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Optimizing Integrative and Preventive Medicine: Connecting All the Pieces 

Optimizing Integrative and Preventive Medicine: Connecting All the Pieces
Chapter:
Optimizing Integrative and Preventive Medicine: Connecting All the Pieces
Source:
Integrative Preventive Medicine
Author(s):

Cynthia Geyer

DOI:
10.1093/med/9780190241254.003.0013

Given the powerful impact that integrative and preventive medicine can have on lowering risk of disease, improving health outcomes, and enhancing overall well-being and vitality, coupled with the depth and breadth of possible interventions, how do we connect the pieces with our patients and prioritize recommendations for each individual? The National Academy of Medicine’s (NAM’s) Vital Directions for Health and Health Care initiative was launched in 2016 in recognition of the strain on the healthcare system due to increased demands and unsustainable cost of care, along with the fact that care decisions do not always align with patient goals. They are mobilizing leading researchers, scientists, and policy makers across the country, and have identified as one of their three goals the ensuring of better health and well-being. The NAM has recognized that shifting emphasis toward prevention, behavioral and social services, and improving physical activity and nutrition while also addressing health disparities will be crucial to advance the health of communities and populations.1,2,3,4,5 A recent review of NHANEs data showed that only 2.7% of Americans met the four core health behaviors/parameters associated with low risk of disease: eating a healthy diet, being sufficiently active, not smoking, and having a recommended body fat percentage.6 Clearly there is a critical need to translate evidence into practice for ourselves and for our patients. Integrative and preventive medicine practitioners will continue to play an increasing role in meeting these objectives.

One of the key tenets of integrative and preventive medicine is a reaffirmation of the importance of the therapeutic relationship, with practitioners and patients as partners.7 The time invested in an initial encounter can be instrumental in establishing a connection in which the clinician develops an understanding of the person seeking care, beyond his or her symptoms: his/her goals, fears, supports, readiness to change, perceived challenges or barriers, and overall philosophy, level of interest, and understanding related to various modalities and potential therapies. Motivational interviewing, which was initially developed by William R. Miller in the early 1980s as an approach for working with people with alcohol problems,8 is one model of collaborative communication that is showing evidence of benefit in areas as broad as medication adherence, weight loss, and dietary change.9,10,11,12 It is defined as a “collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” The principles taught in motivational interviewing can be helpful in the process of working with patients and include the following:

  1. 1. The spirit is collaborative, not confrontational, and seeks to understand the person’s frame of reference through reflective listening, acceptance, and nonjudgment.

  2. 2. The clinician’s role is to draw out the patient’s own motivations and skills for change instead of imposing his or her own opinion.

  3. 3. Focusing on previous success and highlighting existing skills and strengths supports self-efficacy.

The acronym OARS highlights the type of communication used in motivational interviewing that can facilitate dialogue in an empathetic and nonjudgmental way: open-ended questions, affirmation, reflective listening, and summarization.

Although motivational interviewing teaches a nonhierarchical model that may be particularly useful in helping resolve a patient’s ambivalence when the focus is on behavior change, it is also important to understand what motivational interviewing is not. As reviewed by Miller in 2009, motivational interviewing is not the transtheoretical model, decisional balance, or client-centered therapy. It is not a way to convince people to do what you want, nor is it a panacea.13 Positive patient-centered communication,14 another framework that overlaps with motivational interviewing, has been associated with higher levels of self-efficacy, particularly among people with greater chronic disease burden.15 Aspects of patient-centered communication include the following:

  1. 1. allowing patients to ask questions

  2. 2. attending to their emotions

  3. 3. involving them in decisions

  4. 4. ensuring their understanding

  5. 5. helping to deal with uncertainty

Both motivational interviewing and positive patient-centered communication address some of the psychological needs described in self-determination theory that have been found to predict greater adherence to recommended health behaviors.16,17 Those three needs are autonomy (the feeling of having control over your choices), relatedness (a sense of belonging or connection), and competence (having the skill or knowledge needed). The growing field of integrative health coaching incorporates these tenets in a collaborative relationship that is solution focused, working with factors that can contribute to a person’s achieving his or her goals. These factors include accessing resources and support, overcoming internal and external challenges to change, and generating alternatives and backup plans.18

