Commentary

Walking Our Talk: Putting the Integrity into Integration

Daniel Redwood, DC

 

author email    corresponding author email   

Topics in Integrative Health Care 2010, Vol. 1(1)   ID: 1.1002



Published on
August 30, 2010
Text Size:   (-) Decrease the text size for the main body of this article    (+) Increase the text size for the main body of this article
Share:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo

Abstract

With passage of the Patient Protection and Affordable Care Act of 2010, federal law for the first time mentions “integrative health care,” endorsing it as a key component of America’s future health care system, while also recognizing a new designation of provider, the “integrative health care practitioner. However, the law defines neither of these terms. Their ultimate definitions, and the extent to which these may foreshadow a revitalized system of health care delivery, remain very much in play. Discussions exploring the nature of integrative health care have matured in recent years. But no matter how brilliantly conceived, integrative delivery systems cannot be sufficiently functional and sustainable unless the people working within them substantially embody the core values and skills of integrative practice. Integrative structures require integrated individuals, and to the extent that these values and skills are absent or deemphasized in health professions training programs and in the personal beliefs and behaviors of practitioners, the broader reform mission is in jeopardy. A sustainable integrative health care system must identify and nurture beliefs and behaviors that model health-affirming ideals, including patient-centeredness, openness, pluralism, holism, preventive self-care, harmony of action and belief, and minimalism.

Introduction

With passage of the Patient Protection and Affordable Care Act of 2010, federal law for the first time mentions “integrative health care,” endorsing it as a key component of America’s future health care system, while also recognizing a new designation of provider, the “integrative health care practitioner. However, the law defines neither of these terms. Their ultimate definitions, and the extent to which these may foreshadow a revitalized system of health care delivery, remain very much in play. Now is the time for those who perceive themselves and their work as integrative to define them with care.

Toward a New Era of Collaboration and Integration



Discussions exploring the nature of integrative health care have matured in recent years. Two recent, concise background resources for those now seeking to enter the conversation as informed participants are: (1) Leonard Wisneski’s “The Four Pillars and Two Guideposts for the Healing Professions,”1 a chapter in the 2009 edition of his textbook, The Scientific Basis of Integrative Medicine  (Table 1); and (2) Donald Berwick’s “Models of Care,”2 based on his 2009 keynote address at the Integrative Medicine Summit, a landmark event sponsored by the Institute of Medicine of the National Academy of Sciences. Both Wisneski, an integrative physician who now leads the Integrated Healthcare Policy Consortium, and Berwick, a pediatrician and Harvard professor who now serves as Director of the Centers for Medicare and Medicaid Services, highlight the importance of evidence-informed practice and patient-centeredness (as does Berwick in his widely cited Health Affairs article, “What Patient-Centeredness Should Mean: Confessions of an Extremist”)3 while also proposing practical steps toward birthing a new era of collaboration and integration.

Table 1. Wisneski’s “Four Pillars and Two Guideposts for the Healing Professions.” 1

The Four Pillars
1. Integrative collaborative care
2. Cultural competence
3. Clinical sensitivity
4. Technological innovation

The Two Guideposts
1. Increased services to the underserved
2. Decrease the brain drain of healthcare professionals


Wisneski co-founded the Design Principles for Health Care Renewal Working Group, which engaged in an early effort (2001) to develop integrative principles for revitalizing the U.S. health care system. Starting with the seminal Institute of Medicine document, Crossing the Quality Chasm, A New Health System for the 21st Century4 (which Berwick played a central role in developing),5 Wisneski and colleagues expanded upon those of its findings most relevant to the nascent field of integrative health care, identifying the foundations of an emerging integrative paradigm (Table 2).1 With this model as a basis, they called on all health practitioners and policy makers to honor wholeness and interconnectedness in all actions; expand the evidence base; prioritize approaches that enhance self-repair and healing; favor minimally invasive methods except when more invasive approaches are urgently required; partner with patients, family and other practitioners; embrace diverse health care systems; use illness and symptoms as opportunities for learning and growth; and respect the time required for personal and health system change.

Table 2. The Health Care Renewal Working Group’s foundational principles. 1

1.  Honor wholeness and interconnectedness in all actions.
2.  Enhance the capacity for self-repair and healing.
3.  Prioritize care in accordance with a hierarchy of treatment.
4.  Improve healthcare through continuously expanding the evidence base.
5.  Embrace the fullness of diverse healthcare systems.
6.  Partner with patients, their families, and other practitioners.
7.  Use illness and symptoms as opportunities for learning and growth.
8.  Explore integration in one’s own care.
9.  Align resource investment with these healthcare principles.
10. Respect the time required for personal and health system change.


