Using the Values of Integrative Medicine to Create the Future of Healthcare

Abstract

The ideal future state of health for the world’s populations requires a cohesive model that considers the synergistic roles of communities, public health and healthcare. This future state reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare professionals and disciplines to achieve optimal health and healing. This is the definition of Integrative Medicine. We are far from this idealistic future. Healthcare costs continue to escalate while life expectancy declines. We train our future healthcare professionals in our current disease-based model that prioritizes siloed pharmaceutical and interventional approaches over whole person prevention focused care. As healthcare professionals, we disregard our capacity to influence the leading risk factors for disease-related death and disability which include health behaviors, social, economic and environmental drivers. Burnout is high and rising. Rapid shifts are expected in the coming years as the current system’s cost becomes untenable. We need a sustainable future for healthcare. That means we must figure out how to re-center on the patient, on a full spectrum of prevention and treatment, and how to influence public and community health. The future model must focus on health behaviors at its foundation, use systems thinking, be environmentally sustainable, and approach health from a population lens. The future will require an ability to consider complex systems approaches to health and wellbeing that include a focus on both the patient and the healthcare team. Research strategies must not only consider effectiveness but also reach, implementation and institutionalization in a multi-dimensional capacity that looks at whole person health as an outcome while looking at individuals in the context of where they live and work.  The Integrative Medicine community has an opportunity to help lead the way to a sustainable and health focused future.

We are at a crossroads in considering the health of the world’s populations. The way forward is complex. Structural frameworks can help the health care sector chart a path forward. The ideal future state of health for the world’s populations requires a cohesive model that considers the synergistic roles of communities, public health and health care. This future state reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, health care professionals and disciplines to achieve optimal health and healing. This future state is the definition of Integrative Medicine (IM) as defined by the Academic Consortium for Integrative Medicine and Health. These values: relationship centered, whole person, evidence-based, broad range of approaches, and a focus on optimal health and healing, can be a guiding path as we look to the future. While these values or ideals do not belong to IM alone, the field’s ability to bring them together in the health care space is unique.

Sadly, we are currently far from this idealistic future. Health care costs continue to escalate while life expectancy declines. ¹ While modern medicine excels at high-risk rescue focused interventions, years of focusing on procedural and Band-Aid medicine rather than prevention has led to untenable cost growth. The care we provide is ok but not great; rates of chronic disease are rising and life expectancy is going down. ² Burnout and reduced job satisfaction among health care providers is reaching critical levels ³ leading to workforce issues in staffing hospitals and clinics. ⁴ National shortages are predicted to worsen. ⁵

In order to intentionally move towards the future, we have to understand how we got here; we have to consider the ecosystem and examine upstream drivers of the health and well-being of the population and that of the health care workforce. Many drivers of our current system contribute not only to poor care but also to significant dissonance in health care workers, burnout and an increasing dissatisfaction with health professions as a career. We want to improve the health of our patients and communities yet:

• The drivers of health largely lay outside of the health care domain. It is estimated that only 20% of a person’s health is a result of clinical care. ⁶ The rest is mostly health behaviors and environment. ⁷ As health care professionals, we disregard our capacity to influence these leading risk factors for disease-related death and disability.

• The US health care system and many systems around the world are designed by the way we pay for care to drive fast, acute, procedural care. It favors industrialization and monetization, pushing us away from relationships even when relational care may be more effective. Financial models move us away from public health, community and primary care.

• The way we train health care workers is designed to drive them into reductionistic silos. We champion the specialist over the big picture. We train our future health care professionals in our current disease-based model that prioritizes siloed pharmaceutical and interventional approaches over whole person, prevention focused care. While exceptionally important, alone the specialty approach does not provide a patient centered or health centered approach to whole person care. It does not effectively prevent disease. A further complication of this approach is the separation of physical and psychological health as different diseases and processes, creating lost opportunities for patients to address the root cause of disease.

• There is marked health inequity across populations.

• Planetary health has long been considered separately from health care.

We can’t look at each of these problems in isolation. We have to look at the interdependent relationships between each. They contribute to untenable workloads and inadequate support. Together these lead to poor health of populations and moral distress in health care workers who ultimately want to care for patients and serve our communities. Many of the known drivers of burnout such as workload, work-life balance, social community at work, control and flexibility ⁸ contribute to moral distress. Moral distress frequently leads to burnout. ⁹

Why now? These drivers serve as a wakeup call to health care organizations and governments to consider our health care and public health systems, hastened by the COVID pandemic. Patients and health care professionals are interested. Burnout is high and newly recognized as impacting ability to care for patients. There is sudden increased societal interest conversation about mental health and planetary health. There is an intensified drive to consider the interplay between physical and psychological health. The ability to look at the ecosystem of health and health care is critical. We need individuals trained to look at the big picture. Those trained in Integrative Medicine are well suited to help lead the health care sector to a healthier future.

Strategic Framework

To optimize the health of populations, we need to consider medicine in the context of a population health/public health community-based model that puts patients in the driver’s seat of their own health. Using a public health pyramid, we want to consider the interventions that prevent as many diseases as possible at the bottom and the highest risk, most expensive interventions at the top (Figure 1). Not only does this reduce the cost of health care, it decreases the burden of disease, allowing a shifted focus to healthspan over lifespan. This model is designed for the health care sector in considering how to approach the health of populations in concert with other sectors.

Figure 1.

