August 2013 Issue | Woodson Merrell, MD The Continuum Center for Health & Healing

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  • August 2013 Issue | Woodson Merrell, MD The Continuum Center for Health & Healing

 


 

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Welcome to Functional Medicine Update for August 2013. You’re in for a treat this month with our Clinician of the Month. I know I say that every month, but you haven’t been disappointed and you certainly won’t be this month either. Well as you know, historically Functional Medicine Update has breathed its life from that of its core contributors. We call them clinicians and researchers of the month, and I would say as I review the last 31 years, the individuals who have made contribution to the texture and tapestry of Functional Medicine Update have really chronicled the evolution of this emerging 21st century medical discipline, which seems to be catching and getting tracking. We recently had the 22nd International Conference for the Institute for Functional Medicine and much to our surprise—and pleasure, I would have to say—there were over 1200 practitioners there, in excess of, I think, 800 medical doctors from 30-plus countries around the world. It’s not too long ago that we were able to meet in a phone booth and still have room for other people to get in, so it’s quite amazing to watch the change, and the change is occurring on the shoulders of many pioneers who have really paved the way and helped to understand how this form of health care can actually deliver better outcome or cost-effective service levels, and one of those major contributors (for me, a great pleasure) is our Clinician of the Month, Dr. Woodson Merrell.


INTERVIEW TRANSCRIPT

Clinician of the Month

Woodson Merrell, MD
Executive Director, The Continuum Center for Health & Healing
Chair, Department of Integrative Medicine
Beth Israel Medical Center
245 Fifth Avenue
New York, NY 10016
www.healthandhealingny.org

I have had the privilege of knowing Woody now for the better part of 30 years (certainly 25-plus years). His work has just been, I think, extraordinary as a clinician, as an innovator, as a conceptualizer, and as a person who has done something that many might consider the impossible and that is to put together a commercially successful center in the heart of Manhattan in New York City, the Continuum Center for Health and Healing, which is part of the Beth Israel Medical Center Outreach Program. I’ve had the privilege of watching it evolve over the years, now expanding to a whole additional floor in the facility, over 13,000 square feet with multiple practitioners. You might say, “Well this was just plunked down into the world easily and fully formed and fully matured,” but we know that’s not the case. It came as an evolving process, going back to Dr. Merrell’s conceptualization as to what he wanted to be as a doctor.

So it’s a great pleasure to have you, Woody, as our Functional Medicine Update Clinician of the Month, professionally, personally, and vision-questing, to have your voice and your experience to be shared with our listeners. Welcome to Functional Medicine Update.

WM: Oh, it’s exciting to be on. Thanks for having me. I feel honored and I look forward to our conversation today.

JB: Maybe a great place to start is that juncture in your career, after completing your medical training. We all stand as kind of early novitiates saying, “Okay, where am I going to go? What’s my path going to be? And gee whiz, I’ve fulfilled certain hurdles of accreditation and licensure and credentialing, now where am I going to take it?” Take us back to that time and kind of help us understand your transition as you’ve moved through this process.

Looking for East Meets West, and Finding No Common Ground

WM: Mine was interesting. I actually was fortunate. I was raised very holistically. My parents were, in the era of the 50s when they’ve got the vegetable man, and the produce man, and the milkman, and the bread man coming to the home with incredibly fresh products, and a grandfather in the Sierra Club, so amazingly I was raised with homeopathy as a kid. So early on I saw the connection between a really healthy lifestyle as well as some gentle remedies that were outside the realm of conventional medicine.

In the late 60s when I was in college I actually very much was interested in the practices of yoga and meditation, even being a real science jock at the time. I actually went to medical school really not to be a physician but actually to see if I could marry what were considered at the time metaphysical practices, or the Asian disciplines, with western science. I quickly found out that there was really—at that time, in the early 70s—no east-meets-west. There were a few pioneering studies by Herb Benson on the relaxation response and that was basically it. So for the rest of medical school I pretty much poured myself into medicine and my residency, learning all I could about conventional medicine. I realized at the end of my training that I had put my original quest on hold, and when I got out into practice found that most of the information I had garnered wasn’t helpful in a general practice where you are actually seeing people who are in, what I call, the gray area—they aren’t sick, but they aren’t well, and many of them are desperately working on getting sick (kind of the “worried well”), and I needed new tools. They didn’t have these incredibly esoteric diseases that I was so well trained to treat at Columbia in my residency medicine.

