The hiccups wouldn’t stop. It was August of 1996, and an elderly stroke victim lay dying in his home in the small town of Driggs, Idaho. But he could have no rest. He was stricken with a relentless case of hiccups, robbing him of comfort.
The episode gave David Rakel, the man’s physician and neighbor, a memorable lesson in the importance of watching, listening, and heeding the desires of his patients. Drugs, the main weapon in Rakel’s medical arsenal, made the dying man groggy and unaware, and still the hiccups continued. Family members suggested acupuncture.
Like many conventional, or allopathic, Western physicians, Rakel was skeptical. But he figured acupuncture would do no harm. “I humored them. I said, ‘Sure. Why not?’ ” It worked. The acupuncturist came. The hiccups went away without sedation. “He was able to die with loving family around him and a sense of peace. It was a beautiful death,” says Rakel, now a UW-Madison professor of family medicine. “If I had given him more drugs, he would have been lethargic. He would not have been present with his loved ones.”
The incident started Rakel on a path that would lead to his founding the university’s integrative medicine program in 2001.
That journey to the Midwest began in Driggs, nestled between the Tetons and the Big Hole Mountains and just over the pass from Jackson Hole, Wyoming, where he first hung out his shingle as a rural family practice physician. It was there that he began to shed his skepticism about acupuncture, herbal supplements, guided imagery, and a host of healing techniques that he believes medicine can add seamlessly to the mix of traditional Western options.
The Soul of Medicine
In 1999, Rakel decided to learn as much as he could about integrative medicine. He left Idaho for a two-year fellowship at the University of Arizona in Tucson. There, surrounded by desert peace and beauty and influenced by a steady stream of superstars in the field of healing arts and science, he took lessons in the heart, soul, art, and spirit of medicine.
His calling was to bring those lessons back to the broader world of American health care and help integrate them with the best that conventional medicine has to offer. He spent those fellowship years learning how integrative medicine rests on four pillars of health promotion: social, psychological, physical, and environmental.
Once considered on the fringes of health science, integrative medicine has gotten a boost from technology such as functional magnetic resonance imaging, which shows pathways between mind and body, and from research that backs up connections between nutrition, physical activity, and good health.
It’s been a decade since Rakel’s training at the Arizona Center for Integrative Medicine, and he’s just been approved for tenure at the UW. For John Frey, professor in the Department of Family Medicine and the man who hired Rakel in 2001, Rakel’s interest in integrative medicine has been a bonus. “What attracted me about him was that he’s a talented doctor with a wonderful perspective on patient and family care,” says Frey. “The integrative medicine program was something I didn’t know much about.”
Frey was key to getting Rakel to come to Wisconsin. But so was an unconventional decision-making method. Following his fellowship, Rakel weighed teaching offers in Colorado and Wisconsin. Torn by what he saw as two excellent options, he turned to guided imagery. In his mind, he went flying on the wings of an eagle.
Based on the concept that the body and mind are connected, guided imagery is a way of employing all the senses to help steer imagination. The body can respond as though what’s being imagined is a real event. A classic example is to imagine a lemon — think of peeling it, smelling it, squirting it in your mouth. Do your lips purse up in response?
In medicine, guided imagery can be used to control pain and stress. Cancer patients, for example, may be encouraged to imagine tiny healthy cells overpowering destructive cancer cells in their bodies. While the American Cancer Society says there’s no proof that guided imagery influences the progress of cancer, the ACS Web site does cite evidence that the technique can reduce stress, anxiety, and pain and lessen some of the side effects of chemotherapy, such as nausea and vomiting.
As Rakel imagined a golden eagle, he says, “he picked me up by the collar and we went flying.” And knowing how that must sound, Rakel hurriedly assures with a laugh: “No hallucinogens. All with our own bodies. I looked down and there were lakes and oak trees.” No snow-topped mountains. No aspens. He was looking down at the lakes and forests of the upper Midwest, not at the Rocky Mountains. “So we came to Wisconsin,” he says.
Mentoring Students and Patients
At the UW, Rakel began teaching integrative medicine techniques to students, as well as fellow physicians. “He’s been able to attract a substantial number of young clinicians who agree there are a variety of different approaches to care,” says Frey. “He’s developed a very talented group of young family doctors, and was instrumental in getting a fellowship program going.”
In 2002, Luke Fortney ’98, MD’03, now an assistant professor in the family medicine program, was the first of Rakel’s students in a month-long elective rotation in integrative medicine. “Dr. Rakel has been a mentor from that point forward,” Fortney says. In addition to editing the field’s key textbook, Integrative Medicine, Rakel’s work today centers on teaching and caring for patients at the Integrative Medicine Odana Atrium Clinic on Madison’s west side and the Integrative Medicine Research Park Clinic. He also started the integrative medicine clinic at the Comprehensive Cancer Center at the UW Hospital.
