The Coming Paradigm Shift in Health Care – Part 2

Dr. Ralph Snyderman is Chancellor Emeritus of Duke University and chair of the Institute of Medicine’s “Summit on Integrative Medicine” at the National Academy of Sciences in Washington, DC. The Summit s a 2-1/2 day historic event in which some of the most thoughtful and important thinkers are coming together to envision a system that can more effectively improve our health and well-being, integrating the best of traditional and non traditional approaches in healing. These approaches may play an important part in President Obama’s health reform legislation.

Dean Ornish, M.D.: This represents a departure for the Institute of Medicine and the National Academy of Sciences who, in the past, might have been critical of these ideas. What do you think has shifted, and why?

Ralph Snyderman, M.D.: Our current system is in danger of collapse. This is a very critical time for our country to have a meeting with a new administration, a time of hope and expectation of change. The current system is highly flawed on the one hand in terms of what it does do, and on the other hand the things that it does not do–taking into account the needs of the patient when they are facing a severe, life-threatening disease. I give a lot of credit to the current President, Harvey Fineberg, who is committed to science and evidence-based approaches to care but also is open with an appropriate degree of humility that we need to recognize that there may be a lot of approaches which work that we don’t understand.

What is the difference between integrative medicine and complementary or alternative medicine? How would you respond to people like Arnold Relman, the former editor-in-chief of the New England Journal of Medicine, who said, “There’s no such thing as alternative medicine; there’s medicine that works and medicine that doesn’t work.”

Yes, but where I have difficulties in my own mind is the difference between something being scientifically proven and being intuitively obvious. For example, the issue of caring and compassion–does that need to be scientifically proven? When an individual is dealing with a very difficult problem and if we’re thinking about their health approach during that problem–the importance of maintaining will, motivation, empowerment–and the encouragement one could get from support groups or from mindfulness meditation, or from participating in yoga or from receiving acupuncture if the belief is that acupuncture may be helping with the particular problem–is that CAM or is that conventional, or is it common sense? Is it necessary to prove everything if the therapy itself causes no harm but allows the individual to feel empowered and motivated?

Integrative medicine uses the entire armamentarium, both traditional and nontraditional, to give an individual a full array of what they need to maintain and improve their health.

If an individual has a chronic disease such as cancer, integrative medicine may include everything that works and alleviates suffering. It recognizes that in addition to chemotherapy, the tumor is growing within a human being that is facing new fears, anxieties, and complexities in their life. What do they need to do to be able to navigate this very difficult path in which the therapies themselves might be very onerous; how do we enhance the individual’s will to be able to survive a difficult ordeal?

In the same context, many of the well-accepted treatments in conventional medicine are not proven to be safe and effective. For example, randomized trials showed quite clearly that angioplasties and bypass surgery neither prolong life nor prevent heart attacks in most people, yet this hasn’t altered the frequency with which those procedures are performed. Do you think there is a double standard, and if so, why? Do you think this conference may help in that regard?

I think that there is at some times a glaring lack of open-mindedness on the part of individuals that have come up in the same system that I have come up in–the scientific approach to understanding the pathophysiology of disease and the thought that everything that needs to be done or should be done should be scientifically proven. That is almost a religious belief that if we look at what is actually being done, we’re not particularly responding to that belief.

There are certain things that the medical enterprise tends to accept, whereas some people within the system react very negatively to things that are outside of the system. And I do think that on the part of some there is a double standard–that there is an immediate skepticism and rejection of things that would come into the system without it having grown up within the system.

Albert Einstein–no slouch as a scientist–once said: “Not everything that counts can be counted.” In other words, not everything that is meaningful is measurable. A few minutes ago you mentioned empowerment of the patient as something that’s important and yet it would be very hard to do randomized trials evaluating that.

Let me give you a personal experience that was eye-opening to me. I was at the Dana Farber Cancer Institute in Boston–one of the finest cancer institutes in the world–as a visiting professor. They have an integrative medicine program there in which acupuncture is practiced.