Acupuncture Paved the Way to Balancing Science with Medical Training: The Research of JS Han

So I began, really, as a scientist looking for what evidence base existed at that point. It was amazing. One of my first “ah-ha” moments was I went to a lecture in New York by JS Han, who was the Chairman of the Department of Physiology at Beijing Medical School. It was founded by Rockefeller in the early 20th century, and even during the depths of the cultural revolution it was still allowed to train doctors using Harrison’s Textbook of Internal Medicine. JS Han came, and I figured out at that point that acupuncture was, you know, basically kind of metaphysical five elements, yin/yang. JS Han had done hundreds of research studies of core basic science.[1],[2],[3] He literally mapped out every neurotransmitter known to find out how it was affected by acupuncture, and this was exactly what I was looking for: the science, evidenced-based conjuncture of western and eastern so-called practices at the time. So I threw myself into acupuncture training, and realized that there were a number of other places to go for training. There weren’t very many in the 1980s, believe me. I ended up going to a small town north of Montreal to take a course on homeopathy and herbal medicine from George Lewis. Really it was a smattering of trainings that existed back in the late 80s to really help me become knowledgeable in all the different modalities that one could use as an integrative physician. By the late 1980s, I would say I was fairly well trained in most of the integrative modalities: hypnosis, biofeedback, acupuncture, homeopathy, herbs, and understanding the place of that within conventional medicine.

I have to say that it was just about that time, around 1990, when I came to my first lecture that you gave, Jeff, when you used to go around the nation doing one-day talks. That was another major “ah-ha” moment that showed me that there was an unbelievable scientific base to the practice of medicine, and most of the things we spend learning in the first year of medical school had been thrown out the window—the arachidonic acid cascade, the Krebs cycle, the things we learned (and hated), the things we learned and memorized and that’s the last we ever thought of it in our career. And all the information of an entire day-and-a-half lecture on the synthesis of vitamins, which was our entire nutritional counseling, suddenly putting into dead center, and understanding so much better at a profound, deeper level how the body works with the principles of functional medicine, I’d say by the early 90s I felt that really filled in the final piece, and I think the great thing is now we’ll talk about maybe a little bit more in depth how doctors can start with functional medicine, which really should be a foundational learning experience that really students should have as the way to guide them through understanding how the body works physiologically and biochemically, really the first year of medical school.

JB: I’ve never had the opportunity or the privilege, actually, to thank you, and I want to take this moment both between the two of us and publicly to the Functional Medicine Update audience, to thank you as one of the original Board members of the Institute for Functional Medicine. You know, we started with humble beginnings like all organizations do, and we were very, very fortunate to have people like yourself guiding our thought as to how we were going to evolve this model, and I think it’s quite amazing to see what happens when you get good people that are very thoughtful, and conscious, and committed to their ideas, and willing to share and cooperate, what can happen. It started, actually, with a very small group of people, of which you were a core person, so thank you very, very much for all your contributions, both in the inception of the idea and how we constructed the organization, and how it’s evolved with leaders such as yourself at the helm. For the listeners who are new to the field, you would be considered actually one of our very important pioneering leaders in construction of the model.

The interesting thing that I see in this field, which you reflect beautifully, is that when you get pulled into this field it’s a little bit like having a virus that you can’t get out of your nervous system that infects you, and it infects the whole family. I’ve had the privilege of meeting your wife, Kathleen, and I know the two of you co-authored a really great book called Power Up: Unleash Your Natural Energy and Revitalize Your Health.[4] Tell us a little bit about how this journey you’ve been on has affected your relationship, your family, how you see yourself in the world, how the world sees you, how your peers see you. This is all part of what we wear as we travel through life, other than just our initials at the end of our name.

From Disbeliever to Skeptic to Someone who is Intrigued: Integrative Medicine is a Process for Many Doctors

WM: Well, I feel fortunate, again, that I was raised in a very healthy environment, which was really what you are doing with your Preventive Lifestyle Medicine Institute. We were raised with a preventive lifestyle. It’s just a natural thing, what we did: eating healthy, exercising, trying to handle stress properly, getting enough rest—all these key factors, the fundamentals of health, is something I’ve tried to inculcate in my kids, who—God bless them—even love broccoli as teens. And I think they may go in and out of healthy practices, but I think they know. I even taught a meditation class for one of my kids when they were in kindergarten. I feel very fortunate to have a wife who is also very like-minded, as do you, who has been a really incredible life partner, so I think the inner-family journey has been amazing. Our friends and other members of the family who may not be into this eventually will call with some health challenge and see if there is anything that I know about that could be helpful to them, and often—as so often happens in medicine—there is, because these gentler remedies are sometimes quite powerful as adjuncts, or even sometimes instead of, some of the other conventional remedies that may or may not be efficacious. So I think in terms of the family it has been a tradition that I feel blessed to have inherited—being able to transmit to my family.

