Integrative Medicine has its origins in the whole system concepts of Ayurveda and Traditional Chinese Medicine. These non-western approaches do not separate the body into parts, but rather look at the patient as an integrated whole including mind, body, spirit and community. The Arizona Center for Integrative Medicine at the University of Arizona defines Integrative Medicine as healing-oriented medicine that takes account of the whole person, including all aspects of lifestyle. It emphasizes the therapeutic relationship between practitioner and patient, is informed by evidence, and makes use of all appropriate therapies. This approach intuitively understands that humans don’t exist in a vacuum, and neither do their parts. Everything in our lives—what we think, how we feel, what we believe, our habits, our movement, our diet, our environment, our jobs, our relationships, our community, our spirituality—everything affects our health and well being. I am waiting for the day when medical culture really acknowledges this fact. It is the key to not only achieving individual wellness, but also the key to societal change in the health patterns currently taking their toll like obesity, diabetes and heart disease.
Disease has expanded my horizons.
Disease is what Medicine is all about,
Or so I thought.
Disease, or the study thereof, took a decade of my life.
Is that a disease?
Disease and its paradigm are sick--all wrong.
Wholeness is what we should be taught.
Wellness comes from wholeness.
Disease comes from fracture, separation of our parts into pieces.
The whole functions. The pieces do not.
So Disease has expanded my horizons
To see that it is not the horizon.
I'm not particularly a poet, but I wrote this poem as a reflection about the state of Medicine and healthcare in our country. It expresses my view that Integrative Medicine is the best approach to treating patients. It is time that we view patients from a wholeness perspective.
The prefix “peri” means “around”. “Meno” has to do with menses. Pause is obvious. So by definition, perimenopause means around menopause or around the time periods stop. Now, maybe we should also get this word menopause straight. Women talk about going through menopause. Well, you don’t exactly go through it; you go into it—and stay there for the rest of your life. Menopause is the time of life when your periods have stopped. The term postmenopausal is sort of a misnomer because you don’t really ever leave menopause once you are there. Menopause happens because the ovaries’ egg supply dwindles to nothing and the majority of estrogen production ceases. Once you hit this point, you obviously stay there until you die. So what’s perimenopause? This is the time of life as you approach menopause. It is a time of hormonal fits and spurts. Basically it is like when your car’s gas tank is running out of gas. Your car starts to lose power and cough until it just quits. Now you know how one car’s gas gauge seems to sit on empty forever, and you can eek out many more miles, maybe stopping and starting? And another car’s gauge reaches empty, and that’s it—you’re done, and the car stops? Women are like that too. Some women hang out on the perimenopause rollercoaster for a decade with all kinds of annoying hormonal and emotional ups and downs. Other women hit 52, miss a period, and they’re done. Most women are somewhere in between. So what’s to be done about all of this? Well, first you should know that it is normal. Yes, let me repeat that loudly—NORMAL. Society at large and the medical establishment in particular might have you believe that this is not the case. Often patients are told that this time of life is something to dread and basically the beginning of the end. Well, I refuse to see it this way. Life is a progression of transitions from birth to death. This is one of them. That doesn’t mean it’s all kittens and daisies. Change is difficult, and it can be really hard for some women. There are things to be done to smooth the transition if needed. But the first order of business is to understand that this is supposed to happen and is normal. In my mind, a lot of our feelings about all of this find their origin in our fear of aging. Our society doesn’t look kindly upon the aging process. I desperately wish this was not the case, especially as I am fifty now, but I probably won’t change our societal/cultural perceptions. We can, however, change our individual perceptions.
So take a deep breath. Yes, you are getting older. It is the natural way of things. I’m planning to do it as gracefully as possible.
What is wellness? This sounds like a pretty straightforward question. Wellness is the absence of disease. Right? In our traditional Western medical model, this would be the correct answer. Wellness has become a buzzword lately utilized by hospitals, insurance companies, corporations, and doctors to advertise and promote their particular enterprises. Buzzwords tend to lose a lot of their meaning due to overexposure. Think about “simplify” or “holistic,” both of which have also been diluted.