I was making rounds and asked whether I would see a patient with breast cancer who had a recurrence of her disease. Her platelet counts were below the level they felt comfortable with to give her the next round of chemotherapy. I went in to see her and she was in a darkened room in which there was New Age music in the background–very pleasant herbal types of smells–and she was lying with an herbal mask over her eyes. At the foot of her bed was a Chinese physician who was arranging acupuncture needles along her thorax down to her leg. He said he was manipulating her platelet meridians to try to increase her platelet blood cell count. My immediate thought was . . . let me put it politely . . . I don’t particularly believe that acupuncture can work on particular platelet meridians to increase her platelet count.

What were you actually thinking?

“Bulls***!” I asked her, “How do you feel about this?” And she looked at me deeply with a look of concentration and total commitment and said, “I feel empowered.” And the power of that expression and those words almost knocked me over backwards. It had a physical effect on me.

On the one hand, in my own mind–it may have been my left brain saying I have no scientific basis to believe that the positioning of needles is going to function specifically on a platelet meridian. I just have no reason to believe that.

On the other hand, I had this intense belief–maybe the right side of my brain–that this was a good, powerful and important thing. This woman was empowered. This is a good thing. Who are we as the power brokers of the medical profession to deny this degree of empowerment?

So much of what we were trained to do in conventional medical education is to do things to patients–we operate on them; we give them drugs. What I hear you saying is that unwittingly this may rob people of that sense of being in control and empowerment which many studies have shown has therapeutic benefits beyond whatever additional effects the treatment itself may provide.

Absolutely. I think one of the biggest misconceptions that has emerged in our society is the delegation of healthcare responsibility from an individual to the so-called health care system. “I don’t need to worry about this anymore. It’ll be taken care of for me.” That is wrong. There is virtually no condition other than acute, emergency conditions where the individual may or may not play very much of a role–everything else, health promotion, wellness, disease minimization, even treatment of complex diseases requires a tremendous involvement on the part of the individual.

People like yourself have been trailblazers in conducting landmark scientific studies showing the power of integrative medicine which have been necessary to get the attention of medical leaders, that there are strategies that are equal or more effective than many of the dangerous things that we do.

At the same time, there are some alternative medicine practitioners who make unfounded claims that may keep people from getting conventional treatments that may be helpful to them. How do you respond to those critics who are concerned about the Institute of Medicine meeting giving more credibility to people like that?

Well, I am as non-accepting of medical quackery and unscientific approaches as anybody else. I’ve grown up as a card-carrying scientist and I know the power of science to answer questions, and for many questions I don’t know of anything better than scientific approaches to answer them.

What offends me are unscientific claims that would give characteristics to various processes or approaches for which there is not only no rational explanation as far as we know but no evidence that they even work.

I have received communications from individuals worried that the IOM is opening itself up to certifying medical quackery just by using the term integrative medicine. Absolutely not.

Sen. Tom Harkin is one of the speakers. He’s been put in charge by President Obama of those aspects of health reform related to public health, prevention, and wellness, including integrative medicine. How do you see integrative medicine as being an important part of health reform, and what can it contribute?

I think integrative medicine is going to enlighten the discussions of healthcare reform. In my lifetime, I have not ever seen a moment as ripe for productive change as we have right now. With the health care crisis on the one hand and a new administration that has hallmarked itself on meaningful, appropriate change, I think there is an aggregation of more and more people with courage that are willing to say: Yes, we do need fundamental changes in our approach to healthcare.

This will be resisted ferociously by many who will view any kind of change in ways that will try to scare people, but I think for the first time there is such a broad understanding that we need fundamental change. It’s almost as though we’re viewing health care from a telescope looking backwards. The IOM conference is opening the doors, opening the curtains, and saying there are other ways of doing things than the way we’re doing them right now.

I think it would be virtually criminal to load the current system with more and more and more of our precious dollars when it could be done so much better. We are just seeing the beginning of a mass increase in the uninsured and under-insured, and if we needed to provide a lot of resources to help such people I would be totally for it but to provide those valuable resources so inefficiently–ineffectively–I think is criminal. I think it is our responsibility to do everything we can to do it better. We’re so capable of doing it.