It’s a little harder to do institutionally with my colleagues. I remember going to a meeting back in 1989 or 1990. I was doing a preceptorship with medical students at Columbia every year, and I went with a preceptor leader, Dr. Garvey, and I remember one year, after doing it for 2 or 3 years, I decided to broach the subject. Even with acupuncture, I was in the closet at that time. She asked how I was doing, what I was up to. Nobody knew that I was doing all these other modalities. I didn’t really advertise it because at the time the Quackbusters—the National Council Against Health Fraud—were actually quite active. I felt a little protected because I was in a teaching position at a medical school, but they were really going after people. It’s like the IRS; once you get on their radar screen it’s brutal. You know, you become bankrupt just with legal fees. We were all a little bit anxious about hanging up the shingle that was saying we were doing all these—at the time—alternative practices. One day I mentioned to her in our prep session that, “Glenda, I’m actually doing acupuncture.” She froze. I mean, literally froze. She wanted to shake it off like she actually hadn’t heard me say those words, and then quickly moved on to what we were going to be doing with the medicine that I was supposed to be teaching the medical students. In the course of a year, the next year I went back and she actually asked me how the acupuncture was going voluntarily, without being mortified, and then the third year she said to me, “You know, I was a little bit (very) skeptical a couple of years ago, but the more I’ve read about acupuncture, it sounds pretty interesting. I think I may actually try it for my back pain.” And that kind of shows you, in the span of two years, how it went from disbeliever to skeptic to someone who is intrigued to actually someone who comes to become a bit knowledgeable and then almost embracing of it. That kind of parallels what’s been happening in the field of integrative medicine as it began being seen as often practiced by renegades without significant evidence bases to the point now where it’s become most of the practices, even energy medicine, considered if not mainstream, something that is no longer thought of as quackery but as something that might possibly be at the very least an adjunct to conventional practice. And I think the evolution of functional medicine that you thought up and developed brilliantly—I mean, genius visionary, talk about something visionary in the 80s that had this groundswell that began slowly but now is at the point where it is really exploding amazingly with doctors realizing how important it is to have this knowledge base that they didn’t acquire in medical school that they really need to know so that they can actually help so many of the patients for whom conventional medicine falls a little bit short, particular for chronic diseases and prevention.

Science: Intellectual Permission to Try Different Approaches

JB: You know, I’ve had the privilege of meeting a number of your colleagues and friends that you’ve brought into the field who have impeccable academic medical credentials and are top of the line specialty practitioners. I think—as my mother used to say—birds of a feather flock together. You’ve really pulled in, through your example of excellence and rigor, an amazing group of individuals that you’ve infected with this irreversible virus, who are maybe not doing all this in their practice, but they are pretty supportive, and pretty interested, and willing to venture a little bit out of the lines now to try things because they’ve gotten some intellectual permission based upon the recognition that there is some science underlying this that gives them some confidence they can do it without getting into trouble. I think this is how movements grow and you’ve certainly done a wonderful job of introducing all sorts of people very non-confrontationally. That’s something I’ve observed in your style which might be a watchword to a lot of individuals. You’ve got some political savvy as to how you communicate with your colleagues and how you interrelate so that you don’t look inflexible. You take it to the level of the receptivity, the readiness to change model, I think, and you’ve done a very nice job in that.

WM: Well, the non-confrontational aspect I think is huge. I think early on that 30 years ago a lot of the docs who were doing this kind of work were outside the mainstream and they kind of figured that if they even brought it up there was no point in them even talking to conventional physicians because they would be dismissive and they were probably correct. One of the things that was amazing was that when Beth Israel agree to create some services of integrative medicine is that a number of physicians who had been really outside the mainstream but who very much valued the evidence basis of what they were doing, flocked to the opportunity to work within a conventional system that embraced, finally, this approach to care.

Establishing the Continuum Center for Health and Healing

Just quickly, the story of the Continuum Center for Health and Healing. Back in 1997, one of the main trustees, Bill Sarnoff, offered to put in, with a couple of his buddies who were on the Board, three million dollars to set up some sort of program that would provide integrative medical services (at the time called “alternative” or CAM services), not knowing what they would be, but just realizing through coming to a couple meetings I had with a bunch of like-minded practitioners in New York, that the miserable death that his wife experienced from breast cancer, where she received no support…“There must be a better way,” as he put it. The hospital held a think-tank in the summer of 1997 with all the major thought leaders, the CEO, COO, members of the Board of Trustees, Chair of Medicine of Medicine, and Surgery, and Nursing, and amazingly, at the end of this two-day think-tank in 1997, the group decided that integrative medicine was the future of medicine and a lot of patients were using it but seeing who knows what credentials. They knew from the Eisenberg studies that there was a significant interest, and they felt that this is something that they should actually be providing to their patients, so they went on a search to find someone they could trust who would understand the evidence basis and weigh what was credible and what wasn’t for the patients, and I was fortunate that they offered me the position and I took it, and I think you can’t do this anymore, but they basically said, “Here’s five million dollars. Create your dream center.” So I said, “Yeah, I think I would like to do that.”