So what really is wellness? I see wellness as complex and multi-faceted. It involves actively seeking health, but not necessarily the achievement of total health. Who among us over fifty has perfect health? What exactly is perfect health? Can you have wellness and disease concurrently? Perhaps a better way to approach this would be to define wellness as wholeness. This is another one of my favorite words. It oozes depth and complexity, and we humans are deep and complex. Wholeness implies a completeness of mind and body as each of us exists now. It doesn’t matter if you have one leg or one kidney; you are a complete human being. Wholeness implies doing the best with what you have no matter what deficits are present. Each of us is a whole human being despite our deficits.
Seize this concept, and it will be an epiphany. Our society is constantly telling us through media of all types that each of us is incomplete in some way. We would be whole if only we wore the right clothes, took the right trips or owned the right car. Each of us is whole right now, as is. The “mind-body-spirit” that is each person is unique and whole at this moment. This is a difficult idea to grasp, as it seems to imply that no change is necessary. So what if you are 100 pounds overweight or never exercise. This is not the epiphany I’m going for at all! What I am saying is that in this moment you are whole the way you are. . . . and in this moment. . . .and in this moment. . . . .and so on. It is a matter of acceptance of the present in the midst of change, wholeness in the presence of imperfection. This is not the same as resignation, which implies no care to change. The more we are able to accept our present wholeness as is, the more we will see the way toward positive change.
Integrative Medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing. (Definition by the Consortium of Academic Health Centers for Integrative Medicine.)
These may sound to some like lofty goals. Others would insist that we already do this in the practice of medicine. I think the answer is somewhere in between. Over the last 50 years things have changed dramatically in medical practice. When my parents went to the doctor, it was a direct doctor-patient relationship where the doctor knew all about you and your family—where you worked, what religion you practiced, whether you had financial problems and whether your children were troublemakers in school. The doctor knew what stresses existed in your life because he/she really knew you as a person. This type of intimacy may be a thing of the past, but there is a way to reinstate even a small part of this again.
The goal of Integrative Medicine is to return to the basics of viewing the patient as a whole person. The patient is not their disease in isolation of other important factors in their life such as family, community, spirituality, and lifestyle. Most doctors enter medicine for all the right reasons; they truly care for their patients. Somewhere along the path, though, reality sets in when you realize medicine is run like a business, and businesses are about money. Insurance companies, pharmaceutical companies and government all have a hand in squeezing doctors to the point that the average face-to-face time of a visit with your physician now lasts seven minutes. This is enough time for a brief exam and to order tests, but not to get to really know your patient. I won’t discuss the sad cascade of how medicine has come to this point, but doctors and patients are both frustrated. There has to be a better way that is smart and cost-effective.
Integrative Medicine is the answer. It seeks a paradigm shift in medicine where patients are not just their diagnosis, and wellness is the goal. Wellness is not defined as just the absence of disease, but as general well-being and progress toward positive lifestyle changes even in the presence of disease. Approaches include such therapeutic modalities as nutritional counseling, botanical medicine, meditation, yoga, energy medicine, acupuncture, and massage. St. Charles Medical Center is dipping its toes into the world of Integrative Medicine at the Cancer Center, which offers traditional treatment with surgery, radiation and chemotherapy as well as acupuncture and reiki. Evidence-based studies show that alternative approaches such as these help cancer patients with the symptoms of their disease as well as the side effects of treatment.
Integrative Medicine may not be as glamorous as new drugs or new technologies, but it costs less and returns physicians to the root reasons they enter medicine—to care for the whole patient including mind, body and spirit. Integrative Medicine is not alternative medicine. It is merely open to all evidence-based treatment that may help the patient to achieve wellness. Integrative Medicine is really just good medicine. Someday we will call it just that.
This was written by me for The Bend Bulletin's "In My View" column and published today, August 15, 2013.
