy Leagues, and all the University of California AHCs. These AHCs are harnessing the tenets of integrative medicine throughout clinical care, education, research and in the community, as a way to enact system-wide change at their institutions.
Integrative medicine is about integrating the best of ancient wisdom and modern science to create a system that supports the health, wellbeing and resilience of the whole person – mind, body and spirit. The term “integrative medicine” evolved from prior terminology such as holistic health, or Complementary and Alternative Medicine (CAM). Studies show that nearly 40 percent of American adults use some form of CAM.6 In addition, it was estimated the U.S. public spends 36 to 47 billion dollars annually on CAM therapies, with approximately 12 to 20 billion dollars of that total spent out-ofpocket for professional CAM services. This is more than the out-ofpocket expenses for all hospitalizations in a year, and about half that incurred for all out-of-pocket physician services.7 The difference between CAM and integrative medicine is that CAM exists in theory outside of allopathic medicine, as a complement, or an alternative. Integrative medicine incorporates evidence-based modalities, such as acupuncture or nutritional healing, into allopathic settings so that patients can have the best of all worlds at the same time. Yet integrative medicine is not just about adding new modalities, or having a bigger and better medical toolkit. Integrative medicine is a new philosophy of care that empowers the whole person to actively participate in their own care, by adopting natural, healthy practices that cater to each individual lifestyle. It’s about supporting the body’s innate wisdom to heal. Eating right, exercising, getting sleep and reducing stress are low-cost interventions, but they are unfortunately not well-supported in our fast-paced American society or health care system. Considering all the influencers, it becomes obvious that health care transformation must occur at five different levels: clinical care, education, research, business and community.
Clinical Care Transformation
The technological advances made in medicine over the past century are astounding. Emergency care, high tech surgeries and revolutionary drugs have helped our society solve some of the most devastating and life-threatening conditions. And yet, our high-tech health care system seems to have lost some of the more human elements that are so fundamental to good care, especially when it comes to prevention, lifestyle empowerment and natural approaches. Drugs and surgery are the revered focus of our clinical interventions. In the U.S., we spend the most of any nation per capita on pharmaceuticals.8 Perhaps low-cost, high-impact natural approaches, such as acupuncture, massage/manual therapies, nutrition, physical activity, self-care, stress-reduction and sleep, should be the first-line prescriptions for preventing and fighting disease. A 2012 survey9 reports that integrative medicine centers have been highly successful in treating some of our most common chronic ailments: allergies, chronic pain, cancer, depression/anxiety, diabetes, fibromyalgia, gastrointestinal disorders, heart disease, headache, immune disorders, obesity, stress and sleep disorders. Unfortunately, not all health care professionals are adequately trained for this task.10 Individuals and families need to be empowered with new ways to achieve their health goals and incorporate balance into their busy lifestyles. Therefore, all of the AHC Centers for Integrative Medicine in North America devote a portion of their time and resources to education-for existing health care professionals, future health care professionals and the community.
Integrative medicine requires that health professionals do their part to act as role models of the healthy behaviors that they want to see in their patients. The existing health care system – and many employee environments – can be very stressful, and take their toll on the health of their employees. Unhealthy employees are detrimental to any workplace11, and especially so in health care settings, where the negative effects can mean life or death. In fact, experts estimate between 210,000 and 440,000 patients die each year due to preventable medical errors.12 Good old-fashioned common sense tells us that it is virtually impossible to give your best in whatever you are doing if you are not feeling well, physically, mentally or emotionally.
Meditation is an ancient practice that modern science is now showing has numerous health benefits: reduced stress, anxiety, pain, and increased focus, mental health, and self-awareness.13 According to a 2007 National Health Interview Survey, at least 20 million U.S. adults use meditation for health purposes.14 At UC San Diego, medical students now learn mindfulness-based stress reduction training as part of their practice-of-medicine courses in their first and second years of medical school. UC San Diego employees, students and the community can also learn these skills through the Center for Integrative Medicine/Center for Mindfulness.
In order for ancient healing modalities, like acupuncture or meditation, to be incorporated into our health care system, the evidence base must be established. Diet and lifestyle medicine is another area integrative medicine researchers are eager to study. However, researchers consider randomized case-controlled trials (RCTs) to be the “gold standard” for research, and RCTs are not the best way to study whole systems. The reductionist philosophy seeks to isolate a single variable from its context in order to study it. However, life behaves differently when isolated out of context because life works in systems. Behavior patterns, eating patterns, sleeping patterns and all lifestyle patterns are important in integrative medicine. Even the placebo effect has a misunderstood, important role in medicine, showing how our psychology and the influence of caregivers (health care professionals, family members and friends) can be catalysts in healing.