I took, basically, eight practitioners in New York City who had been doing the work with me in various fields—pediatrician, Larry Pulaski; OB/GYN, Alan Warshowsky; family medicine practitioner, Ben Kliegler; internist, Robbie Lee; acupuncturist, Ari Nielson; nutritionist, Mary Beth Augustine—and brought them in to the practice and said, “Would you like to join and create something together?” and they said, “Yes.” So, it took us about two years to build it, and in 2000 we opened with the nine of us in practice, we opened with a full practice because these were practitioners at the peak of their practice—all fee-for-service—and we opened in to essentially a full practice. This is something that is very hard to do even now—to find that number of people to create it. In fact, I wouldn’t recommend most people build a 13,000 square foot center and populate it with 8 providers, but we were well funded, and we were in New York, and we had a very supportive clientele and 8 providers, and I think one of the things we’re proud of is over the evolution of the last 13 years that we’ve been open is we’ve actually brought in junior practitioners who actually began to take insurance, and now about 70 percent of our practice is managed care, where it began 100 percent fee for service. Right now we’ve grown from 13,000 to 26,000 square feet, and from 9 providers to 24, with a staff of 80 providing pretty global comprehensive services—primary care medicine where about 70{56bf393340a09bbcd8c5d79756c8cbc94d8742c1127c19152f4230341a67fc36} of the 5 family physicians practice pediatrics, 2 gynecologists, 3 internists, an ear, nose, and throat specialist, 2 psychiatrists, and 7 physical therapists and sports trainers, podiatry, chiropractic, a nurse practitioner doing only homeopathy. We have a new integrative cardiologist, Vivian Cominos, who is about start a Dean Ornish program at our center as well. We also have acupuncture, two nutritionists. We have an incredible…I mean, I could go on and on about the providers. Once you start naming them you don’t want to leave people out.

The key is that we have probably the most comprehensive outpatient services that exist. We were fortunate five years ago the president of the hospital, after our being very successful for eight years—no complaints, only praise and incredible PR for the hospital—said, “I think it’s time to create a department. The good news is we’re going to have a Department of Integrative Medicine on the same level of the Department of Medicine and Surgery. You’ve been coming to the Chairs meeting for seven years and we all know and appreciate what you’re doing. The good news is there is a department and you’re the Chair. The bad news is your operating budget is zero, so anything you can do, you can do, but you have to provide self-funding.” This is one of the issues I wanted to get into in our discussion—about institutionally how you can actually bring this in when there is no way the CEO, or COO, or CFO would want to spend a penny for this stuff, and how you can possibly bring it in without always having to have it be grant funded.

JB: I’ll tell you what, you just gave in that last 5 to 10 minutes was so concentrated news-to-use, exciting, goosebump history. I mean, if that’s not motivational to people listening I don’t know what is. And that list of your original collaborators is like a who’s who of the founders for some of the implementation programs (successful implementation) of this integrative and functional model. So that was really a great history. I’m glad we captured that. Remarkable. I don’t know how many times you’ve told that story but that was beautiful. Let me, if I can, just for the listener who may not have been around since 1997 in this field, go back with you just for a sec because you said something that I think is very important historically, and that’s David Eisenberg at Harvard and the study he did in JAMA, and his finding from this survey that, when extrapolated to the whole of the United States, the out-of-pocket expenditures for these services that we would consider now to be integrative, holistic, functional are somewhere in the range of that of out-of-pocket expenses for hospital care in the United States.[5] They were very substantial, and there were more visits to these providers of alternative care based on that article, than there were to primary care providers. It’s a paradigm-shifting concept, and a lot of people wanted to fight that data back and say, “No, no.” They wanted to marginalize it or say that it wasn’t statistically significant, or he didn’t do the study correctly, but I think it was a frame-shifting reality check on the whole of the field, and it seems like it must have had also an impact in Beth Israel that kind of softened peoples’ views and helped you to incubate your program.

Three Events that Changed Thinking on Integrative Medicine

WM: I think we’re fortunate at Beth Israel because it has always been kind of an outlier in medical centers as a hospital in the city where there are more elite hospitals and to compete they actually have offered services that the other hospitals would eschew as being unfounded or unnecessary for real medicine. We’re very fortunate to be in a culture—and you have to have good fortune in life, too—I feel very blessed that I’ve kind of been in the right place at the right time to help facilitate all this. I think that the hospital had an understanding that some of these therapies might be successful, but pre-dating the 1997 think tank were the Eisenberg studies, and actually I’ve always looked back in the field of what used to be called alternative medicine, and there were three events that actually kind of came together more or less at the same time that made even the most conservative physicians stand up and think that there might possibly be alternatives. One was David’s study for sure, showing that 40 percent of patients were using this. Another was Bill Moyer’s series, Healing and the Mind, that showed the incredible power that we have to actually transform our health with our own mind. And the third was AIDS, actually, interestingly enough. At that time, back in the late 80s, there was no treatment before HAART came out. Conventional medicine—these hematologists and infectious disease specialists—literally had nothing to offer their patients, so often their patients said, “Look, I did therapy or this herb or that IV drip or whatever, and I seem to feeling better.” Before this medication, these formerly very conservative docs who would never let patients do anything “alternative” were kind of open: “Well, why don’t you try it and let’s see if it works.” And, of course, most of them didn’t, but it made them knowledgeable that there might be something out there.

