Cover Story
From the Margins to the Mainstream
By Howard Bell
Complementary therapies are being integrated into large medical centers as physicians see their benefits.
Cardiac surgeons at Mayo Clinic were looking for ways to help bypass patients heal quickly and feel comfortable. So they decided to do a small experiment: They gave 30 patients massages on the second and fourth day following surgery. They had another 30 listen to a massage therapist talk about the benefits of massage. Those who received massages in the 2005 study had statistically significant reductions in pain and anxiety, maintained healthier heart rates and blood pressures, and required less narcotic pain relief than those who did not. Intrigued by these results, they did a second study two years later of 220 bypass patients and got the same results. Today, all cardiac surgery patients at Mayo get postoperative massages and listen to Mannheim Steamroller recordings, the combination of which lowers heart rates and blood pressure and reduces the need for pain
medication.
Complementary therapies such as massage and music therapy used to lurk on medicine’s margins. Now Mayo Clinic and nearly all of Minnesota’s major medical centers are incorporating them into everyday patient care. Increasingly, the line is blurring between what is “conventional” and what is “complementary” in an approach to practice called integrative medicine.
Integrative medicine combines low-tech, low-cost therapies such as acupuncture and acupressure, massage, yoga, meditation, guided imagery, aromatherapy, and energy therapies with conventional treatments. It also takes into consideration the patient’s social and spiritual connections, diet, and activity level. The idea is that none of these therapies is alternative when used with, rather than in place of, conventional medicine and that practitioners ought to use whatever combination of treatments works best for a particular patient.
Patients have embraced these therapies for a number of years, even though insurers still don’t pay for most of them. Thirty-eight percent of all adults in the United States currently use one or more complementary therapies, according to a recent survey by the National Center for Complementary and Alternative Medicine, part of the National Institutes of Health. To an extent, integrative medicine is an effort to catch up with consumer demand. But there’s more to it than that. Mainstream medicine is adopting these therapies not just because people want them but because they work. A growing stack of studies, many authored by researchers in Minnesota, shows that when properly combined with conventional medicine, complementary therapies can alleviate symptoms, enable patients to recover from procedures faster, and help those diagnosed with a chronic illness live healthier lives (see “Building the Evidence Base,” p. 28). Says Gregory Plotnikoff, M.D., M.T.S., medical director for Abbott Northwestern Hospital’s Penny George Institute for Health and Healing, “Integrative medicine is catching on because it’s hard to refute solid data.”
Established Programs
Patient demand, however, prompted Hennepin Faculty Associates (HFA) to begin offering complementary therapies 23 years ago. In 1993, HFA formally established its alternative medicine clinic—one of the nation’s first. That clinic became the first alternative medicine clinic to become JCAHO-accredited and one of the first to be designated a Center of Complementary and Alternative Medicine Excellence by the NIH.
The Hennepin clinic, which has grown from its simple beginnings as an acupuncture clinic, now also offers functional medicine, an integrative pain and rehabilitation program, massage, meditation, holistic physical therapy, chiropractic care, and Chinese herbal medicine. Pat Culliton, a licensed acupuncturist and clinic founder and director, has given lectures on integrating complementary therapies and consulted with staff at nearly every Minnesota medical center that now has an integrative medicine program. The clinic logs, on average, 1,200 patient visits each month. “In the early days, nearly every patient was a self-referred treatment failure who’d tried conventional therapies that didn’t work,” Culliton says. Now half of its patients are physician-referred. “The fact that we don’t need referrals for what we do but are getting them anyway shows how much physicians accept what we do,” she says.
The process of making complementary therapies part of everyday patient care is what integrative medicine is all about. “We’re not talking about spa treatments or add-ons,” Plotnikoff says. “The size of the health care pie stays the same. Instead, we’re redirecting resources—using nonpharmaceutical approaches that have therapeutic value and produce the best outcomes most cost effectively.”