Each facility offers therapies such as massage and acupuncture; the Research Park clinic also provides health psychology, Feldenkrais (movement therapy), healing touch, mindfulness stress reduction, yoga, and tai chi.
Patients are taught to meditate to reduce stress and encouraged to eat a diet rich in fruits, vegetables, whole grains, nuts, soy, olive oil, cold-water fish, and dark-colored berries for heart health. Part of their prescription for good health will surely be to exercise and get moderate sunshine to reduce depression. They might be told to try acupuncture for arthritis pain. And their spiritual beliefs will be considered as individual health plans are developed. Often, patients who come to the clinics are facing difficult chronic diseases and complicated tangles of symptoms.
For Lynette Peterson, Rakel has been a lifesaver. Now sixty-five, she has had multiple sclerosis, a disease that attacks the central nervous system, for thirty-five years. Symptoms can be mild or increasingly severe, but there is no cure. She found Rakel after her physician prescribed a chemotherapy regimen that left her with hair loss, sores on her lips and tongue, and loss of control of her bladder and bowels. “I told him I couldn’t take any more chemotherapy.
It was killing me,” she says. Rakel steered Peterson to acupuncture, changed some of her prescription medications, added dietary suggestions, and encouraged the use of fish oil, herbs, and regular exercise. It has taken more than a year, and hasn’t been a miraculous cure for Peterson, who remains in a wheelchair. But her symptoms have stabilized. “He’s got such a positive approach,” she says. “He knows he can’t cure everybody. But he also knows there are things he can do to make their lives easier.” She swims twice a week, remembering his advice: ‘Keep exercising, keep swimming. Think positive, think positive.’ ”
But changing an American’s lifestyle is difficult. Rakel is realistic, seeing change as a highly individual endeavor. A lifestyle prescription must, he has written, “be individualized based on the health, energy, resources, and personality of the patient.” “We really spend a lot of time listening,” Fortney says of those who practice integrative medicine. They listen for clues about what in patients’ lives might be contributing to ailments such as restless leg, acid reflux, or chronic pain, as well as what they might be willing to do to make changes.
Conventional medicine is part of integrated medicine. In fact, Frey says, without that mix, integrative medicine would get no respect. “If it becomes part of what doctors do in primary care, working with different healers as a team, then I think it has an important role,” says Frey.
Patients in integrative medicine, like any primary care patients, get flu shots, blood-pressure medications, or recommendations for surgery when their health calls for allopathic medicine. “I have no hesitation to use drugs,” Rakel says. “They’re often indicated and beneficial.” But all the while, patients are encouraged to look beyond a quick prescription-pad solution for what ails them, and to take as much control as they can over their well-being.
Ups and Downs
With fundamental changes to the nation’s health care delivery system recently passed into law, integrative medicine may well get increased attention. And it should, according to an article that Rakel co-authored with Wayne Jonas in a 2009 issue of Alternative Therapies.
“If the health reformers are looking to get the biggest ‘bang for their buck’ both in the prevention and management of chronic disease,” they wrote, “they need look no further than delivering [integrative medicine’s] four pillars [of social, psychological, physical, and environmental health].”
It’s not certain how integrative medicine will fare under the newly passed health reform law. But, according to the Integrated Health Care Policy Consortium, a coalition of conventional, alternative, and complementary health professionals, there are some positive signs. They include an emphasis on prevention, and on standards of evidence that will allow alternative therapies to be evaluated head-to-head with conventional therapies.
The hope is that as scientific studies find alternative therapies to be beneficial, insurers will cover them, just as they do a proven blood-pressure medication or an effective surgical procedure. Rakel says this doesn’t necessarily pan out, however, as there is now “good evidence for acupuncture,” and very few insurers cover it.
The discipline has had its ups and downs since Rakel’s training in integrative medicine began in Tucson. He was one of four fellows to study with Andrew Weil, a pioneer in a field that has changed names a few times as it has slowly earned grudging respect. The label alternative medicine has morphed into integrative medicine, via the terms “complementary” and “holistic.”
But by any other name, it means health care as opposed to disease care, an emphasis on wellness even as it deals with illness. And it is based on the same rigorous standards of evidence as any branch of medicine. “This is not belief without substance,” says Frey. “[Integrative medicine is] dedicated to pursuing the science behind [the discipline].”
Its practitioners are schooled in ways to hold on to their hearts and souls even as they master the intricacies of anatomy, physiology, biology, and psychology. They see their work as healing the whole patient, rather than being limited to specific body parts. When integrative medicine is hot, the universe responds with initiatives such as an office within the National Institutes of Health. When it’s not, funds are cut. “In my career, it’s gone up and down about three times,” says Rakel. “The financial incentives [that focus on rewarding the treatment of disease] always swing against it.”