The solution: Research that uses whole systems approaches: the whole person (body, mind, and spirit), the whole dietary pattern (not just one food or nutrient) and whole systems (environments that surround and influence individuals). To this end, many Centers for Integrative Medicine are turning their time and resources to large-scale, cost-saving, systems-based approaches that analyze patient data, or practice-based research, to evaluate the effectiveness and safety of different treatments and lifestyle behaviors. One such example is BraveNet and the PRIMIER data repository project, which focuses on uniformly collecting patient outcomes and health data across Academic Health Centers. That large dataset can then be used for quality improvement, evidence-based research and determination of “best practices” to help improve the health and wellbeing of patients. UC San Diego has just applied to participate in this large-scale practice-based research project.
Last but not least, community involvement is key to health care transformation. People spend most of their time outside of the health care system, within the community-as highly social creatures, we tend to be influenced by those around us. Studies suggest that people are more likely to stick to healthy behaviors if they develop those good habits with friends.15 Therefore, true health care must take plan on the community level and encourage group-based participation with family and friends-wherever people spend their time such as faith-based organizations, workplaces, community centers.
At UC San Diego, the Center for Integrative Medicine acts as a sort of navigator for people to find services like integrative physician consults, manual therapies, acupuncture and other evidence-based modalities at various clinical sites. It also helps clients to participate in group classes that engage the whole family like mindfulness-based stress reduction, self-compassion, mindful eating, tai chi, qi gong or natural healing and cooking. At the same time, all integrative activities are recorded and communicated across disciplines through our electronic health record, Epic. Specialized questionnaires, flowsheets, care teams and a referral system help with tracking and metrics. Education occurs through group classes for the community, continuing education events and courses for existing health professionals and major curriculum changes this past year within the medical school. One major curriculum change is a requirement for nutrition and mindfulness in the practice of medicine for all first- and second-year medical students. UC San Diego Center for Integrative Medicine also collaborates with the University of Arizona to offer an integrative residency program, in which the majority of our residents are currently enrolled. Slowly but surely, a cultural shift is occurring. Viewing our health care system from a much wider, more empowering, holistic perspective has inspired changes already that give us hope-better patient outcomes and higher satisfaction at a lower cost.
Lauray MacElhern (Rady MBA, 2016) is the Managing Director of the UC San Diego (UCSD) Center for Integrative Medicine. She is also co-founder and elected co-chair of the Business of Integrative Medicine sub-committee of the Consortium of Academic Health Centers for Integrative Medicine. Lauray earned her Bachelor’s degree majoring in communication and commerce through coursework in the Wharton School and Annenberg School of Communication at the University of Pennsylvania.
- Organization for Economic Co-operation and Development (OECD)
- Academic Health Center is defined as an institution consisting of a medical school, at least one other health professional school, and a teaching hospital or health system.
- Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. National health statistics reports; no 12. Hyattsville, MD: National Center for Health Statistics. 2008
- Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data. 2004;(343):1-19
- Health at a Glance 2013: OECD Indicators, OECD Publishing. Expenditure on pharmaceuticals per capita and as a share of GDP, 2011 (or nearest year) DOI:10.1787/health_glance-2013-graph157-en
- Kreitzer, Mary Jo, Kligler,Benjamin Kligler, William C. Meeker. HEALTH PROFESSIONS EDUCATION AND INTEGRATIVE HEALTH CARE. Commissioned for the IOM Summit on Integrative Medicine and the Health of the Public. February, 2009
- http://bishop.hul.harvard.edu/bitstream/handle/1/5345879/Workplace%20 Wellness%20Programs.pdf?sequence=1
- Journal of Patient Safety: September 2013 – Volume 9 – Issue 3 – p 122-128 doi: 10.1097/PTS.0b013e3182948a69
- The Spread of Behavior in an Online Social Network Experiment. Science 3 September 2010: Vol. 329 no. 5996 pp. 1194-1197 DOI: 10.1126/science.1185231 and Experimenting with Buddies. Science 2 December 2011: 1220-1221