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What is Integrative Medicine? Present Perspective 2020

Integrative Medicine and Health celebrates its present successes and acknowledges its on-going challenges. This article continues the blog series on What is Integrative Medicine? Past, Present, and Future Please review the first article for the definition and history of Integrative Medicine.

Current Integrative Medicine & Health in US

  • A study sample of 125 US allopathic medical schools showed 50% taught topics in Integrative/Complementary and Alternative Medicine. Osteopathic medical schools  continue to teach osteopathic manipulative treatment (OMT), a type of manual medicine. 
  • There are currently 20 active Integrative Medicine fellowships approved by the American Board of Physician Specialties. The largest fellowship, at the University of Arizona, has graduated around 1,500 fellows.
  • 64 premier US academic healthcare organizations have Integrative Medicine departments
  • Functional Medicine has emerged as a popular form of integrative medical practice, focusing on the root-cause of chronic disease through a systems approach utilizing knowledge of biochemistry, cellular biology,  nutrition, genetics, and environmental science. 
  • Lifestyle Medicine developed along a similar timeline as Integrative Medicine and focuses on treating and reversing chronic disease by promoting lifestyle change through proper diet, exercise, stress-management, healthy habits, and social support.

Integrative Medicine Successes

Integrative Medicine and Health (IM) continually evolves and encounters opportunities for growth and constant redefining of healthcare innovation. Much of its success has been in developing evidence-based research and guidelines on non-pharmacological treatments, especially lifestyle interventions overlapping Lifestyle Medicine. The principles of holistic medicine have made a resurgence for treating the mind, body, and spirit throughout the continuum of life and health in a growing number of healthcare practices. 
Lifestyle interventions, once relegated to the sidelines of medical care, are now front and center in the fight to prevent and treat chronic disease. The best evidence example is the lifestyle-based, Diabetes Prevention Program, which consistently has been proven to be superior to placebo and the medication, metformin, in the long-term prevention of Type 2 diabetes. It also has been proven to be cost-effective. In secondary prevention, there is favorable evidence of intensive lifestyle change in controlling cardiovascular disease (CVD) risk factors [1]positively altering CVD biomarkers [2], and reducing chest pain symptoms [3]There is also weaker (yet encouraging) evidence of reduction in heart attack and death [4] as well as improvement in or slowing the rate of atherosclerotic disease [5],[6]. Lifestyle intervention programs most often include dietary modification, moderate exercise, stress management classes, and group support.
Adherence to lifestyle change presents a challenge, especially when taking into account an individual’s personalized health journey and perspective. IM practices are uniquely equipped to address barriers to change through communication strategies, such as Motivational Interviewing and the inclusion of trained health coaches into the care team. Patients learn to set goals and self-manage their chronic medical conditions through the guidance of their medical provider and/or health coach. Progressive IM primary care practices focus on patient empowerment through extensive chronic disease self-management education and a team-based care model. 
A first of its kind, system-wide IM care model is currently being implemented at Veterans Affairs (VA) facilities around the country. The VA Whole Health model emphasizes IM complimentary therapies combined with conventional treatment, preventive medicine, and holistic self-care principles to addresses multiple aspects of a veteran’s life.  The Circle of Health elegantly depicts these aspects and their synergy in a veteran’s journey to creating his/her health and wellness. Complimentary therapies are offered to veterans like yoga, mindfulness, or acupuncture. Approximately 2,800 Department of Defense/Veterans Affairs providers have been trained in battlefield acupuncture, a form of auricular (ear) acupuncture, to assist in their patients’ pain management.  

Integrative Medicine Challenges

There remains much room for improvement in the actual “integration” of IM into healthcare systems and organizations. Many distinguished healthcare organizations hesitate to adopt a system-wide IM approach. A major problem stems from the continued elusiveness of what exactly IM means or encompasses. Seemingly interchangeable terms (functional, lifestyle, integrative, holistic, etc) are not easily discernible to those unfamiliar with them. The broad scope of complementary therapies and practices under IM often leads to confusion and controversy. No standardized IM practice model or validated quality control exists, and available complementary therapies vary from practice to practice. Thus, IM potentially can encompass unproven or controversial treatments that critics argue do not improve outcomes over the standard-of-care. No data yet exists on the cost-effectiveness of implementing a comprehensive IM model for an entire healthcare organization. 
Insurance reimbursement has lagged behind, even for those IM therapies with credible scientific evidence. This has resulted in IM being less feasible for inclusion into practices relying on third-party payers for primary revenue. Concierge, membership, and self-pay private practice models have emerged to address this problem. These well-intentioned revenue workarounds have garnered success in affluent practice locales but also create challenges with IM accessibility for low-income patient populations. 
IM centers and departments within academic medical institutions serve a vital role in supporting continued research, teaching, and development of best evidence IM clinical practice guidelines. Nevertheless, the departments many times are isolated from the bulk of hospital and ambulatory primary care services within an institution. IM consultation services exist to form and maintain relationships with inpatient and outpatient providers seeking advice and IM therapies for interested patients. Consultation provides a necessary bridge to the healthcare organization, relying on referral volume and a continuously visible presence outside the IM department walls. Academic IM falls short, though, when it comes to actual integration into core primary care services for the majority of the community patient population.                             
Further, the future sustainability of IM remains a lingering issue in expert circles because there is no consensus as to the specific end-goal for this healthcare movement. What should the primary focus be, and how will it be achieved? Should IM be unified with or differentiated from Functional and Lifestyle Medicine? Can IM practice be standardized to ensure consistent care outcomes? Will demonstration of cost-effectiveness be the missing piece to widespread IM implementation in our healthcare systems? 
These questions and the future of IM will be explored in future blog articles from this series. 

IM continues to evolve with new questions about the current state of it’s role in healthcare and it’s future viability. This article series will include past, present, and future perspectives on Integrative Medicine. Stayed tuned for upcoming articles in the series!
© 2020 Danielle Zelnik, MD. 

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