Even as acceptance grows, there are setbacks. In 2009, physician Lucille Marchand saw her integrative medicine work at the UW oncology clinic go from full time to one day a week because of a funding reduction from the hospital. Fortunately, the Department of Family Medicine stepped in, providing resources to continue her work. The care she provides involves listening and talking, not performing high-income-yielding procedures. “Hospitals see integrative medicine as less necessary. If they’re going to survive, they feel they need to maximize interventions,” she says. “One oncologist said he didn’t believe in integrative medicine. Luckily, most oncologists and other cancer health professionals see the benefit.”
Rakel confirms that “the UW Hospital has been supportive of our program” and that an interdisciplinary UW Hospital Health and Healing Committee was started a few years ago for just that purpose. The American health care system, however, has always rewarded physicians skilled in invasive procedures more than those who listen to patients and talk them through healing. A heart surgeon, for example, earns an average of $515,000 a year, according to an Allied Physicians salary survey, while a family practice physician averages $135,000.
And primary care physicians, forced by the health care delivery system to spend as little as fifteen or twenty minutes with a patient, don’t have the time they need to get to the core of symptoms or to really influence the course of a chronic disease. The way payment incentives are set up through America’s insurance systems, a physician earns more for seeing four patients in an hour than for spending an entire hour with one patient. “[Practitioners] get good at seeing people quickly by just treating symptoms,” Rakel says. “If someone comes in with upper gastric pain, I can turn that off with Prilosec, and the patient leaves happy. But we miss out on what that symptom is trying to teach us, what it is that might be eating [the patient] up inside.”
An Ounce of Prevention
Contemporary American medicine focuses on diagnosis and treatment of existing disease. “We have a wonderful disease care system,” Rakel says. “We can reverse acute episodes of disease. But we haven’t paid enough attention to helping people avoid disease.”
Rakel is a staunch advocate for moving prevention and wellness from an afterthought to the core mission of health care. Study after study shows that he is on to something. In January 2010, the New England Journal of Medicine found compelling evidence that reducing salt intake would save lives and money.
A public health intervention designed to reduce salt consumption by 1,200 milligrams — or about two-thirds of a teaspoon — a day, could nearly cut in half the number of new cases of heart disease, stroke, and heart attack. In the process, it could save between $10 billion and $24 billion a year in health care costs. “This is a good example of how a low-cost intervention can result in dramatic effects on human health,” Rakel says.
But making it work for millions of people is profoundly difficult. “To understand how to implement a low-salt program, we have to understand how complex systems interact. We need to communicate a common goal to the food industry, school lunch programs, marketing personnel,” Rakel says. “We need to create financial incentives to make these changes. No one makes money by reducing salt in the diet.”
Like many lifestyle changes, reducing salt intake is so much easier said than done. A 2005 study in the Archives of Internal Medicine examined the top five health-producing behaviors: not smoking, getting adequate exercise, eating a healthy diet, managing stress, and using early disease detection tools such as mammograms and colonoscopies. The study found that only 2 to 4 percent of Americans engage in all of them.
Helping people change unhealthy lifestyles requires an investment in health care teams that will stand by patients as they try to change. Rakel is now working on just such an initiative to create patient-centered units — being recognized nationally in primary care as “medical homes” — that are composed of teams of treatment professionals. Generally these teams consist of doctors and nurses, but Rakel would also like to include nutritionists, exercise physiologists, health psychologists, social workers, and even spiritual guides working with individuals to help them stay healthy on their own terms. While a physician may lead the medical team, the workload is shared among various professionals, and the patient ends up getting more time devoted to health education, disease prevention, and chronic disease control.
The goal is to shift the health care system from its emphasis on reacting to a symptom or disease toward being more proactive. Rather than waiting for a person to develop diabetes, for example, and then rushing in with kidney dialysis or surgery for failing kidneys or limbs, Rakel hopes that developing these health teams will help with prevention. “These lessons are hard to learn,” he says. “But what if we had whole teams of professionals to help make those [lifestyle] changes? We need our health and political leadership to stress the importance of this.”
He continues to go back to lessons learned from the folks in the small Western town of Driggs, Idaho, with its 1,300 people and its fourteen-bed hospital. In a town that small, a doctor doesn’t wait until people come into the office to make observations about their well-being. “You see your patients at the grocery store and in church,” he says. “You develop insights into why they might be coming to see you with headaches.”
His initial skepticism has turned to enthusiasm, and then evolved into a true passion for practicing and teaching as one of the nation’s leaders in integrative medicine. Rakel knows that not everyone will buy the whole package, which could include flying with an imaginary golden eagle to help nail down a difficult decision. But offering options such as guided imagery, acupuncture, nutrition education, and lifestyle advice along with conventional medical options can help.
“You’ve got to read your audience,” he says, “meet them where they’re at, and maybe bring them to a new place of awareness.” Susan Brink is a freelance health writer based in Chicago. She has written for U.S. News & World Report and the LA Times and has published online for MSNBC.com and the Boston Globe.