Giving doctors another view of alternative medicine
A fellowship run by integrative medicine guru Andrew Weil, MD, is showing physicians new ways to practice
From the July/August 1998 ACP-ASIM Observer, copyright © 1998 by the American College of Physicians-American Society of Internal Medicine.
By Deborah Gesensway
Karen Koffler, ACP-ASIM Member, had worked long, hard hours as an intensivist-hospitalist in Colorado's Kaiser-Permanente system for five years when she one day realized that she couldn't keep up such a grueling pace forever.
"At 36, it was still not that hard staying up all night to take care of patients, but I knew that I would not want to be doing it at 46 or 56," Dr. Koffler said. She had seen too many patients wind up in the hospital because they had not taken care of their own health. So, to avoid becoming a patient herself, she decided to make a change.
Meanwhile, Roberta Lee, ACP-ASIM Member, found herself searching for what she used to love about practicing medicine. The multispecialty clinic in Tucson, Ariz., where she had worked as a general internist for five years had changed ownership, prompting a nasty battle over unionization. She found herself reminiscing about the four-and-a-half years she had spent after residency working for the U.S. Public Health Service on remote Micronesian atolls. "We didn't have all the science and technology there," she said, "so what I learned was basically the value of the art of medicine."
For both internists, a new fellowship in "integrative medicine" started by alternative medicine guru Andrew T. Weil, MD, at the University of Arizona, was the way to both save their health and reinvigorate their medical careers. Today, the women are two of four primary care physicians in the new two-year program, which is just finishing up its first year of classes, clinics and tutorials.
As part of the fellowship, the physicians are learning about—and using—all sorts of alternative therapies ranging from acupuncture and herbs to therapeutic touch and guided imagery. When finished, they will be able to incorporate referrals to alternative practitioners in their medical practices—or at least know how to advise against specific treatments that appear unlikely to work for certain conditions and diseases.
Perhaps just as importantly, they are learning how to live healthier, more balanced lives themselves. "One of our contentions is that physicians should model health for patients," said Dr. Weil. "I think one of the big black marks against conventional medical education is that it makes it very hard to come out with a healthy lifestyle."
She works hard all day, Dr. Lee said, but now she gets home by 5:30, a contrast from the last few years. "What is a better example for patients than seeing a physician who is well-rested and fully present, vulnerable and compassionate?" she asked. "That's the true art of medicine—focusing your attention on your patients in a partnership relationship."
For Dr. Koffler, who described herself as one of the most skeptical of the fellows, a key part of the fellowship has been the chance to try alternative treatments before she recommends them to patients in the program's integrative medicine clinic. Before moving to Arizona, Dr. Koffler had never even heard of rolfing; today she has tried the treatment herself. In the last year, she has also tried acupuncture for insomnia, osteopathic manipulation for low back pain and therapeutic touch for stress-induced irregular menstruation. "Now when I make recommendations, it's out of personal experience as well as book sense of how these things might work," she explained.
That experience is so critical because before joining the fellowship, both Drs. Lee and Koffler knew next to nothing about most of the forms of alternative therapies their patients were using. In Tucson, where Dr. Lee was working in the Thomas-Davis Clinic, patients told her about alternative therapies they were using—often instead of her recommended conventional drugs and treatments—only when she pressed them for information.
"If someone was depressed, I'd suggest Paxil and the person would take St. John's Wort," Dr. Lee explained. "And they might do some other things, like healing touch and other mind-body things, and I didn't know what those were, what to say about that, or what to do about it."
At the same time, Dr. Lee said that she was becoming increasingly aware of the side effects of the conventional therapies she used and that some procedures were unnecessary. "I was beginning to realize that, in a sense, my ignorance was medical malpractice," she said. "There are effects of combinations of conventional medicines and herbals that I should know about."
That's a feeling more physicians are likely to encounter as growing numbers of patients consider trying alternative treatments. A study published in the May 10 issue of the Journal of the American Medical Association, for instance, found that about 40% of Americans surveyed reported using some form of alternative health care during the past year, with only 4.4% of the respondents reporting that they rely primarily on alternative forms of health care.
