What does the future hold for integrative medicine?What does the future hold for integrative medicine?

Where are we now? Where are we headed? NBJ spoke recently to health practitioners from a variety of practices to understand the current landscape facing integrative medicine and to assess the true degree of disrepair facing the traditional U.S. healthcare system.

Keri Marshall, ND, working out of Washington, D.C., is a practicing naturopathic doctor and medical director for herbal supplement company Gaia Herbs. Todd Hoover, MD, is a Philadelphia-based family physician specializing in homeopathic medicine. He was formerly medical director for Lockheed Martin. Molly Punzo, MD, is medical director for quality improvement at Shore Health System, a community of hospitals on the eastern shore of Maryland. Before that, she practiced internal medicine in Connecticut. We spoke to each practitioner independently and compiled their responses into the roundtable discussion that follows.

NBJ: What kind of practice do you operate? Who do you treat?

Keri Marhsall: About 50% of my practice is pediatrics. It's really rewarding for me to work with children because you get to make changes that will affect the whole family. You're working so much on dietary and lifestyle changes that you can't expect a child to make those types of changes without the rest of the family also embracing that. In addition to working with kids, the other half of my practice is both prevention and chronic disease management. So a lot of times I'll see people who have very complicated disease processes, who have been to see many different doctors, have had many tests done and are told that everything seems fine, yet they have a slew of symptoms that don't seem to resolve.

Todd Hoover: I've been in a solo practice for about the last 19 years. In my office, my primary focus is homeopathy first, and then nutrition, herbal and conventional medicines. What's different about me from an average physician is that when a patient comes in, I spend an hour to an hour and a half as an initial evaluation. I look at every parameter of health that I can from the perspective of what pushes the body out of health and how the body tries to get back into health. I feel that that interface shows where the current problem exists, and if you trace that line back into the past, you can get a sense of how health is eroded by chronic disease. Once I get that picture, I can predict the future in some ways, like if we continue along this path what's likely to happen next and what interventions need to take place.

Molly Punzo: I am an internist by training. I graduated in the early ‘90s and started seeing private patients up in Connecticut. They didn't teach me anything in medical school about nutritional supplements or nutraceuticals. Patients would come in and start talking about what they were taking, and I guess I just rolled my eyes less than most. They would really open up to me about what supplements they were taking and what seemed to help and what didn't, and I became really intrigued and concerned that I hadn't learned those things in my medical training. So I really took it upon myself to go to lectures and read books and just try and figure out the evidence behind supplements.

<center><strong>NBJ Practitioner Survey: What Do You Like About Selling Supplements?<br><em>Select the graph to enlarge</em></strong></center>

KM: In the end, some supplements are going to be prescribed short-term, whereas other things are most definitely going to be long-term. Long-term would definitely be things like fish oil, vitamin D, calcium, things like that. Short-term fixes would certainly be immune products or something like a botanical sleep aid. So if someone's having insomnia and it's affecting everything else in their life, then you need to do a short-term fix to address the insomnia so that they're able to sleep better, because if someone's not sleeping, nothing else will get well in their body.

TH: If someone's coming in with very acute problems, I see conventional therapies as excellent. If someone's had a heart attack, there's nothing better than western medicine. The emergency room is where western medicine shines. If someone's having a heart attack, I'm going to send them to the emergency room. They need nitroglycerin, morphine, a percutaneous angiography to get a stent placed. That's going to save their life. But that's not going to do anything for their heart disease. Statins can be helpful but may carry side effects. I'm going to look at what's happening with the diet, how the person got to this place. Diagnostically, I might look a little bit further than the average doctor.

MP: Arthritis is a good example. So many people have arthritis, and there are so many side effects from the anti-inflammatories. Especially when the news broke about cardiovascular side effects, people stopped using them, but didn't have anything for relief. And then the people using Tylenol had to worry about liver toxicity. For me, it was a natural fit to figure out what were the natural anti-inflammatories. There are all sorts of supplements to help reduce inflammation. And they reduce inflammation in the arteries so they also reduce the risk of cardiovascular disease. They don't have the side- effect profiles of the anti-inflammatories that cause gastric bleeding, among other things. So fish oils and turmeric and cumin, all those anti-inflammatories are a good place to start treating arthritis.

NBJ: What are your thoughts about the ethics of selling supplements through practitioners?