Abbott Northwestern has become another national leader in integrative medicine. It now has the largest hospital-based integrative medicine program in the United States, with its inpatient integrative medicine teams averaging more than 90 visits per day. The program just celebrated its 50,000th inpatient visit, which makes the service at least 50 times larger than the next largest integrative medicine inpatient program in the United States, according to Plotnikoff, who is trained in internal medicine, pediatrics, medical acupuncture, mind/body techniques, herbal medicine, and theology.
Abbott employs 22 integrative medicine practitioners who work in six teams. Each team includes a registered nurse, massage therapist, and acupuncturist (a reflexologist and music therapist are available as needed). And each team has a specialty: cardiovascular medicine, rehabilitation/neurology, orthopedics/spine, medical/surgical, oncology, and women’s health. Admitting physicians can request a consult for any patient they think might benefit, and the team determines which therapies will be provided.
For example, a physical medicine and rehabilitation physician at Abbott recently requested an inpatient consult for a teenager who had had a spinal cord tumor. The tumor had been surgically removed, but the boy still had some loss of motor and sensory capacity in both legs. The boy was emotionally agitated, “bouncing off the walls,” says Plotnikoff, so much so that he was unable to do the physical therapy he needed to recover. “You ask yourself, what can you do medically at this point? Call in a psychiatrist? Prescribe Valium? Persuade? Coerce?”
Building the Evidence Base
Money is scarce for integrative medicine research. But Minnesota medical centers have cobbled together a patchwork of internal funds, philanthropic donations, and federal dollars to pay for integrative medicine studies.
Collaboration among major medical centers is one reason why Minnesota is a national leader in integrative medicine research, according to Brent Bauer, M.D., director of Mayo Clinic’s complementary and integrative medicine program. “It’s been very easy for me to pick up the phone and talk with my colleagues at other institutions,” he says. “There just aren’t many places in the country where competing institutions collaborate like we do in Minnesota.”
Bauer says having a research component is critical for building credibility and getting physician buy-in. Minnesota’s largest integrative medicine programs all have research directors who oversee their studies, which generally have three goals, according to Jeffery Dusek, Ph.D., director of Abbott Northwestern Hospital’s Integrative Health Research Center: To demonstrate that a treatment is therapeutically effective and why, show that it’s cost-effective, and identify protocols that illustrate which combinations of therapies can benefit certain patients.
The idea, according to Dusek, is to build a portfolio of techniques and therapies that are equally effective so that patients have a choice of what to try. For example, someone who doesn’t like meditation might like tai chi or acupuncture.
Integrative medicine study designs include clinical trials, cost analyses, patient satisfaction surveys, and basic research on how complementary therapies affect the human body. The following are highlights of some of the research being done in Minnesota.
- At Abbott Northwestern, Dusek and his colleagues are studying how relaxation response/meditation training reduces blood pressure. The hypothesis is that the training increases nitric oxide levels in the blood, which in turn lowers blood pressure and keeps blood vessels flexible (p. 47). So far, they have found that older patients with elevated systolic pressures who completed eight weeks of relaxation response/meditation training lowered their systolic pressure by an average of 8 mm Hg. In some cases, patients were able to stop taking one hypertension medication.
- At the University of Minnesota’s Center for Spirituality and Healing, an NIH-designated development center for complementary medicine research, a recently completed pilot study by a School of Nursing faculty member found that patient-selected music reduces anxiety and increases comfort for ICU patients on mechanical ventilators. University researchers are also studying the effect stress has on the length of telomeres, the ends of chromosomes that control longevity, and whether a mushroom extract might shrink breast cancer tumors and reduce fatigue. Among its other projects is an ongoing five-year study of how meditation and yoga can reduce depression, anxiety, and sleeplessness in organ transplant patients.
- Researchers at Hennepin Faculty Associates’ Alternative Medicine Clinic have done clinical outcome studies that show acupuncture significantly reduced pain in patients with a variety of conditions and is effective in treating addictions.