One challenge in integrative and preventive medicine is that this type of collaborative approach takes a considerable time investment, especially initially. In addition, the increasing use of electronic medical records can serve to put a physical barrier between the patient and the practitioner. Optimizing time spent between the practitioner and the patient while minimizing distraction that can interfere with the therapeutic relationship is of utmost importance. Having a previsit intake, using a questionnaire and review with a nurse, is one model that can be very effective (CR personal experience). Not only can the nurse ascertain goals, readiness to change, health habits, past and family history, supplement and medication list, and perceived barriers to change prior to the appointment but also he or she can review recommendations, assist with goal setting, and ensure follow-up afterward as a critical member of the integrative healthcare team. The information gathered in advance can be input into the Electronic Health Record (EHR) and help the practitioner and patient prioritize their focus in their subsequent visit. Being present, maintaining eye contact, being able to acknowledge and respond to nonverbal communication—these critical aspects of the therapeutic encounter are at risk of being lost or diminished if the practitioner’s focus is on inputting data into the EHR. Having as much done as possible ahead of time creates more time for personal interaction.

In choosing which modalities or therapies to recommend, there are several factors to keep in mind. The concept of “evidence-based practice,” introduced by Dr. Sackett in 1996, illustrates the integration of the best research and highest level of evidence in the literature with the expertise and clinical skills of the practitioner and the unique values, concerns, and personal preferences of the patient19 (see Table 13.1). Dr. Braithwaite wrote an editorial in JAMA in 2013 stating that evidence-based medicine’s six most dangerous words are “there is no evidence to suggest,”20 an argument frequently used to reject the use of integrative and preventive approaches to treatment. While “absence of evidence is not the same as evidence of absence,”21,22 it is equally important for clinicians to look for the best evidence possible and to guard against recommending treatments that might be harmful, expensive, or that might delay a patient’s use of more effective treatments. Patients seeking care may be worried, suffering, exploring a multitude of therapies, and receiving conflicting advice from various practitioners; it is incumbent on those of us making treatment recommendations to be as transparent as possible about the level of evidence supporting them, what is not known, and the potential benefits and risks associated with those recommendations. A framework for guiding clinical decision-making, called the Clinical Applications of Research Evidence construct (CARE), has been outlined by Ali and Katz.23 This guide factors in efficacy, safety, level of evidence, availability of other treatment options, patient preference, and cost in the clinical application of evidence.

Table 13.1 Clinical Applications of Research Evidence Construct (CARE)

Safety

Efficacy

Science

Other Therapeutic Options

Patient Preference

Cost/Accessibility

Utilization Frequency of Treatment in Question

High

High

Decisive

None that is superior

Prefers recommended approach

Not a concern

Always

Probable

Possible

Unclear

None/few

Anything that will work

Needs consideration

Often

Low

Low

Absent/opposed

Many that are superior

Anything that will work

Prohibitive

Never

Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009

Source: Reference 24.

A recent Cochrane review found that the use of decision aids, which not only provide evidence-based information about a condition, treatment options, benefits, harms, and uncertainties but also help patients recognize the role of their values in making their decision, showed benefit in several outcome measures. Patients had better knowledge and understanding of risk, were more engaged and decisive in the decision-making process, and felt less decisional conflict related to feeling uninformed or being in conflict with their values, and there was a positive effect on patient–practitioner communication.25

Generally speaking, the lowest cost, lowest risk, most effective, and quickest acting option that aligns with the patient’s goals will be the highest priority. In the setting of pain, stress, or sleep deprivation, executive function in the frontal lobe is down-regulated and decision-making is more emotionally driven.26,27,28,29 This impacts one’s ability to set intentions, think about the long-term impact of lifestyle choices on health and well-being, and engage in behavior change. Someone experiencing physical pain may first need targeted referrals for physical or manual therapies or acupuncture before being in a position to consider dietary change or starting an exercise program. The recent review by the National Institutes of Health (NIH) of nonpharmacologic treatments such as acupuncture and manual therapy for pain30 is timely in light of the growing opioid epidemic. This along with the broader implications of the benefits of treating pain as an adjunct to supporting people’s efforts to adopt and maintain healthier lifestyle habits will hopefully translate toward better insurance coverage for these options. People in emotional distress may need to see a psychologist, social worker, or other qualified mental healthcare specialist to address those concerns first. Working as part of a multidisciplinary integrative and preventive healthcare team can be an effective model for prioritizing treatments and making appropriate referrals. For practitioners who are not working as part of a team in their practice setting, keeping a database of trusted specialists in the community to whom they can refer and having a good understanding of existing community resources and programs that target exercise and nutrition allow the recreation of a team-based approach for their patients.