KM: For some physicians, whether it be medical doctors or chiropractors, it's actually illegal for them to sell dietary supplements out of their medical clinics. So there is an ethical component to that. As a naturopathic doctor who has sold dietary supplements out of my clinic, it's more about the understanding that, if I'm going to prescribe something for a patient that I'm anticipating will treat their disease process, then I want to know that it's a quality dietary supplement, rather than just sending them to the health food store and telling them to just pick up this dietary supplement.

TH: I think that I'm a little bit unusual in that I have chosen not to sell dietary supplements out of my office. For one, there's a conflict of interest that occurs. Ethically, I thought it would be better for me to have the freedom to choose whatever I felt was best for the patient rather than choosing what I sell. The second point is that I think it's good for my relationship with the community. So I'll send a patient out with a list of what I would like them to take. It creates an interface between me and the health food stores and Whole Foods. I'm sending them patients. They then have the ability to refer back to physicians like me. I think there's a natural interchange that takes place.

MP: I'm not a salesman. When you're trained as a physician, you're trained as a physician. In medicine, there are Stark Laws that say you can't make money on things you refer. But I always felt good about the products I recommended. I never chose a company based on what my reimbursement would be.

NBJ: What do you look for in a supplement company? Any companies that stand out?

KM: I want to know absolutely that the company is doing due diligence, especially with botanicals, around genus and species verification. I want to know the company is controlling adequately for things like heavy metals and pesticides, and also meeting label claims. As we all know, a lot of times we see testing that's done on products and they don't have the number of milligrams that's on the label.

TH: I look for commitment in a supplement company. Commitment is frequently reflected by longevity in the business. From an herbal standpoint, folks that tend to grow their own herbs, who control the process, the harvest, continually look for better extraction methods, measure the active ingredients in their compounds, those are hallmarks of a solid company for me. Gaia Herbs, for example. I like Gaia because it's readily available in the marketplace, it's pretty standardized and they're continually updating their process. Companies like Pure Encapsulations and Standard Process that market through offices, I'm interested in them, but it's just not a part of my practice.

MP: Quality control comes first and foremost. I look to make sure companies have GMP labels, that they do independent authenticity testing, that they test for — especially with fish oils — dioxins, carcinogens in the water, heavy metals. I really make sure that the company is GMP- and USP-certified for purity and quality. When I was practicing in Connecticut, Vital Nutrients was nearby. Back in the ‘90s and early 2000s, Vital Nutrients was doing quality testing when it wasn't popular. It costs a lot of money to do that well, so they were giving up a good part of their profit margin to say they were GMP. Since then, there are tons more. I'm sure I'd leave someone out if I tried to start naming them.

NBJ: How would you describe the quality of research in integrative medicine?

KM: We need a better understanding of nutrients and botanicals in the context of not being single-entity therapies. It's very infrequent that a single isolated nutrient or botanical will be given in isolation without dietary or lifestyle changes or other aspects also being altered. We need to have a better understanding of the concept of true integration of these things in clinical practice.

TH: I think we're moving to something called a comparative effectiveness research model. I want to distinguish the difference between efficacy and effectiveness. Efficacy means “better-than-placebo” for a specific symptom or disease. In western medicine, frequently a disease will be characterized by the fact that there is a treatment available. Fibromyalgia was not really recognized as a disease until they found a drug to treat it. That just requires a demonstration of efficacy. In comparative-effectiveness trials, what you're doing is comparing one treatment against another in a full person in a regular setting in their life. So you say, for fibromyalgia, does treatment with drug A work better than treatment with homeopathic drug B when the person is allowed to practice in the way they normally practice?

MP: I think one of the biggest obstacles is that not nearly as much research money goes into studying supplements as to studying drugs. A lot of medical research is funded by the pharmaceutical industry, which has a lot of money to throw at it. We don't have a lot of money because you can't patent a lot of this stuff. If you can't patent it, there's not a lot of money to be made. We need to put a lot more pressure at a national level to see more evidence-based research.

NBJ: What barriers are holding back the widespread growth of integrative medicine?

KM: One of the main things that's holding it back is, for one, a definition. A lot of people argue over what integrative medicine means. And along that same line, there's very little insurance coverage for it, and it varies state to state, so it's not something that's readily accessible or affordable to all people.