Are you hypothyroid? I am. I was reading a book recently that literally called women to action to spread the word about hypothyroidism. Do you have any idea how common this is--especially in women? My opinion is that it is extremely under-diagnosed. The symptoms include weight gain, low heart rate, cold intolerance, cold hands and feet, mood problems, fatigue, brain fog, hair loss coarse hair, depression, abnormal periods, puffy face, and dry skin. What woman hasn't complained to her doctor about at least one or two of these?
Doctors are taught very little about hypothyroidism, its causes, treatment and lab tests in medical school. Basically we are taught to screen patients with a TSH if they have symptoms or are a certain age. If the TSH is 0.3 to 5.0, it is considered normal, and the patient cannot have a thyroid problem. If it is 5 to 10, the patient has subclinical hypothyroidism, and is not treated. If the TSH is 10 or above, the patient has hypothyroidism and is placed on Synthroid thyroid replacement. These lab values are printed on every lab printout for TSH results that I get. They are inaccurate and erroneous. In 2002, the American Association for Clinical Chemistry recommended changing the upper limit for TSH to 2.5; in 2003, the American Association for Clinical Endocrinologists recommended an upper limit of 3.0 mIU/L. I can bet your doctor doesn't now this. I didn't know this until a few years ago when I started having thyroid problems. I trusted the lab to tell me the normal range. Big mistake.
I realized at that time that most doctors don't have a clue about the nuances of hypothyroidism. We are taught in med school that it is very cut and dry. Treat for a TSH above 10. Treat with Synthroid (yes, specifically that brand of levothyroxine). At a TSH of 5 to 10, the disease is subclinical and should not be treated until it rises to 10. This makes no sense. The problem is that many patients have symptoms when their TSH is below 10 or even below 5. Subclinical is defined as "no symptoms." How can we call it subclinical when there are symptoms and we are basing the definition solely on a lab result? Again, this makes no sense.
I speak from personal as well as professional experience. I started having symptoms of a pounding heart, possibly palpitations, a few years ago. My TSH was 9.5. I was told this was subclinical hypothyroidism based on the TSH even though I was having symptoms and my pulse was low at 57. No, I am not an elite athlete with a remarkably low pulse. I was hypothyroid but told I didn't need thyroid replacement until my TSH was 10. So I guess I had "symptomatic subclinical hypothyroidism." I wanted to take Armour thyroid rather than Synthroid. Basically I organized my own regimen and then switched to a more integrative doctor.
The most common reason for hypothyroidism in women is Hashimoto's thyroiditis. This is an autoimmune disease where your body produces antibodies which attack and damage your own thyroid gland. This is what I have. I was told my antibody status was not important to know. Well, it is important. Wouldn't you want to know if you have an autoimmune disease rather than just ignore it? Most doctors don't know that it predisposes you to other autoimmune problems, especially Celiac Disease (gluten intolerance). This is important information as it can help you make changes in lifestyle, diet and supplements that may impact your disease. Knowledge is power.
I am now on a mission to help women (and their thyroids) be understood. If 24% of women 42 yo and older are on thyroid replacement, this is not a small problem. Hypothyroidism is under-diagnosed and ignored largely because it is a female problem. I can't help but think there is some latent bias at work here. Many of the symptoms are common female complaints often classified as whiny or hypochondriacal or normal aging. This is unfair. Often these symptoms are easily dismissed because they are common and vague. If you or a friend or loved one is experiencing these symptoms, get checked. Ask to see your numbers. If you are ignored, go elsewhere.
FYI: Mary Shomon, who is an advocate for hypothyroidism, has some excellent books about all this. Check them out.