I think the rap in the 90s was that there was no evidence base, and really there wasn’t a lot of evidence base as published clinical studies, although in functional medicine there was. You had the evidence and the science. It was grounded in the conventional medicine textbooks that they were telling students that this is what they needed to do but then they weren’t making it clinically available, so functional medicine was the earliest progenitor of the evidence base of what really already existed. You didn’t need more studies to inform doctors in terms of how to practice, but then over the next 10 or 15 years, really there has been in the last decade, an explosion of good quality, evidence-based studies on acupuncture, and mind/body practices, and botanical medicine, etc. to help guide us. So early on, even the president of the hospital, when he founded the center, said, “You know, evidence-based is really important, but it also can be a bit tyrannical.” In the case of Chinese medicine, for example, if you’re not taking any drugs where there may be a drug/herb interaction, this is a 2500-year empirical trial that seems to have been pretty successful, so your level of evidence depends upon what the risks are and how severe the illness is, so some of these very gentle remedies like homeopathy, you’re not going to give it for multiple myeloma, but you can do it early on, particularly to help ameliorate some processes, or to be adjunctive to processes.

I think we’ve been fortunate that now, for the young practitioner wondering what they should do, there is so much evidence and data out there to back up what we are using in our practices that it is a much better place. When I was doing it in the late 80s there were almost no quality courses and now there are so many CME-level courses. I mean, functional medicine alone, the AFMCP week-long intensive course, and the weekend courses, and the annual symposium, and the FMU, and all the materials you have, as well as courses in botanical medicine and mind/body practices, and food as medicine, and places such as Scripps, and the Center for Mind/Body Medicine in Georgetown, and the Integrative Healthcare Symposium we have in New York, providing an incredible smorgasbord of opportunities for even the most hard-lined, evidence-based doctors to see how much there is that can be incorporated into conventional practice.

Establishment of the Bravewell Collaborative and the Consortium of Academic Health Centers for Integrative Medicine

JB: Let’s talk a little bit, on that stream of thought, about the Bravewell Collaborative, because I think the Bravewell Collaborative and the Consortium are two very interesting evolving parts of the story that you’re describing of the frontier of accreditation and respectability of the field. You’ve been actively involved in both Bravewell and the Consortium. Tell us a little bit about how those came about and their impact.

WM: The Fetzer Institute brought together five senators back about 12 years ago to do a study to see what they thought would be possible, if there is anything to this field at the time called CAM medicine, and the outcome of that was that there was, but it was unclear what to do about it. I wasn’t a part of that. We were in the second year at Beth Israel. There was one other institution—I think it was Thomas Jefferson—that was allowed in by vote of the group of five. Each of these seven academic centers had an existing center that utilized integrative medicine, and at the time, the schools, including Arizona, Duke, Harvard, UCSF, Thomas Jefferson, Beth Israel, Maryland, and one or two others, decided how to best help the field of integrative medicine to evolve forward. We decided that there were two tracks. One was philanthropists: Bill Sarnoff, Penny George, and John and Christie Mack setting up the Bravewell philanthropic collaborative for integrative medicine to go out to other philanthropists who were wanting to contribute, but they were not sure where to give their money and they wanted their money to be well spent and not just get them down some sinkhole on some study that didn’t show much and then their money was gone. They wanted to see how they could actually use the money. And also some of them, once the word got out that a particular donor was giving money, then they were besieged by requests, so they wanted to set up kind of like a Ford Foundation, almost, of a philanthropic collaborative. And while they were doing that we decided that there should be a consortium of medical schools that actually would get together and would support each other and help to expand this within academic medicine, and so that was the birth of the Consortium of Academic Health Centers for Integrative Medicine.

It originally started with the five investors, and with the seven at this think tank in Miraval, and to the point now where 40 percent of the nation’s medical schools are members of this consortium, so when young docs are looking for support in most every major city in the US and in 40 percent of the medical schools, these centers exist. The ticket of admission is three things: you have to have an existing center that provides integrative medical services in two of the key three areas of research, education, and clinical care; you have to have been in existence for three years; and, most importantly, the dean of the medical school has to sign a letter attesting to the fact that integrative medicine needs to be an integral part of undergraduate and graduate medical education and training in their school. This is huge. I mean, the fact that deans of the medicals schools would actually say integrative medicine should be incorporated into conventional medical training, ten years ago was an enormous statement. It still happens, every once in a while a reporter will say to me, “Well, people say there is not much of an evidence basis to this and this still really shouldn’t be mainstreamed.” And I say, “Well, I don’t know who your sources are, but if they think they know more than the dean of the medical schools of Harvard, Yale, Stanford, UCSF, Einstein, Georgetown, and Duke, I’m curious to have that debate.”

Like functional medicine, I think that the incorporation of a range of integrative services into academic medicine is a good idea whose time has come and it’s here. It’s not just the future of medicine, but it is the current practice in many places. I will say that there are considerable challenges. The fact that the dean says it should be done, it’s a big leap to then actually providing the education and training to the medical students as residents and the equivocal care to patients.

JB: Let’s move—I think that’s a very good segue—into where we probably should go from this extraordinary and robust history that you reviewed for us, and talk a little bit about the clinical approach, the funding, and some of the barriers, and some of the things that might—from your experience—help some newer people coming into the field to be knowledgeable about that might help them as they make their transition forward.

