Doctors have the ability to heal.
Unfortunately, the current health care system has turned many away from their natural ability to do so. But things are changing.
A core aspect of integrative medicine is whole person care by doctors who take the time to listen and understand their patients, and a treatment protocol that incorporates therapies which enhance the body’s ability to heal its self.
I was recently invited to attend Eisenhower Medical Center’s Annual Primary Care Medical Conference specifically to hear their guest speaker. As I reviewed the agenda, I saw the anticipated topics of neurology, orthopedics, and gynecology, but was pleasantly surprised to also see lectures on integrative medicine, gut health and optimizing the GI ecosystem, and rejuvenation biology.
Their guest speaker, David Rakel, M.D., is director and founder of the University of Wisconsin Integrative Medicine program and associate professor in the Department of Family Medicine at the University of Wisconsin School of Medical and Public Health. He is board certified by both the American Board of Family Medicine and the American Board of Integrative Holistic Medicine, and is co-editor of Textbook of Family Medicine and editor of the go-to textbook Integrative Medicine.
As the lead feature in one of our first issues was “U.S. Medical Schools Embrace Integrative Medicine” (March/April 2011), it was exciting to see things come full circle and the practices now taught in our medical schools coming to our
Although his accreditations are vast, Dr. Rakel focused on his work as a small town doctor. After medical school and a family practice residency in Greeley, Colorado, he spent five years in a rural practice as one of two physicians staffing a 14-bed hospital in Driggs, Idaho. He joked that the town was so small, you never used a blinker because everybody already knew where you were going.
“When you work in a small town, you really get to know about people’s lives, and you realize that there are things we can do to really help facilitate complex systems to self-heal.” The experience changed his perception of how he practiced medicine. “How can we facilitate change within a complex system so that a person is resilient, healthy and happy? It’s a different focus.”
“All doctors are trained in pathogenesis (the manner of development of a disease), but what we need to do is create a new expertise in salutogenesis,” a term coined in the 1950s by Aaron Antonovsky, a professor of medical sociology to describe an approach focusing on factors that support human health and well-being, rather than on factors that cause disease. “Integrative medicine is a step towards this approach, and is what primary care really is all about.”
How can this simply become good medicine? “We all know that this is more complex than just treating the branch of the tree. We have to look at the dynamic uniqueness of every life within a changing environment. And that requires us to hear the story of every unique person that comes into our care.”
In his small practice one of the most effective drugs he prescribed for depression and anxiety was sertraline. “A patient would come into my office, they knew me well and felt comfortable talking about the chaos in their life and how they were feeling. I would listen – hopefully kindly and with compassion – and would say, ‘Hey, it’s not your fault. You have low serotonin levels. We have a drug for that! It will increase your levels and in a couple of weeks, you’ll be back on your feet.’ I would write out a prescription and the angels would sing!”
What he was doing was identifying a reason for the way his patient was feeling, creating positive expectations and putting the patient back in a position of control. Then a study on serotonin reuptake inhibitors (such as sertraline) was released showing very little effectiveness of the drug for mild to moderate depression over a placebo where both were effective in 58 percent of cases.
“After going back and looking at all the research, I found that I was fooling myself about the effectiveness of this drug. My true belief now is that the healing effect comes in the ceremony and ritual of caring enough to hear someone, to give them an understanding of their illness, and to say ‘we are going to get through this together.’”
Those actions stimulate the healing in the brain and body that helps someone overcome their depressed mood he says, “And that, I truly believe, is the main healing influence.”
He tells the audience that as doctors, we need to look beyond the disease and prescription, because in instances like this, “the ceremony that you create is more important than the pills you prescribe.” And this ceremony can enhance the effect of a pill.
Recognizing that exercise and mindfulness therapy are also an important and effective part of long-term healing, he describes the benefit of belly breathing for chronic bowel conditions (one of the toughest conditions to treat). “Breathing exercises stimulate the vagus nerve which stimulates the parasympathetic nervous system allowing the pancreas to secrete digestive juices that digest food. That is why one of my favorite treatments is teaching people how to do the relaxing slow deep breathing. What if you eat while relaxed with people you love? If you take a few deep breaths before you start your meal – through prayer or just taking a moment – I guarantee that you are going to digest your food much better than if you are stressed out and eating on the run – as many of us do in between patients.”
Supporting the fact that there is no separation between mind and body, Rakel states a study of 200 people with chronic bowel conditions who underwent 12 one-hour sessions of hypnotherapy. 71 percent responded positively, and the benefits lasted up to 5 years. The treatment also reduced their anxiety, depression, medications and number of doctor’s visits.
He added that he has never prescribed a drug for irritable bowel because it is too simple. “This is a complex, dynamic body-mind we are dealing with.” For those patients who feel that he is just another doctor stating the problem is ‘all in their head,’ he tells them, “No. We want to use hypnotherapy as a therapeutic ally and stack the deck in favor of your body’s ability to heal itself – so you need less things. One of the most effective treatments is to use this as part of your medication regiment.”
Rakel understands that the system doesn’t always allow for doctors to give this type of care, but it is compassionate doctors who will help change the system.
“Why is there so much burn-out in primary care? How many times are we forced to go in and out without having the time or systematic support to really go deeper into that person’s story? And we wonder why that hurts so much and leads to burn-out. We need to connect with our patients. Connecting stacks the deck in favor of healing.”
He encourages his audience to create time and intention for specific clinical appointments just to do healing work. He referenced an intriguing study he authored that showed patients who saw a caring, empathetic doctor for the common cold actually got better sooner than those who saw a ‘burned-out doc’ who didn’t connect. The intriguing part was that not seeing a doctor at all actually showed better improvement than seeing the burned-out doctor. “So the patient is better off staying home than seeing a doctor who doesn’t have the energy to care!”
“This study and countless others support the trend that health is more about what we do than what we take.”
“How do we create a perception for our patients so they believe that they can get better?” By listening and understanding their individual concerns and goals. “Non-compliance is two people working towards different goals. If your patient is non-compliant, you haven’t listened to them long enough to understand what their goals are.” He adds that so often doctors try to project what they know onto their patients, when value-based care is really what you want your health for, and how we can help you achieve it.
He reminds us that in 2018, The Centers for Medicare & Medicaid Services (CMS) are going to shift their reimbursement model so that 90% is value over volume which means physicians will be reimbursed for the number of people they keep well. “We are not going to be paid by how much we do in the future; we are going to be paid on how much we keep people out of the hospital.”
“That is the shift: putting the patient in control, and that’s why primary care is a 15-fold return on investment because hopefully we know the story and can go a little deeper.”
Dr. Rakel closes by saying, “It really gives me hope as a physician because the art of medicine can really improve these outcomes just with your ability to sit, listen – and care.”