TH: What I see are practitioners that tend to work in isolated situations and they tend to try to treat everything. But in reality, there are some things that won't be helped by their discipline. What happens is these practitioners tend not to refer. In a hospital setting or with a family doctor, and I do this now, I refer to orthopedics, to neurology, urology. There's a lot of cross-referral and utilization of people within their specialties. But within the alternative medicine world, there's very little of that. People don't often refer because they don't know what the other discipline is good for. But if we get more people together, I think we'll see more cross-referral and I think it will feed growth.

MP: Because it's not always regulated, people worry about what's in the product. That's why I think we, as an industry, need to regulate ourselves. I'm not suggesting the FDA should do it. That's a whole other bag of worms.

NBJ: The recent overhaul to healthcare legislation is such a beast. Do you have particular insights into how the passed legislation might affect your industry in the short- and long-term?

KM: I think we can expect to see the healthcare bill revisited and see some changes. I welcome that in the sense that I think they did a poor job discussing preventative medicine. In the current bill, preventative medicine is discussed in the context of preventative testing, such as colonoscopy, mammography and prostate screening, rather than addressing underlying causative factors of disease, such as diet, nutrient deficiency or even nutrient excess. There are so many different aspects of lifestyle and wellness to be addressed in the context of prevention, rather than just diagnostic tests.

TH: There are provisions where complementary and alternative therapies show up. Two specific things have occurred. The definition of practitioners was altered such that insurance would cover alternative practitioners. Section 2706 — what it says is that, as long as you practice within the scope of your license, then you won't be discriminated against from an insurance coverage standpoint. Which, if translated correctly, means acupuncturists and homeopaths will suddenly become part of healthcare plans. How much they'll pay, or if they'll put on insurance caps, we don't know. There are many ways around it. But this is the first really inclusive definition of healthcare practitioners.

MP: There is a lot of possibility in that bill. How they end up budgeting it is going to be a whole different conversation,but it is inclusive of integrative medicine. Part of the reason that the public has been wary of integrative medicine is because there isn't a lot of credibility. By having those practitioners acknowledged and recognized, it will add a whole new level of credibility, finally.

NBJ: How do you view current levels of health insurance for alternative practices?

KM: It varies state to state. For example, naturopathic medicine is pretty much licensed in the far West Coast states and many of the New England states and some random states here and there in the middle, but there's really no uniformity to it. So what happens is it's just not accessible to people in states where there isn't full insurance coverage or licensure. Even states where there may not be reimbursement for visits, there can be reimbursement for labs that are ordered. There are just so many variables that keep it from being accessible to everyone.

TH: Healthcare insurance is heavily weighted toward treatment rather than prevention. And I think this'll be the downfall of the country in the long run. I used to work for a corporation, Lockheed Martin, and they've shifted to an insurance plan that's paid for and, to some degree, administered by the company itself. They recognize that if they don't take care of this problem, they will go bankrupt. What they did is start a vast preventive medicine system to help maintain healthcare costs. A lot of that is centered around obvious things like smoking cessation and weight loss. But I think it will creep into many avenues of prevention. If people get healthier, they don't spend as many healthcare dollars.

MP: Right now it's awful. It's still pretty much out of pocket. I think the only good thing is flex spending accounts. So the health savings and flex spending accounts, if they're prescribed by a doctor, sometimes you can get your supplements covered. And I would be happy, as a physician, to write that letter for patients to submit to get reimbursement from their health savings accounts. But for the most part, it's not even close to where it needs to be yet.

NBJ: Do you see our government and the healthcare industry moving more broadly toward a focus on disease prevention?

KM: As an individual who has been active on Capitol Hill for the past few years lobbying for healthcare, I can tell you that any healthcare team in a senator's or congressman's office is going to be hard-pressed to argue that there are no problems with the healthcare system. I just don't see them agreeing anytime soon on how to resolve them. I've even been in one senator's office, a senator from one of the most obese states in the country, and they're still not going to put forth dollars to work on obesity or diabetes prevention. They have some of the highest diabetes rates in the country. They acknowledge it, but they're not quite ready to address it.

TH: What I've seen over the past 20 years is that things that used to be very fringe are now entering the mainstream in a lot of ways. So 20 years ago I started training with a fellow who was doing heavy diet management for managing cholesterol. At that time nobody was managing cholesterol. We didn't have the drugs for it. I think there was just one statin coming onto the market. But now we see these things more in the mainstream. As evidence-based medicine moves forward, we'll gradually see that more and more in physicians' offices. We've seen it with glucosamine sulfate. We've seen it with vitamin D, calcium, magnesium, things that nobody used in the past.