Time: The Greatest Challenge for Providers in Providing Personalized Lifestyle Medicine

WM: Well, I think if you’re looking to be a student, obviously, my opinion of where you go—the best college and medical school—is where you get in, so it’s not like you have the choice of every place you’re going to go to, but to try to find a medical school, if you can and you get accepted to, that actually provides some training in integrative medicine, and the same thing with a residency. There are almost no residency programs except for a couple, including Beth Israel’s going back 15 years, that provide training in integrative medicine. As a matter of fact, at Beth Israel, Red Schiller, who is the Chairman of the Department of Family Medicine and Chairman of the Credentials Committee, to show you how deeply ingrained this is, has required a rotation in integrative medicine for 15 years in the 3-year family medicine programs. These programs and trainings exist for people, but these academic centers also exist that have many CAM courses where doctors can actually find quality information, and even if they can’t do it within their medical schooling and residency training, there are probably evidence-based/science-based information that they need to incorporate into their practice. Once they get out into practice it can become more difficult because of insurance systems. One thing that integrative medicine requires is that you understand your patient at a deep level and you spend time with a personal social history to really get into what’s going on in their lifestyle.

I know something, Jeff, that you’ve championed for such a long time and you’ve now set up an institute for it, PLMI. Without understanding the background of where patients are, it is very difficult to treat one or two symptoms of a problem and never really make an effective change for most of the people. I think that doctors need to really focus and have the time to do this, and they often don’t, so that’s a real challenge. Another challenge is actually within the hospital itself—making these practices available to patients in the hospital where it is desperately needed. I’ve been going to Chairs meetings at my hospital for nearly 12 years now. About 4 years ago one of the surgical division chiefs—I won’t say the name—very conservative, editor in chief of his journal, actually decided after hearing me talk about this for years that he would hire a half-time Reiki provider, of all people to bring in. It wasn’t even acupuncture or nutrition; he started way out there with Reiki. He brought in a Reiki practitioner half-time in the recovery room, offering it to patients coming out of surgery. And he said a month after bringing this person on board that not only from his perspective were the outcomes improved by having this person, but it changed the entire culture of the department. This is profound, but you have to be lucky and get somebody who is kind of a champion within the medical center who believes in this and helps you to get it going.

The Importance of Cost-Effectiveness Studies: Can You Afford to Save a Million Dollars?

One of the things that people are working in institutions where they are dragging their feet about doing it that I think is really important is there are a lot of studies on clinical outcomes. Beginning 15 years ago we began to understand how a lot of these things worked and if they worked. I think in terms of nutraceuticals and botanicals, the studies are just beginning to come out now in terms of the downside of using too many antioxidants and other things, so they are beginning to see that there are negatives; it’s not all positives, so we need to put that in balance. The thing that particularly hospital administrators are having a hard time with—and the same thing with insurers–is, “Okay, so this works, but how do I know this is not going to cost four times what I’m paying now with the same outcome. Why should I do this?” So you really need cost-effectiveness studies and there are cost-effectiveness studies people can point to. There are studies going back 10 years by Citibank, of all places, showing there was a 10-to-1 return on investment for bringing in and actually just counseling on basically lifestyle practices for their employees.[6],[7],[8] So many companies have found that bringing in preventive lifestyle practices significantly reduces healthcare costs. Within our hospital we did a study—a wonderful study that was funded by the Urban Zen Foundation and Donna Karan—where we transformed the entire cancer floor of Beth Israel into an optimum healing environment, and we provided patients with self-care. We empowered the patient to engage in their own healing process rather than being victims and passively waiting for the nurse to come with yet another pill for their symptoms, to engage their mind in the healing process. What we tracked is that over the course of four months of the study amortized over a year, by bringing in the person who would be an advocate for them and doing yoga therapy and teaching them mind-body practices, just tracking three medications for pain, anxiety, and nausea, we—amortized over a year—saved a million dollars in medication cost from having that one person.[9]

So you go to the administrator—which I did—and you say, “You know, I think this is good evidence that we should bring in a yoga therapist onto the floors because we’ve shown in our study that we published in the American Journal of Managed Care [not exactly a radical journal] that amortized over a year you could save a million dollars just in medication costs alone. Patients would hit their pain button with their mind rather than asking for the pain medication.” He said, “Well we can’t afford that.” I said, “Can’t afford what? To save a million dollars?”

Mount Sinai did another great study by Guy Montgomery showing that if nurses just went up to patients in the gurney in the hallway waiting for the most commonly done surgical procedure, which is breast biopsies and lumpectomies, and you asked them if they wanted to learn a hypnosis technique to help them through the procedure, they found that they saved an average of $772 per patient with less anesthesia, less procedure time, and less medications in recovery.[10] So basically after the first 100 patients, providing a full-time nurse, the rest is gravy in terms of savings. I think for those people who are working within an institution, there is now evidence they have to take to the administrators and say, “You not only can improve outcomes, by the way, you can improve the patient satisfaction, which is going to end up being 20{56bf393340a09bbcd8c5d79756c8cbc94d8742c1127c19152f4230341a67fc36} of Medicare reimbursement. You can actually save money.”