- Woodwinds Health Campus in Woodbury uses clinical trial results to develop protocols for acupuncture. Researchers are currently analyzing the effect acupuncture has on perception of pain in orthopedic surgery patients. Woodwinds also maintains a healing arts registry of outcomes, one of only a few such registries in the country, which is used to determine what combination of therapies works best for which patients.
- Children’s Hospital and Clinics just hired a full-time integrative medicine research coordinator and is seeking funding to become the first national Center for Integrative Pediatrics. Among studies completed so far, three have found that a variety of integrative therapies control pain, nausea, and anxiety in young hospital and day-surgery patients, potentially reducing the need for prescription medications.
- Mayo Clinic has completed 28 randomized controlled trials and is in the process of doing 58 more studies on complementary therapies ranging from herbal remedies to music, massage, and meditation. Among their findings: ginseng significantly reduced fatigue in 200 chemotherapy patients and acupuncture reduces fibromyalgia symptoms. Mayo is also doing a larger study to determine if massage reduces postsurgical narcotics use and shortens the length of hospitalization.
Another goal of this and all the studies taking place in Minnesota is to find out whether integrative medicine reduces health care costs. “That’s the holy grail,” says Bauer. “Small pilot studies suggest it can.”—H.B.
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Instead, Plotnikoff says, the integrative medicine consult team provided acupuncture, massage, and aromatherapy, which, according to Plotnikoff lowered the boy’s stress level and decreased his agitation to the point where he was able to take part in physical therapy. “This wasn’t alternative or complementary,” Plotnikoff says. “It was integrative care—the best from all healing traditions blended together.”
Abbott is formalizing some of its protocols for integrative therapies. So far, it has developed an eight-week program for patients with depression who are not adequately helped by antidepressants called resilience training. The approach includes meetings with a holistic psychiatrist, a nutritionist, and an exercise physiologist (see p. 12). Plotnikoff says 65 percent of patients who have taken part in the program have achieved remission of their clinical depression.
Abbott is also identifying integrative best practices for reducing pain and anxiety. A study of more than 34,000 inpatient visits found that integrative therapies lowered pain and anxiety symptom scores by at least 50 percent in two-thirds of patients, according to Jeffery Dusek, Ph.D., Abbott’s director of integrative medicine research. “In one-third of patients, we reduced their pain to zero,” he says, adding that a mix of therapies was customized for each patient. “What we’re seeing here is the power of the mind-body connection.”
Physicians at Abbott are also using integrative medicine for treating patients who have unexplained symptoms or whose symptoms don’t add up to a clear-cut diagnosis. Such patients receive an intensive 60- to 120-minute physician assessment. “Time, compassion, and intellectual curiosity are powerful tools for tough diagnoses,” Plotnikoff says.
Like a regular medical assessment, integrative assessments include a physical exam and laboratory tests. But the visits are longer because the physician will explore the patient’s complete mental, physical, and spiritual health; consider nonpharmaceutical options for treatment; and coach patients on how they can care for themselves. One patient seen at the clinic was a woman who had suffered for years with chronic, unexplained, severe pain whose symptoms were getting worse. She didn’t want to take narcotics, so her physician requested an integrative medicine consult. According to Plotnikoff, they came up with an intervention that included nutrition, acupuncture, biofeedback, exercise, and learning mind-body skills.
Abbott has made a concerted effort to inform its physicians and nurses about the efficacy of integrative medicine. Lori Knutson, R.N., who started the Institute for Health and Healing in 2002 and is now its executive director, says she’s observed a significant change in attitude toward integrative medicine among Abbott Northwestern physicians and nurses in recent years. “They’re not as skeptical,” she says. “They’re seeing it works.” Initially, just four physicians referred patients to Abbott’s inpatient integrative medicine service. Now more than 400 do so. In addition, Knutson says, more than 100 Abbott nurses voluntarily completed training required for board eligibility in holistic nursing. “This,” she says, “is a sea change.”
That change in attitude is occurring across the entire Allina system. According to a recent survey of more than 2,000 administrative and medical leaders by Paul Goering, M.D., Allina’s director of mental health, most respondents believe integrative medicine enhances care and outcomes. Key medical leaders at Allina have strongly advocated for integrative approaches to care, according to Plotnikoff.