I had an interesting conversation with a savvy patient the other day. She has experience in the healthcare industry, and we were having a lively discussion about the present state of American healthcare especially in light of the coming changes. We were discussing Western vs. Eastern models of health. In the West, we follow a Cartesian model which is disease oriented. In medical school we teach students to diagnose and treat these diseases. The orientation is largely aimed at identifying what is broken and what can be fixed. Eastern models take a holistic whole systems approach which tends to view the person as generally well; there is more right with the person's system than wrong. Our Western disease-laden approach creates dis-ease. Western doctors tend to see patients as their diagnoses. We are uncomfortable looking truly at the whole person. We are taught this from the start; as a student you are told,"Go check the labs on the post-op appy in room 205." (Appy is short for appendectomy.) You are your disease and/or your procedure. This extends all the way through to the insurance industry, which requires a diagnostic code and procedural code for billing and reimbursement. No, "worried well" (an actual code) will not get your doctor reimbursed, and you will likely get the bill for that visit. Does this make sense? Not to me. It's a big part of why I'm doing what I'm doing.
Anyway, back to my smart patient. She had an interesting take on one reason why modern Western healthcare keeps going down this path despite it being obvious that it doesn't work and will bankrupt us. Cancer. The Big C. We are all afraid of this, including doctors. Cancer is very real and no one wants to have it. She feels that one reason we are still running down the disease/dis-ease path is that we are all scared of cancer and need to keep spending more and more to test for it, treat it and cure it. Preventing it is not as sexy unless it involves a screening test like a PSA or colonoscopy. Now I'm not saying that screening tests have no value. On the contrary, they save many lives. But the crux of our healthcare situation is that we segment people up into their parts and the disease risk to those parts. We don't look at the whole being and try to prevent the problem adequately in the first place. I could just as well substitute obesity for cancer and discuss all the ways we could prevent this problem and all it's subsequent disease processes and diagnoses.
So now you can see why I put the word "whole" in my practice name. Wholeness is the thing we humans seek, need, crave. We are not the sum of our parts. We are not a list of diagnoses. We are whole beings from the time we are born until we die, and we should be treated that way.
My office is open. I love the ambience of it; I hope my patients do too.
I've been thinking a lot about mindfulness lately as I work on materials for patients. Meditation is something I wish I had discovered earlier in life. I think it should be taught in medical school to all aspiring doctors. Not only would it help medical students with the day to day stress, but it would help them to learn empathy for their patients by learning empathy for themselves.
I went to medical school in the eighties. Nobody talked about complementary and alternative approaches to healthcare or mind-body medicine. It wasn’t that we students thought it was weird; it wasn’t even on our collective radar screen. I know it was out there even then. Andrew Weil was busy in his movement toward integrative medicine, and Jon Kabat-Zinn was pioneering his Mindfulness-Based Stress Reduction program at the University of Massachusetts. I had only fleeting awareness of these activities peripheral to the traditional medicine taught in medical school. I attended medical school in Kansas, which was not exactly a hotbed of creativity in the alternative medicine world.
Medical school was just as grueling in Kansas as it was anywhere else. Medical education then, as now, was fraught with stress and sleeplessness. Little exercise and poor diet were ways of life. Many of us accumulated debt exceeding six figures, and this has only worsened through the years. One of the cardinal lessons when entering medical school is that you may think you are the cream of the crop on acceptance, but once you get there you are one of many bright folks. Needless to say it is hard on the ego. When we add together all of these factors we have a major problem with how to cope with all of these difficulties. Medical school is not particularly known for teaching students how to deal with personal issues. The end result is that we graduate doctors who are on their way to burnout, cynicism and depleted empathy. Unfortunately this is before residency takes its enormous toll.
The question then is how do we teach medical students (and doctors) to deal with all this stress? How do we do it in an efficient and cost-effective manner? In one word--meditation. Obviously meditation has been around for thousands of years. All great religious traditions practice meditation in some form although it is most often associated with Buddhism. I am not advocating that students partake in a religious exercise. The practice of meditation is largely the practice of mindfulness.
Mindfulness is what we need from our doctors. Mindfulness is what we need in society at large. Mindfulness allows us pause and assess as well as to remain engaged. It allows us to maintain compassion and equanimity, joy and love for our patients.
Dr. Heather's musings about medicine, mindfulness and life.
Heather Krantz, M.D.
Mailing Address: P.O. Box 6913 Office Address: 1012 SW Emkay Drive
Bend, OR 97708 Bend, OR 97702
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