One important aspect of the therapeutic relationship that is often overlooked, both in traditional and integrative and preventive medicine, is how we use language. Our word choices can have far-reaching impact not only on the establishment of trust but also on a patient’s perception of the status of his or her health and sense of self-efficacy. Two areas in particular can have unintentional, and potentially negative, impact: when a practitioner’s opinion is stated as fact, and when diagnostic labels are used. An example of the first is illustrated by the story of a woman who came to see me confused about how to manage her significant low mood and vasomotor symptoms that started abruptly after an emergency hysterectomy. Her internist told her she should not take hormones or she would be at risk of a stroke or a heart attack; her gynecologist told her she should take them or she would “dry up and age.” Both physicians were undoubtedly interpreting the sometimes conflicting literature about hormone therapy and disease risk. However, by conveying their interpretations as definitive and reaching opposite conclusions, not only was the patient left confused, conflicted, and torn between her two physicians but she was also not asked how she felt about hormone therapy nor offered alternatives to manage her symptoms.31 An example of the pitfalls of labels is shown in the story of a woman who consulted my colleague for a second opinion after seeing an integrative medicine practitioner who had ordered a battery of tests. When asked how she felt and what was going on related to her health, her answers were primarily repeating the “diagnoses” she was given after her test results: “They told me I was a poor detoxifier and had mercury toxicity that caused adrenal fatigue.” In the attempt to find explanations for symptoms, her practitioner had used labels based on testing that is not widely accepted in traditional medicine. The end result was to contribute to her patient’s negative and seemingly fixed view of how healthy she was. While both these examples may represent the extremes, it is incumbent on us to be mindful of how we use language. Acknowledging uncertainty in the literature; being clear when our recommendations are based on personal experience/opinion/interpretation of studies versus clear guidelines derived from large clinical trials; and using descriptive language instead of limiting labels when appropriate will guard against the unintentional negative consequences our words may have on our patients’ well-being.

What about the role of laboratory testing? It is not necessary to do lab work in order to work with people around strategies to improve dietary habits, incorporate mindfulness or breath-based approaches, or start low-level movement or exercise. Recognizing the potential vulnerability of patients who do not feel well, practitioners have an ethical responsibility to guard against the unnecessary use of expensive laboratory testing that does not add to the clinical picture. Testing may be important to rule out a condition that might need more targeted treatment, such as sleep apnea, hypothyroidism, anemia, or significant ischemia or hypertension in response to exercise. One of my mentors when I was a medical student used to say, “between the laboratory and the diagnosis, you have to stop at the bedside.”32 Those words of wisdom are relevant both in guiding the clinician’s choice of testing based on the person’s clinical presentation, and in the interpretation of the results. Some types of testing, even in a patient without symptoms, can be motivating for behavior change, aid in the customization of recommendations, and provide a trackable marker of response. No-cost or low-cost anthropometrics, such as height and weight, BMI, waist:hip ratio, validated measures of fitness and strength, and blood pressure are relatively easy to obtain and helpful to track progress for many patients. Questions to consider when ordering tests:

  1. 1. Is this necessary to rule out a treatable medical condition?

  2. 2. Will the results modify treatment recommendations?

  3. 3. Is the patient going to incur significant out-of-pocket cost for testing?

If you are not doing laboratory testing in your practice, know to whom you can refer in the event that someone is not improving or if there are concerning signs or symptoms that warrant more than just a lifestyle or preventive medicine approach.

Whenever possible, an opportunity for experiential learning should be provided.33,34 This can help someone move from a theoretical or cognitive understanding of a recommended modality or desired behavior toward an embodied connection to how he or she can feel in response to that selected behavior change or treatment option. That also serves to shift motivation for ongoing change away from an external source (provider’s recommendation, fear of a disease) to an internal source (feeling better, a sense of self-efficacy), which may be more predictive of long-term success.35,36,37 In some instances, for example a guided cooking or exercise class, the experience teaches skills, provides an opportunity for fun, and reinforces confidence in one’s ability to embrace change. Options for providing experiential learning range from a destination health resort; to a clinic which might house a teaching kitchen and fitness and yoga classes on site; to a community network in which referrals are made to offsite facilities (such as a local YMCA). Many practices are incorporating group visits as a way to provide these lifestyle-focused experiences and reach more people in a cost-effective way. Groups can also create an additional support structure for patients and an opportunity to share their insights with and learn from others who may have experienced similar symptoms, conditions, or challenges to change.