JB: You know, you have just…there are so many pearls that you just dropped and so many little tidbits of news to use that are applicable in every practitioner’s—actually every person’s—life. That was just very, very beautiful, dense information. One of the things that struck me coming out of the most recent Institute for Functional Medicine International Conference on energy medicine, that what you really beautifully described is kind of an energy field—that you change the context of healing, which is really a state of energy. It’s hard to quantize. It’s invisible. You can’t taste, touch it, or feel it, but it’s very real, so it’s almost like an electromagnetic field state that interfaces with physiology to produce different outcomes that are probably measureable with different mediator molecules of emotion and things of that nature that ultimately affects end-stage physiology. It’s a remarkable example of distant effects, action at a distance, through energy fields that sometimes we marginalize or we don’t take seriously. That was a beautiful, beautiful explanation.

The Case for Positive Energy Fields

WM: I’m a big fan of the work of Larry Dossey and other people who have talked about energy fields. Even if you just look at it more conservatively, just the intentionality that is brought into the room of a nurse or a doctor who are actually going in to be the patient’s advocate rather than being ticked off that they’ve got to go in and give another medication or change the IV, can make a huge difference. When we have trained these people at the hospital with the Urban Zen training from the Urban Zen program to be therapists, we train the nurses and some of the Chairs say, “Well, that’s great but the nurses have no time. They can’t sit for 10 minutes and teach the patient a healing technique. They barely can get the medications charted.” I point out, “You know, once you understand from self-care what it takes to be whole, the nurse or caregiver, in the 30 seconds they are taking to change an IV, they can just say to the patient, ‘This is an opportunity. Why don’t we just sit here and do some breath work together. It will help you and it will help me. Let’s just close our eyes and do that technique you just learned together.’ While they are doing their work.” That energy that surrounds that experience is profound and powerful and it stays with someone for a very long time.

It’s just like when you hear a tune—Dean Ornish was just saying this the other day—when you hear a tune on the radio in the morning and you find yourself like three or four hours later humming the tune, it’s like as you do these meditative practices, they actually begin to stay with you even at a subconscious level, and not only stay with you but begin to radiate out into your field. It’s kind of like that study that showed that the circuit of obesity that actually went through three or four contacts of people, if you were around people who were obese you were much more prone to be obese just from your contacts, even three or four removed.[11]

JB: Yes, I think that’s a beautiful example. We’ve taken a tremendous amount of your time, but I’d like to give you a chance to do a little forward looking, vision thinking with us. Where do you see the field going? What’s your prognosis? Is this something that if you were recommending to one of your children or loved ones to go into medicine that you’d be optimistic about the future? What’s your state of the vision of the future?

WM: I think you have go into medicine loving the opportunity, the blessing you’re given, the great privilege to be able to engage in a healing encounter with patients. It’s a gift, and I think you have to be motivated for that. Who knows, really, in the current healthcare environment with the reimbursement model? You certainly can make more money doing some other fields, perhaps in finance rather than medicine (unless you’re a plastic surgeon). You have to go into it loving the opportunity to actually help people, and you need to be able to, perhaps sometimes on your own, learn those modalities in your own life, for your own self, that balance you, and that you bring that into the workplace, and when you do that, you will be satisfied. You need to make sure you love the field because there will be many challenges ahead. Even though there are a lot of kinks in the armor and it’s almost like there is a very soft armor now at a lot of the institutions that are allowing these to take place, but they are still often only available where they are grant-funded. They aren’t institutional priorities. Even the teaching and training is not yet an institutional priority. You go from the Dean saying these things should be taught, to training the hundred and fifty-odd faculty to be knowledgeable, to train the students is a definite leap.

I think this is the future of medicine. It’s here. I think that the ability to train and become knowledgeable with functional medicine as the foundation, and mind/body practices, and then adding in other things that you want to put in your practice are there, or at least knowing who in the community is someone great to refer to. It’s an incredibly exciting time. It’s kind of like the best of times and the worst of times. I don’t see the worst of times now. I think, really, even though they didn’t make a huge leap with Obamacare, you are providing care to tens of millions of people who didn’t have it before, and I think that we are in a state where increasingly integrative medicine is going to become the standard of medical practice. Because I’m a glass half-full guy, I’m very, very positive about it. Where we’ve come in the last 15 years…it’s unimaginable that we’d be this far with these formerly considered kind of wacko alternative medicine therapies now becoming mainstream.