Strategic Framework for Optimal Health outlining recommended amount of focus and attention towards the health of populations.

At the bottom of the pyramid are health behaviors that make up the foundations of health, grouped into four categories: food, movement, sleep and connection (Figure 2). Connection includes a focus on self-awareness, social connection and connection to meaning and purpose. Most chronic diseases stem from these behaviors. While there are many models for health with different buckets, these four categories focus on positive actions and look at basic human behaviors that drive health. They are the root of physical and mental health disorders, including addiction. Health behaviors are strongly influenced by social, community and environmental factors which require attention. ⁶ Health care can partner with public health and communities to influence health collectively with shared responsibility, each coming from different angles towards a common goal. These approaches are not new but have been consistently overlooked in health care more broadly. Examples of systematic approaches for well-being are emerging. The World Health Organization’s framework for public health approaches ¹⁰ and the U.S. Surgeon General’s framework for worker well-being ¹¹ are two examples.

Figure 2.

The Foundations of Health. In this model Connection includes connection to the self, to others and to meaning and purpose.

The second tier of the pyramid uses our understanding of the stress cycle to improve both physical and psychological health. A major failing of the modern health care system is the inability to acknowledge physical and psychological health are two sides of the same coin and address them together. As stress builds, coping skills must rise to meet it. When this doesn’t happen, both physical and psychological symptoms and disease can arise. The foundations of health are essential to managing stress which is necessary to achieving optimal health. The next tier is early intervention is high quality relationship centered primary care and can be incorporated into systems that provide assistance on the foundational tiers. The last tier is high impact emergent medicine and management for complex chronic illness that requires specialty specific expertise.

If we were to use this framework in how we design and fund health related interventions we could substantially reduce the cost of the health sector, improve the quality of care we provide and improve the experience not only of the patient but that of the health care workforce working towards the quadruple aim of health care. ¹² This would be particularly true if done in collaboration with other sectors such as agriculture, transportation and urban planning. Importantly, burnout among health care workers is connected to the moral distress we feel when we can’t provide the care a patient needs and wants. It is connected to a loss of impact. ⁸ These improve with this model through an increase in self efficacy that would come from strengthened relationships and being able to help patients achieve health outcomes.

IM has much to offer to medicine and health care as we move forward collectively. Until now, IM has existed in pockets. While popular, it has not captured the imagination of academic medical centers, funding agencies, other health care, public health, human services, or educators. We are poised to help lead medicine towards a future where we focus our true north on whole person, human centered, accessible, equitable care. Ultimately, IM is about being patient centered and moving beyond the absence of disease towards optimal health. It is not about promoting specific modalities. As we consider the role that Integrative Medicine may provide in that future, we must not be pulled back into the diagnosis and treat paradigm, replacing medications with natural products. As we consider this approach, we must be patient centered, take advantage of all possible approaches and continue to address psychological health on par with physical health, and work closely with public health.

Medicine has long valued the specialist over the generalist. IM is the ultimate generalist, able to see the big picture in ways that are uncommon in healthcare. There is a Ying and Yang. In order for the specialist to succeed, they must be paired with the generalist. We have skewed too far in one direction and our systems are crumbling. We need to embrace the generalist and champion it. We need to be able to scope out and in to treat the whole person as they exist in their community. Those with IM backgrounds are ideally positioned to connect the dots between ideas and fields, able to see the big picture. By partnering with the patient in health, by centering on the patient as a whole person in the context of their family, community, and belief system, by focusing on the strength of the relationship with the healthcare worker, and by maintaining a true north of optimal health and healing, we can look broadly at the health of individuals and populations. Importantly, by focusing on a broad range of approaches, we can take advantage of multifaceted solutions.

Path to Transformation

This approach requires a substantial shift in how we do business in health care and will require expertise from a variety of dimensions, such as public health, psychology, medicine, nursing, economics, law, public policy, urban planning, agriculture, etc. It must take advantage of this wealth of expertise across our universities and communities. We must take advantage of cross-disciplinary work that branches across multiple fields to fully understand how to improve the health of patients as well as preserve our health care workforce into the future. While IM as a field has thought broadly, we will need to continue to broaden further the kinds of expertise we seek, partnering with patients, communities, and varied scientific fields beyond those typically found in health care.

We can consider what we know from the science of behavior change, such as the Transtheoretical Model (stages of change) ¹³ and apply it additionally to organizations. We can reduce stigma around mental health starting by normalizing discussion about the body’s response to stress and how to deal with that stress. We can build culture and community by leaning into relationships with patients, colleagues and how we connect with purpose. We can lean into improvement science ¹⁴ and shared governance. Research strategies must not only consider effectiveness but also reach, implementation and institutionalization. We can look to the science of wellness centered leadership which suggests we care about people always, cultivate relationships, inspire change. ¹⁵ As we train people in leadership and how to function in the circles where decisions are made, we can infuse a whole-person integrative health paradigm into all of our clinical services, threaded through our educational and research endeavors. We can also come together with others in the places where relevant decisions are made: hospitals, state committees, credentialing boards, medical review committees, payer relations committees, legislative and advocacy groups to influence policies and direction. Together these changes will almost certainly decrease the moral distress which is prevalent in health care workers. Early evidence has shown improvement in worker well-being in the VA health system as a result of the Whole Person Health Program. ¹⁶ We have an opportunity to not just do the work but lift the work. It is time for us to lead. Together we are stronger. Together we will change the world.