Providing written recommendations and clearly articulating the rationale behind them, how they align with the patient’s goals, describing possible side effects and the expected time frame to see the impact helps set expectations. Allowing time for patients to ask questions and reflect their understanding of recommendations can clarify any potential misunderstandings. Planning follow-up and making sure patients know how to contact the practice (and who the primary contact should be) if questions or concerns arise between visits helps build in accountability and connection. Ongoing coaching between visits can be particularly helpful in supporting behavior change, especially related to nutrition, movement, and smoking cessation.

In summary, it is clear that the practice of integrative and preventive medicine has a critical role to play in improving the health and well-being of people, families, and communities. Key steps to optimize the effective practice of integrative and preventive medicine include the following points.

  1. 1. Spend time establishing a collaborative, mutually respectful partnership with your patients; motivational interviewing and patient-centered communication models teach validated approaches to facilitate this process.

  2. 2. Align your recommendations with your patient’s goals and frame of reference.

  3. 3. Recognize when addressing pain, stress, and emotional distress needs to take first priority; in turn, that may support a person’s ability to engage in lifestyle changes to support health.

  4. 4. Know when and to whom you can refer: create your integrative team of experts in the clinic and in the community.

  5. 5. Be clear about whether recommendations are based on personal opinion, clinical experience, or published guidelines.

  6. 6. Be mindful of the impact that the use of diagnostic labels may have on a person’s sense of well-being and hope.

  7. 7. Provide opportunities for experiential learning when possible.

  8. 8. Provide a written summary of recommendations and expected/possible outcomes.

  9. 9. Ensure understanding of recommendations and allow time for questions.

  10. 10. Schedule follow-up at a given interval and provide contact information for questions or concerns.

Engaging patients as partners in their health journey, making appropriate referrals to other members of the integrative medicine team, supporting self-efficacy and health behavior change that is congruent with patients’ goals, and ensuring periodic follow-up and reassessment can increase the efficacy of integrative and preventive medicine approaches to improving health outcomes.

References

1. Dzau VJ, McClellan M, McGinnis JM. Vital directions for health and health care. JAMA 2016;316(7):711. doi: 10.1001/jama.2016.10692.Find this resource:

2. Dietz WH, Douglas CE, Brownson RC. Chronic disease prevention. JAMA 2016;316(16):1645. doi: 10.1001/jama.2016.14370.Find this resource:

3. Goldman LR, Kumanyika SK, Shah NR. Putting the health of communities and populations first. JAMA 2016;316(16):1649. doi: 10.1001/jama.2016.14800.Find this resource:

4. McGinnis JM, Diaz A, Halfon N. Systems strategies for health throughout the life course. JAMA 2016;316(16):1639. doi: 10.1001/jama.2016.14896.Find this resource:

5. Loprinzi PD, Branscum A, Hanks J, Smit E. Healthy lifestyle characteristics and their joint association with cardiovascular disease biomarkers in US adults. Mayo Clin Proc 2016;91(4):432–442. doi: 10.1016/j.mayocp.2016.01.009.Find this resource:

6. Maizes, V, Rakel D, Niemiec C. Integrative medicine and patient-centered care, Explore (New York, N.Y.) 2009;5(5):277–289.Find this resource:

7. Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol 2009;64(6):527–537. doi: 10.1037/a0016830.Find this resource:

8. Martins R, McNeil D. Review of Motivational interviewing in promoting health behaviors. Clin Psychol Rev 2009;29(4):283–293.Find this resource:

9. Bean MK, Biskobing D, Francis GL, Wickham E. Motivational interviewing in health care: results of a brief training in endocrinology. J Grad Med Ed 2012;4(3):357–361.Find this resource:

10. Hardcastle S, Taylor A, Bailey M, Harley R, Hagger M. Effectiveness of a motivational interviewing intervention on weight loss, physical activity and cardiovascular disease risk factors: a randomised controlled trial with a 12-month post-intervention follow-up. Int J Behav Nutr Phy 2013;10:1–16. doi: 10.1186/1479-5868-10-40Find this resource:

11. Resnicow K, McMaster F, Bocian A, et al. Motivational interviewing and dietary counseling for obesity in primary care: an RCT. Pediatrics 2015;135(4):649–657.Find this resource:

12. Miller W, Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychoth 2009;37(2):129–140.Find this resource:

13. King A, Hoppe RB. Best Practice for patient-centered communication: a narrative review. J Grad Med Ed 2013;5(3):385–393.Find this resource:

14. Rutten F, Hesse B, Sauver S, et al. Health self-efficacy among populations with multiple chronic conditions: the value of patient-centered communication. Adv Ther 2016;33(8):1440–1451.Find this resource:

15. Eynon M, O’Donnell C, Williams L. Assessing the impact of autonomous motivation and psychological need satisfaction in explaining adherence to an exercise referral scheme. Psychol Health Med 2017;22(9):1056–1062.Find this resource:

16. McDavid L, McDonough M, Blankenship B, LeBreton J. A test of basic psychological needs theory in a physical activity-based program for underserved youth. J Sport Exercise Psy 2017;39(1):29–42.Find this resource:

17. Simmons LA, Wolever RQ. Integrative health coaching and Motivational interviewing: Synergistic approaches to behavior change in healthcare. Glob Adv Health Med 2013;2(4):28–35.Find this resource:

18. Sackett D.Evidence-Based Practice. http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036021. Accessed December 5, 2016.

19. Braithwaite R. A piece of my mind: EBM’s six dangerous words. JAMA 2013;310(20):2149–2150.Find this resource:

20. Altman DG, Bland JM () Absence of evidence is not evidence of absence. BMJ 1995;311(7003):485.Find this resource:

21. Alderson P. Absence of evidence is not evidence of absence. BMJ 2004;328(7438):476–477.Find this resource:

22. Ali A, Katz DL. Disease prevention and health promotion. Am J Prev Med 2015;49(5):S230–S240. doi: 10.1016/j.amepre.2015.07.019.Find this resource:

23. Stacey D, Légaré F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014;28(1). doi: 10.1002/14651858.CD001431.pub4.Find this resource:

24. Ali A, Katz DL. Disease prevention and health promotion. Am J Prev Med 2015;49(5):S230–S240. doi:10.1016/j.amepre.2015.07.019.Find this resource:

25. Arnsten A. Stress signalling pathways that impair prefrontal cortex structure and function. Nature Reviews: Neuroscience 2009;10(6):410–422.Find this resource:

26. Arnsten A. Stress weakens prefrontal networks: molecular insults to higher cognition. Nature Neuroscience 2015;18(10):1376–1385.Find this resource:

27. Reidy B, Hamann S, Inman C, Johnson K, Brennan P. Decreased sleep duration is associated with increased fMRI responses to emotional faces in children. Neuropsychologia 2016;84:54–62.Find this resource:

28. Wang L, Chen Y, Yao Y, Pan Y, Sun Y. Sleep deprivation disturbed regional brain activity in healthy subjects: evidence from a functional magnetic resonance-imaging study. Neuropsychiatr Dis Treat 2016;12(1):801–807.Find this resource:

29. Nahin R, Boineau R, Khalsa P, Stussman B, Weber W. Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clinic Proceedings 2016;91(9):1292–1306.Find this resource:

30. Becerra-Perez M, Menear M, Turcotte S, Labrecque M, Legare F. More primary care patients regret health decisions if they experienced decisional conflict in the consultation: a secondary analysis of a multicenter descriptive study. BMC Family Practice 2016;7(1):156.Find this resource:

31. Middendorf D, faculty at Ohio State University College of Medicine, 1986. Personal communication.Find this resource:

32. Davis JN, Spaniol MR, Somerset S. Sustenance and sustainability: maximizing the impact of school gardens on health outcomes. Public Health Nutr 2015;18(13):2358–2367. doi: 10.1017/s1368980015000221.Find this resource:

33. James A, Hess P, Perkins M, Taveras E, Scirica C. Prescribing outdoor play: outdoors Rx. Clin Pediatr 2017;56(6):519–524.Find this resource:

34. Teixeira PJ, Carraça EV, Markland D, Silva MN, Ryan RM. Exercise, physical activity, and self-determination theory: a systematic review. Int J Behav Nutr Phys Act 2012;9(78). doi: 10.1186/1479-5868-9-78.Find this resource:

35. Teixeira PJ, Silva MN, Mata J, Palmeira AL, Markland D. Motivation, self-determination, and long-term weight control. Int J Behav Nutr Phys Act 2012;9. doi: 10.1186/1479-5868-9-22.Find this resource:

36. Schneider ML, Kwan BM. Psychological need satisfaction, intrinsic motivation and affective response to exercise in adolescents. Psychol Sport Exerc 2013;14(5):776–785.Find this resource:

37. Schneider ML, Kwan BM. Psychological need satisfaction, intrinsic motivation and affective response to exercise in adolescents. Psychol Sport Exerc 2013;14(5):776–785.Find this resource:

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