MP: Absolutely, because now the finances are going to incentivize it. Before, you didn't have that. It was fee-for-service. Disease paid. Drug companies were paid big bucks. Nobody was looking at trying to save money in addition to saving lives. I do think incentives are now aligning.

NBJ: Have you noticed a lack of primary care physicians in U.S. medicine?

KM: Absolutely. Across the country, but definitely in more rural areas. It's a huge problem. And that's where, in the integrative medicine discussion, a lot of other practitioners, whether it be nurse practitioners or naturopathic doctors, who are essentially trained as primary care physicians, there are lots of individuals who can easily fill those voids if legislation allowed.

TH: There has certainly been a change in quality over the years. We've seen a shift — and it started about 20 years ago — from U.S.-trained physicians entering primary care to foreign-licensed physicians. And now you're seeing increasing amounts of physician extenders in the field, leaving nurse practitioners and Pas to do that work. I think it's a loss.

MP: There's a huge shortage. And there are two reasons. You can't train enough primary care doctors. It takes 14 years to get up to speed as a primary care doctor, and we don't have time to train that many doctors. It's also expensive. It takes the most resources to train a physician, whereas a lot of this can be done by nurse practitioners and physician assistants on the ground level, leaving the doctors to get involved in the more complex cases.

There's a big shortage of primary care doctors, and we're not going to make it up for a long time — if we even should make it up. Why would you want to spend all that money educating the primary care doctors when you can spend a lot more educating nutritionists, Pas and NPs?

NBJ: How can we better educate conventional medicine about the benefits and necessities of a more holistic approach?

KM: It's not necessarily the industry's responsibility to go after doctors to teach it, but they end up doing it because that's one of the only ways that doctors can learn that information. They don't teach it in conventional medical school. There are elective courses, but they may meet once a week for 12 weeks for one to two hours. You're just never going to learn nutrition that way, or learn about individual nutrients, or learn about how drugs and nutrients and herbs all interact together. It's just not the right context. You really can't shift medical education at that core level, at this point, to ultimately integrate all of it, because the core curriculum is already so full.

TH: I think, ultimately, it will happen at the political level. I think we're seeing things become more integrative. In the last 20 years, we've seen it shift that way. And the thing that moved it the most was probably the Eisenberg study which showed a huge number of Americans spending a huge amount of dollars on alternative medicine. Once that happened, the National Center for Complementary and Alternative Medicine showed up. And integrative centers across the country and various universities showed up because there was money involved. So ultimately, I think it'll be grass roots. The public will push it.

MP: I think curriculum reform is going to be very important, including integrative medicine education right at the level of medical school nurse practitioner programs. NPs and Pas are going to be very big in the health reform movement because there is a shortage of primary care doctors. How do you make that up? You make it up with other providers. So including integrative education for NPs, Pas and medical students right up front is essential.

NBJ Takeaways

Education: The remarkable lack of education available on nutrition, chronic disease prevention and supplement-drug interactions in the current medical curriculum means that practitioners are mostly on their own. Electives and industry-sponsored weekend courses don't cut it anymore.

Community: Fostering communication and networking between practitioners with diverse specialties could lead to more responsible care for their patients. Dr. Hoover has built a network of approximately 600 alternative care providers in the Philadelphia area. A well-knit group of specialists like this forms a kind of super physician to serve the needs of an entire community.

Research: A lack of evidence-based research in integrative medicine has contributed to a credibility gap for alternative care providers. On top of that, current research models that focus on a single nutrient reversing a single ailment fail to conform to the idea of holistic health. “I know nutritional medicine makes a difference,” said Dr. Punzo. “People who practice integrative medicine know they're keeping their patients out of the hospital. We have to show that and prove that.”

Prevention: The exorbitant cost of treating chronic disease could be greatly reduced if healthcare focused more on prevention. “Things like obesity, heart disease and diabetes,” said Dr. Marshall, “those are the three costliest diseases in this country, and they're certainly preventable in so many ways.”

Legislation: Alternative practitioners have finally received mention in the Affordable Care Act, with some promise of meaningful increases in insurance coverage. But advocacy groups and lobbyists will have their hands full convincing the 112th Congress to fund more reform. “I really have high hopes that, in the future, in maybe the next five to 10 years, there are so many groups that have this on their radar that we'll be forced to deal with it,” said Dr. Marshall.