Those numbers—and the existence of programs like Dr. Weil's—are attracting the attention of the medical establishment. Before this year's Annual Session in San Diego, for instance, ACP's Board of Governors invited Dr. Weil and well-known alternative medicine practitioner and internist Deepak Chopra, MD, to speak at its spring meeting.
William J. Hall, FACP, past Chair of the College's Board of Governors, said that the Board has been bombarded in recent years with requests from internists for more continuing education in the field of alternative medicine. "The reason why physicians are seeking information in this arena is that their patients are way ahead of them on this," he said. "It's not that we are necessarily going to embrace everything that's been said about integrative medicine, but we need a knowledge base that most of us have never received."
Dr. Weil, a Harvard-trained family physician, who is well-known for best-selling books that include "Eight Weeks to Optimum Health" and his popular Web site, Ask Dr. Weil (www.drweil.com), spoke to ACP's Governors about what he said is internists' obligation to learn more about forms of "integrative" medicine. (He eschews the more traditional terms of "alternative" and "complementary" medicine.)
Dr. Weil's fellowship program is taking conventionally trained physicians—the first group includes two internists, a family physician and an emergency medicine doctor—and giving them instruction in all sorts of subjects that are not currently taught in medical school. The idea is not to turn these doctors into alternative practitioners, but to get them to explore the strengths and weaknesses of various systems of care, to know how to make intelligent referrals to experts in different types of treatments, and to begin high-quality research into therapies that have not been tested. When they are finished, all four fellows hope to get teaching jobs at other academic centers that are interested in setting up similar integrative medicine programs.
Courses at the fellowship focus on everything from mind-body, nutritional, botanical and energy treatments to spirituality in medicine, and medicine and culture. The fellows are also learning the techniques of four commonly used alternative therapies: osteopathic manipulative treatment, medical acupuncture, guided imagery and homeopathy. In addition, they staff an integrative medicine clinic that opened within the internal medicine clinic last summer and now has a waiting list of more than 1,000 patients.
The clinic tends to attract patients who have complicated, intractable health problems such as severe rheumatoid arthritis, mood disorders and terminal cancer. Both Drs. Lee and Koffler said they would like the clinic to focus more on prevention because that's where they think integrative medicine has the most potential, but healthy patients tend not to be attracted to such a unique clinic located in an academic health center.
Dr. Hall, who is vice chair of the department of medicine at the University of Rochester in New York, admitted that while he is not a great proponent of everything Dr. Weil professes, he does admire his attempt to create an academic program in the field. "His program has to adhere to all the same standards that we all do in terms of accreditation, and what he is trying to say is we want to evaluate whether these things really work or not," Dr. Hall said. "I have trouble with saying there's something wrong with that."
For Dr. Koffler, her conviction about what she is doing was tested earlier this year, when her father visited her in Arizona and started experiencing symptoms of unstable angina. She had him admitted to the university hospital where cardiac catheterization found two significant blockages, and she immediately scheduled him for bypass surgery with the top cardio-thoracic surgeon at the hospital.
"And then it dawned on me that I'm here to learn alternative practices to common diseases, and my gut reaction had been to go right back to what I knew when I was practicing conventional medicine," she said. "So I went back to my dad and said it was up to him, but I told him that Dean Ornish has a very aggressive program that spares people from undergoing bypass surgery. I explained it to him, and he thought about it, and he decided to go for it. Well, it's five months after the date he was supposed to undergo open-heart surgery and he has lost 25 pounds, is walking three miles a day, has started playing tennis again and is totally chest-pain free."
Dr. Koffler said that she knew she couldn't guarantee her father than he wouldn't have a fatal MI in the meantime. But as her fellowship has emphasized, conventional treatments like bypass surgery can't offer any guarantees either. Either way, she said, surgery still remains an option down the road.
"When I actually applied it to the one man in my life that I cherish above all others," she said, "that's when I got what I'm doing here."
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