Building Credibility
Integrative medicine is beginning to shape institutional behavior and culture at Mayo Clinic as well, according to Brent Bauer, M.D., director of Mayo’s complementary and integrative medicine program in Rochester. An internist for 20 years, Bauer got interested in complementary treatments when he saw many of his patients at Mayo Clinic-Scottsdale using them.
His efforts to build an integrative medicine program in Rochester in the late 1990s started small. “It was just me,” Bauer says. He spent time studying on this own and making connections with colleagues who had an interest in complementary therapies, submitting review papers, and talking up ideas. His efforts were met with surprisingly little skepticism.
In 2001, Bauer officially started Mayo’s integrative medicine program. He says a key to gaining acceptance has been gathering outcomes data from small pilot studies. “We’ve attached outcomes to everything, so we can know whether it comes out good, bad, or indifferent,” Bauer says. “This is how we build credibility. All pilot studies are small and time-limited, requiring no on-going commitment.” Currently, Bauer is collaborating on more than 20 integrative medicine studies at Mayo. The research is diverse, ranging from a study of acupuncture for postoperative nausea to qigong for arthritis pain.
Since 2004, Mayo physicians have been able to refer patients for consults in the Integrative Medicine Clinic, which is part of the department of medicine. Five internists who have completed integrative medicine fellowships oversee those consults. “We’ve seen phenomenal growth of 30 percent each year,” says Bauer, adding that all patients need a physician referral to receive a consult.
Many patients seen in the clinic have cancer or another chronic condition. Meditation, acupuncture, massage, yoga, biofeedback, and guided imagery are used to relieve their nausea, pain, poor sleep, anxiety, or depression. “We’ve learned how powerfully beneficial meditation is for our patients and our employees,” says Bauer. “It lowers stress levels and blood pressure, and improves sleep and overall quality of life—without risk.”
Complementary therapies have proven so beneficial in Mayo’s department of surgery, they’ve hired their own full-time integrative therapies specialist, Sue Cutshall, R.N. Her job is to take the therapies that worked well in cardiac surgery and incorporate them in other areas as well. In order to do that, she monitors and helps design studies, collects the data, and uses the information to create integrative protocols.
So far, Mayo has used integrative protocols in oncology, cardiology, surgery, and pediatrics. The department of surgery has even hired its own full-time massage therapist. “We are truly integrating complementary therapies throughout the clinic,” Bauer says. “It’s a gradual process that will grow because it works, but it’s not forced on anyone.”
A Different Model
Complementary therapies have been part of patient care at Health East’s Woodwinds Health Campus since it opened in 2000. Woodwinds’ “healing arts therapies” include acupressure, acupuncture, healing music, guided imagery, use of essential oils, and energy-based healing such as healing touch, therapeutic touch, and Reiki.
Woodwinds incorporated holistic care from the beginning because focus groups of area residents made it clear they wanted a medical center that combined the best of conventional and complementary medicine. Physicians at other HealthEast facilities refer their patients to Woodwinds when those patients express an interest in integrative therapies, according to Val Lincoln, R.N., Ph.D., clinical leader for integrative services. “Because Woodwinds offers these services,” Lincoln says, “our market share has steadily increased in maternity care, the orthopedic center, the infusion center, and surgical services.”
Other HealthEast facilities have taken note. In 2002, St. Joseph’s hospital started using healing arts therapies with cardiac surgery patients and St. John’s started using them in its Cancer Care Center. At all three HealthEast hospitals, care of babies in the NICU now includes music, healing touch, and massage.