Berwick, who is now in a position to implement at least some of what he espouses, proposed in his Institute of Medicine keynote an eight-point set of principles for integrative medicine (Table 3) well-aligned with the overall thrust of the Health Care Renewal Working Group’s proposals. Berwick’s model of integrative care emphasizes patient empowerment, social support, coordinated care, and evidence-informed practice. These are urgently needed to ensure that delivery structures aimed at broadly implementing integrative health care become more than hollow shells with new names. Berwick’s understanding of these issues is a hopeful sign that creation of streamlined, health-affirming structures of integration will garner a sufficient portion of policy makers’ attention, time, and energy in the critical transition years of the coming decade.

Table 3. Berwick’s eight principles for integrative medicine.2

1.  Place the patient at the center.
2.  Individualize care.
3.  Welcome family and loved ones.
4.  Maximize healing influences within care.
5.  Maximize healing influences outside care.
6.  Rely on sophisticated, disciplined evidence.
7.  Use all relevant capacities—waste nothing.
8.  Connect helping influences with each other.


But no matter how brilliantly conceived, delivery structures cannot be sufficiently functional and sustainable unless the people working within them substantially embody the core values and skills of integrative practice. Integrative structures require integrated individuals, and to the extent that these values and skills are absent or deemphasized in health professions training programs and in the personal beliefs and behaviors of practitioners, the broader reform mission is in jeopardy.

Nurturing an Integrative Worldview: Beliefs and Behaviors



A sustainable integrative health care system must identify and nurture beliefs and behaviors that model health-affirming ideals. What are these beliefs and behaviors? (Table 4)

Table 4. Redwood’s six integrative beliefs and behaviors.

1.  Openness
2.  Pluralism
3.  Holism
4.  Preventive self-care
5.  Harmony of action and belief
6.  Minimalism


1. Openness. Integrative health care, at its heart, is based on openness to new information and rejection of dogma. Practitioners and support staff must, therefore, be willing to change opinions and practices as new information emerges. Moreover, they need to understand (and training programs must strongly emphasize) that such changes are a built-in feature of contemporary healing arts and should be expected to continue throughout their careers. This is particularly challenging in periods of major transition between paradigms, when old models no longer provide adequate answers and new constructs are still in the formative stages. Such times of uncertainty are fertile and dynamic, yet unstable and often uncomfortable. The security of tradition exerts a powerful pull. Unless change is handled with great care, it can activate a reactionary passive-aggressive mindset (or, in some cases, overt rebellion) in some of those tasked with its implementation.


Openness also involves receptivity to the opinions of patients, other practitioners and other healing arts. It is the critical starting point upon which all else depends.

 

2. Pluralism. The most important thing I learned in 25 years of full-time private practice is that in health, healing, and health care, most questions have more than one correct answer. Recognizing the redundancy and multiplicity of the body’s healing pathways and the means to access them, should lead thoughtful practitioners to a profound sense of humility. As we learn to see the clinical picture from different angles (the basis of traditional grand rounds and its virtual analogues) with the help of colleagues whose training and skill sets complement our own, we usually find that we have part of the answer but not all of it, that others’ knowledge expands and enhances our own, and that cross-disciplinary referral and collaboration is a sign of strength rather than weakness.


3. Holism. The great lesson we have learned from the science of ecology is that components of natural systems are richly interactive, with cause-and-effect relationships moving simultaneously in all directions in a complex network of multiple feedback loops. This has wide-ranging implications. The key application for the healing arts—by no means fully appreciated and integrated as yet—is a growing and probably irreversible loss of legitimacy for single-source causation as a fundamental organizing principle in the health sciences.


Even for those areas where the tightly focused gaze of medical research has achieved its greatest breakthroughs (e.g., antibiotics for life-threatening infections), there is now broad recognition that public health and lifestyle-based prevention measures often obviate the need for such cures, and that health care systems that focus too much on treatment and too little on prevention are deeply dysfunctional. The current system’s imbalances in resource allocation, with budgets heavily skewed toward disease treatment rather than prevention and health promotion, mirror the bodily imbalances created by unintegrated modern lifestyles.


4. Preventive self-care. Though dramatic cures may reap more headlines, health promotion and disease prevention are the highest expression of the healing arts. Diet, exercise and stress management are the three pillars of lifestyle-based prevention and health promotion. As integrative physician James Gordon, the director of the Center for Mind-Body Medicine who chaired the White House Commission on Complementary and Alternative Medicine Policy6 has aptly noted, self-care is primary care.7 No systemic solution to the current health care crisis is possible unless large numbers of people choose to live in far more healthy ways. As integrative practitioners, we need to model the practices we recommend to others.