The Need for Integrative Medicine is Patient-Driven

I feel very fortunate. I think that the next generation—it’s only going to get better for being able to really be truly holistic in your practice of medicine and in your own lifestyle. One of the shifts that has occurred is we are much less doctor-centric. I think that this began, again, back 20 years ago with the Moyers and the Eisenberg work, the fact that this is a patient-driven movement. This isn’t because doctors wanted this to happen with alternative practices being incorporated. They were almost led kicking and screaming into it. As part of that I think we’ve now realized that some of the other professions have profound benefits to offer, not just as an adjunct where you send someone out to them, but incorporated with conventional medicine and really making it patient- and relationship-centered. Utilizing doctors where you need to, but also thinking about naturopathic medicine, which has at its core the scientific understanding of the use of nutrition and many other modalities. Acupuncture, Chinese medicine, holistic nursing—all of these professions working together as John Weeks and many other have been trying to get going for a very long time. I think we’re in an era now where conventional medicine is beginning to lose its grip on having all the power and recognizing that they can’t help all their patients and there are many other providers who are extremely well-trained and knowledgeable about conventional medicine and about the evidence basis of their own field that actually can dramatically improve overall healthcare outcomes.

JB: Thank you. I think that’s a really great way to end this discussion. That’s one of the reasons that I’ve been advocating with my colleagues the formation of this Personalized Lifestyle Medicine Institute, because it is a consumer-driven movement that we’re witnessing, and we need consumers to be well informed and have access to quality information across where genes meet environment meets lifestyle to create the right outcome, and then that has to be interfaced with health professionals that are credentialed and properly trained to deliver services to people that have chronic illness. I think that interface will then drive the change that we’ve all been looking forward to. I believe that your comments around various ways of approaching this problem is the definition of a distributive healthcare system versus a top-down linear reductionistic healthcare system, where you get to know more and more about less and less until you know everything about nothing. I think that we’re seeing this distributive system start to emerge where different skills can be woven together to create a better outcome. So, I thank you. You do this beautifully, by the way, in your oversight of the integrative health meeting in New York City each year. I think that’s a wonderful meeting that embodies multiple disciplines showing how this cooperativism can emerge. Dr. Merrell, to say this has been inspirational would be a great understatement. This has been an incredible word journey we’ve taken with you here.

It’s ironic. I’m sitting here, as I’m interviewing and listening to you, looking out over the Seattle, Washington skyline at Providence, Swedish, Harborview, our medical centers in Seattle that are all associated with the University of Washington School of Medicine, and I’m just thinking of my 40 years here in the Pacific Northwest, and kind of morphing, or doing holography of what you’re saying into this community here and recognizing that every one of those medical centers, when I first came here, would be considered right down the center of the line. Now each has their own integrated medical facilities within those centers, and they have affiliations with Bastyr University—many of these—through the naturopathic medicine that is licensed in the state of Washington. As you just said, who would have thunk that 40 years ago? It didn’t sound possible. I think that we really are seeing a paradigm shift and it’s going to be built on authenticity, and competency, and on the shoulders of people that have done the really heavy lifting like yourself in creating an environment that will deliver improved outcomes and more cost-effective care. I can’t tell you how much, both on a personal level, I’ve appreciated our friendship and your guidance over the years (the decades, actually) in developing my model, but also on behalf of all the listeners for the extraordinary contributions you’ve made to the field. It’s just quite remarkable.

WM: Thank you so much for having me on. It was a pleasure and honor to be on FMU and to get a chance to speak with you and share a little bit of the history of where we’ve come from and the excitement that holds for the future.

JB: Again, all of our thanks for your years of work and efforts and we look forward to continuing and following closely what’s going on there at Beth Israel and all of your activities

 


Bibliography

[1] Han JS, Tang J, Ren MF, Zhou ZF, Fan SG, Qiu. Central neurotransmitters and acupuncture analgesia. Am J Chin Med. 1980;8(4):331-348.

[2] Han JS, Terenius L. Neurochemical basis of acupuncture analgesia. Annu Rev Pharmacol Toxicol. 1982;22:193-220.

[3] Han JS. Acupuncture analgesia. Pain. 1985;21(3):307-310.

[4] Merrell, Woodson and Kathleen Merrell. Power Up. Unleash Your Natural Energy, Revitalize Your Health, and Feel 10 Years Younger. New York: Free Press, 2009.

[5] Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280(18):1569-1575.

[6] Reiff MG, Sperling KL. Measuring the savings from managed care: experience at Citibank. Benefits Q. 1995;11(2):9-15.

[7] Ozminkowski RJ, Dunn RL, Goetzel RZ, Cantor RI, Murname J, Harrison M. A return on investment evaluation of the Citibank, N.A., health management program. Am J Health Promot. 1999;14(1):31-43.

[8] Ozminkowski RJ, Goetzel RZ, Smith MW, Cantor RI, Shaughnessy A, Harrison M. The impact of the Citibank, NA, health management program on changes in employee health risks over time. J Occup Environ Med. 2000;42(5):502-511.

[9] Kligler B, Homel P, Harrison LB, Levenson HD, Kenney JB, Merrell W. Cost savings in patient oncology through an integrative medicine approach. Am J Manag Care. 2011;17(12):779-784.

[10] Montgomery GH, Hallquist MN, Schnur JB, David D, Silverstein JH, Bovbjerg DH. Mediators of a brief hypnosis intervention to control side effects in breast surgery patients: response expectancies and emotional distress. J Consult Clin Psychol. 2010;78(1):80-88.

[11] Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007;357(4):370-379.

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