At Woodwinds, surgery patients are offered guided imagery to reduce presurgical anxiety and healing music to ease stress. Orthopedic surgery patients have a standing order for acupuncture and holistic nursing care to relieve postsurgical pain, stress, and nausea. In the infusion therapy department, chemotherapy patients are offered essential oils, acupuncture, and healing music to help them relax. Emergency physicians admitting a patient often order acupuncture to relieve pain. In addition, emergency staff started using essential oils for pain and anxiety control in select patients after noticing the success of a small study of their use in orthopedic patients. “Physician acceptance of healing arts therapies at Woodwinds has been exemplary and extraordinary,” Lincoln says. “We all share this extraordinary culture and awareness that we’re doing the right thing.”
Pediatric Benefits
Nationwide, complementary therapies have been used less with children than with adults; but at Children’s Hospitals and Clinics of Minnesota, they’ve been offered for years. Children’s has the largest and oldest (it was started in 1999) pediatric integrative medicine program in North America, according to Tim Culbert, M.D., medical director of integrative medicine. “We’ve seen a 20 to 30 percent growth in inpatients and outpatients every year since 2001,” he says.
Of the 15 pediatric integrative medicine programs in the United States, Children’s is the only one that includes research, education, and everyday use of complementary treatments throughout the hospital by a team that includes a physician, advanced practice nurse, psychologist, nutritionist, and massage therapist or physician trained in acupuncture. Parents prompted Children’s to start offering complementary treatments because they wanted nonpharmaceutical options to reduce cancer-related nausea and pain. Surveys show 84 percent of pediatric cancer patients in the United States use at least one complementary treatment to control these side effects. Children’s also uses such therapies to alleviate depression, anxiety, sleep disorders, bedwetting, and constipation—whatever their causes might be.
Culbert recalls a 17-year-old girl with depression and a sleep disorder who wasn’t getting relief from her antidepressants and at the same time was struggling with their side effects. “By getting her to exercise regularly, eat healthier, and take vitamin supplements,” he says, “we got her off most of her prescription medications and got her depression under control.”
He explains that Children’s has had success using omega-3 fatty acids to treat depression, attention problems, and inflammatory conditions such as rheumatoid arthritis. Vitamin D has also proven effective for alleviating chronic pain and boosting immune system response.
Children’s offers a free pediatric integrative medicine telephone consult service to physicians and parents in the Twin Cities, and it has a website (www.childrensintegrativemed.org) that explains complementary medicine to kids. It also is a cosponsor of Pangea, a conference about pediatric wellness. “Surveys show 80 percent of pediatricians want more CME on pediatric integrative medicine,” says Culbert, who is editing a textbook on the topic that is schedule to be published in August. “More than half of pediatricians surveyed say they’d refer patients for integrative therapies if they were available in their area.”
Transformative Model
Some say integrative medicine is just what is needed to transform health care. Mary Jo Kreitzer, Ph.D., R.N., director of the University of Minnesota’s Center for Spirituality and Healing, which focuses on research into and education about integrative medicine, agrees. “What we’ve had until now is a disease-management model that pays for coronary bypass surgery but won’t pay for the nutrition and exercise counseling that can help prevent heart disease.” Kreitzer recently testified before the U.S. Senate on integrative medicine.
She believes integrative medicine needs to be a cornerstone of national health care reform because it can lower costs and improve outcomes at the same time. Last February’s Institute of Medicine symposium on integrative medicine, the first event of its kind, attracted the largest audience ever for an IOM conference. Keynote speaker Dean Ornish, M.D., an integrative medicine pioneer, emphasized its preventive benefits, likening conventional medicine to mopping the floor after the sink overflows and integrative medicine to turning off the faucet before that happens. Ornish says that when a patient does become ill, conventional and complementary therapies used together produce better outcomes because together they have “recuperative synergy,” an effect that’s greater than what either can produce on its own.
Some are suggesting that integrative medicine change its name to integrative health because the term “health” better reflects its treat-the-whole-person, self-help, preventive emphasis. Whatever it’s called, it boils down to using whatever therapies produce the best outcomes most cost-effectively. As the line fades between complementary and conventional medicine, Mayo’s Brent Bauer hopes we’ll stop using these terms altogether and maybe settle on “JGM”—just good medicine. MM
Howard Bell is a medical writer in Onalaska, Wisconsin.