Health practitioners whose lifestyles offer an example of health-affirming choices are in the best position to influence patients to do likewise. This does not mean that we must be in perfect health before we can legitimately offer advice; it means that we need to make a sincere, ongoing effort to choose a healthy lifestyle. This reflects on our own integrity as well as that of our professions. Honest self-evaluation should include questions like these:8


  • Does my diet consist mainly of whole foods?
  • Do I eat several servings of vegetables and fruits daily?
  • Do I eat junk foods more than occasionally?
  • Do I exercise regularly?
  • Do I get adequate rest?
  • Do I utilize stress reduction methods?
  • Do I smoke?
  • Do I use alcohol or caffeine immoderately?
  • Do I abuse drugs?

We need to walk our talk.


5. Harmony of action and belief. Many years ago, toward the end of a presentation I was giving, a man in the back of the room raised his hand and asked, “What would you say are the five most important things we should do to be healthy?” As any speaker who has been asked a five-part question will immediately understand, this required some quick thinking on my part. My first thoughts were about a whole foods diet, regular exercise, and stress management approaches that elicit the relaxation response.


But I was troubled by a nagging sense that I was missing the main point. Then, in a flash, I realized that the single most important thing we can do for our health is to bring our actions into accord with our beliefs. This is, in a word, integrity. For example, if you are convinced that it would be healthy for you to stop eating so much sugar and meat, and to go to the gym twice a week rather than once a month, and if you fail to act on these insights, you are sending to the deepest levels of your body and mind a message that you are not serious about your health.


Above and beyond any specifics of our health-related choices, moving toward greater harmony between our beliefs and our actions is crucial. None of us is perfect; we all have room for improvement. Every step in the right direction matters. Large steps matter more than small steps. And first steps—the ones where we break out of our long-entrenched patterns of inertia—carry the greatest transformative potential of all.


6. Minimalism. At a deep level, health care practitioners, educators, and policy makers are activists. We want to change things for the better—for our patients, our society, and our world. This is a fundamentally healthy impulse, yet one that must be deployed consciously and artfully to avoid the “doing too much of a good thing” conundrum. Across the healing arts spectrum, from the most invasive approaches (e.g., major surgery, genetic therapy), to the least invasive (e.g., art therapy, non-cognitive meditation), we have learned (or will learn) that to effect sustainable change, we must do just enough and no more. If one course of medication, or acupuncture treatments, or spinal adjustments can prove sufficient to the needs of a patient, then we should not assume that two, or two dozen, will yield a better result. Everyone understands this, yet the dynamics of the market system militate in precisely the opposite direction, with quantity consistently trumping quality. This is the crux of the health reform challenge—can we find ways to apply, in a fair manner, the principle of therapeutic minimalism across the board?


The danger of endorsing a minimalist strategy is that, if applied in an unfair and discriminatory manner, it can easily serve as a philosophical justification for policies that supply minimal services to the weak and maximum profits to the strong. Moreover, in budgetary deliberations where competing healing arts and specialties vie for pieces of a finite reimbursement pie, it can be used to rationalize draconian limits on groups with less political clout, even where this rewards approaches that are less effective or cost-effective. These dangers are always with us; the current health reform effort arose directly from widespread revulsion with these and other injustices in the U.S. health care system. Our goal must be to learn from the failures of the past rather than creating new permutations of those failures.


We are poised at a pivotal moment. At every point along the way, health care reform will face efforts to subvert its underlying vision of equal access, quality, evidence- and prevention-based policy, and integrative care. We are only at the beginning of the reform process. Its ultimate success depends on our holding to the vision, carefully nurturing and refining models of integrative and preventive care that embody its essence, prioritizing the genuine needs of the many over the excessive profits of the few, and working on ourselves so that we more fully personify the principles we profess and thereby midwife the transformation we seek.
Share:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo

References

1.   

Wisneski LA, Anderson L. The four pillars and two guideposts for the healing professions. In: The Scientific Basis of Integrative Medicine. 2nd ed. Boca Raton, FL: CRC Press; 2009:309-343.



2.   

Berwick DM. Models of care. In: Schultz AM, Chao SM, McGinnis JM, rapporteurs: Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit. Washington: The National Academies Press; 2009:53-59.

 [ Full-Text Link ]

3.   

Berwick DM. What 'patient-centered' should mean: confessions of an extremist. Health Aff. July 1, 2009;28(4):w555-565.

 [ Full-Text Link ]

4.   

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington: National Academies Press; 2001.



5.   

Berwick DM. A User’s Manual for the IOM’s ‘Quality Chasm’ Report. Health Aff. May 1, 2002;21(3):80-90.

 [ Full-Text Link ]

6.   

Final Report: White House Commission on Complementary and Alternative Medicine Policy. Washington: Department of Health and Human Services. NIH Publication 03-5411, 2002.

 [ Full-Text Link ]

7.   

Gordon JS. Self-care as primary care. In: Manifesto for a New Medicine. New York: Perseus Books; 1996:92-164.



8.   

Redwood D. Pathways for an evolving profession. In: Redwood D, Cleveland CS III, eds: Fundamentals of Chiropractic. St. Louis: Mosby; 2003:623-628