Bringing It All Together

Chapter 8 Bringing It All Together In this chapter we explore: • What the patient takes home with them from an integrative medicine consultation • Some ideas on creating an individualised Wellness Plan • Why an integrated care model of health works • What integrative medicine might need to look like in the future. Introduction The European Prospective Investigation into Cancer and Nutrition-Potsdam Study which included 23,153 German participants investigated the impact of four factors on the risk of developing several chronic diseases, with a follow-up of 7.8 years: 1. 2. 3. 4. Never smoking Having a BMI <30 Performing  3.5 h of physical activity per week and Adhering to healthy dietary principles: high intake of fruits, vegetables and wholegrain bread and low meat consumption The study found that the risk of developing a chronic disease decreased progressively as the number of healthy factors increased. Compared to participants without one healthy factor, participants with all four factors at baseline had a: • • • • 36% 93% 50% 81% lower lower lower lower risk risk risk risk of of of of getting cancer developing diabetes stroke myocardial infarction [1]. © Springer International Publishing AG 2017 K. O’Brien and A. Sali, A Clinician’s Guide to Integrative Oncology, DOI 10.1007/978-3-319-56632-0_8 305 306 8 Bringing It All Together What would have made this study more interesting is if they had included additional factors such as stress reduction, sunlight exposure, vitamin D levels and sleep. Nonetheless, this study serves as an illustration that the more a person can address key factors that contribute to poor health and adopt behaviours that contribute to good health, the better their health outcomes are likely to be. As clinicians, we often meet the patient when something has already gone awry and they are ill. We don’t often get to see them when they are healthy and are just having a check-up to make sure they are doing okay. Perhaps that’s changing a bit, particularly in the corporate world where companies are now realising the value of their employees having health checks as a preventive measure—as it does no doubt cost companies a lot more when employees do get sick at work. As an aside, at the National Institute of Integrative Medicine in Australia, for example, we run an ‘Integrative Health Check’ which involves a comprehensive health check-up with an integrative medicine doctor, a naturopath and an osteopath. Some of the investigative technologies used include standard pathology blood tests, heart function analysis using a vascular compliance machine, hair analysis (toxicity and nutritional status testing) and live blood analysis. The person goes home with a folder full of information, including results of their tests and information about health, and a plan about what they can do to improve health. Back in our consulting room with our patient in front of us, it’s our job to assist them to understand what factors may be underpinning their ill health, how to make changes, and why, as well as some of the evidence behind our recommendations. It is about helping them become the Ultimate Patient, one who is empowered with knowledge and who is proactive about making the necessary changes to become as healthy as possible. As we have said on a few occasions now, a healthy patient with cancer will do better than an unhealthy one. Also, even for patients who are at the end of their journey and are in palliative care, there is much that can be done to keep them as comfortable as possible physically, emotionally and spiritually. The key is the patient’s will to make the necessary changes to a healthier way of living, to form new healthy habits. Most of us are creatures of habit, so our task as clinicians is to help our patients form healthy ones. It will take discipline on the part of the patient. In This Chapter We started this book with the premise that you need the Ultimate Patient to obtain the Ultimate Result. We have devoted Chap. 1 to the features of how to conduct an integrative medicine consultation, and Chaps. 2–7 to the information that can form part of the conversation during the integrative consultation, as well as the evidence behind the various recommendations. In this final chapter, we will focus on the last two features of the Ultimate Consultation: • The patient takes home something tangible at the end of the consultation • The Integrated Care Model provides the framework. What the Patient Takes Home at the End of the Consultation 307 What the Patient Takes Home at the End of the Consultation There is a lot of information for a patient to try to remember in an integrative medicine consultation. It therefore helps to have some take-home information that can be given to the patient and their support person at the outset and worked through during the consultation. Professor Sali provides his own patient notes, which were the original basis for this book. We find that a lot of patients will come with a notebook to take notes, and this is a good sign, as it shows a level of commitment to learning how they might help themselves. The written information provided by Professor Sali to his patients follows the Seven Key Health Strategies discussed in Chaps. 2–7: • Reducing and unloading the storage of life stresses, and harnessing the power of the mind (Chap. 2) • Eating healthy food (Chap. 3) • Getting adequate sleep (Chap. 4) • Getting a daily dose of sunlight (Chap. 5) • Exercising (Chap. 6) • Taking supplements and herbal medicines (Chap. 7) • Exploring innovative investigative technologies and therapies (Chap. 7) Professor Sali and colleagues have also written a short publication suitable for any patient seeking better health, entitled: The NIIM Roadmap to Wellness, which is a preventive healthcare guide providing general advice on three pillars of healthmind (reducing stress), nutrition and movement. We often recommend books on nutrition that are a relatively easy read and contain valuable information about foods that are useful to add to diet. For example, oncologist Dr David Wilkinson’s book Can Food Be Medicine Against Cancer, is a favourite of Dr O’Brien’s, as it sets out information including scientific evidence clearly and in a style suitable for laypersons, not just clinicians. Creating a Wellness Plan Another something a patient can take home with them at the end of their integrative consultation is an individualised Wellness Plan. Whilst it is useful to give the patient information in the form of notes, discussed previously, there is also a need to create a strategy to guide how to move forward. A Wellness Plan can be something as simple as a schedule of appointments with various practitioners and perhaps a list of supplements that might be recommended, or it can be more comprehensive and include recommendations and goals in relation to the seven key health strategies that were covered in Chaps. 2–7. Progress toward achievement of such goals can then be reviewed by the patient and clinician at subsequent consultations. For some 308 8 Bringing It All Together patients, the Wellness Plan helps provide useful structure and a plan to follow, and the achievement of wellness goals can promote a sense of empowerment. The Wellness Plan can be co-created by the clinician and the patient: by creating it together, the patient is taking an active part in setting their own goals and thereby actively participating in improving their own health. This is about helping them become that Ultimate Patient. The Wellness Plan could be developed at the first consultation, or at least started. However there’s a more practical reason why it might be best developed at a follow-up visit—it gives the patient some time to work out what they can and can’t afford, as all of these therapies and investigative technologies cost money. It’s very important to be sensitive to the person’s financial situation, and some may be embarrassed to mention costs and what they can afford. That’s why it’s useful to be upfront with the patient, and let them know that these various complementary medicine options will cost money, give them an idea of costs, and then suggest that they have a think about what they might like to incorporate in their strategy to improve health. Some of the recommendations might be able to be filled in at the first visit—for example, recommended foods to include in diet, those to avoid, and some supplements that they could get started on. However, other goals could be left blank for the time being. The patient could fill some of them in at home, after digesting the information given to them at the time of that initial consultation, for example, what they might like to try in order to reduce stress. These could then be discussed at a follow-up consultation. Key Points • Advise the patient upfront on the costs of the various investigative technologies and complementary therapies. • Co-creating a Wellness Plan at a subsequent/follow-up visit allows the patient time to digest information and work out what they can and can’t afford. • Co-creating a Wellness Plan with the patient gives them ownership of the strategy and allows them to play an active part in improving their own health. Key Benefits of a Wellness Plan There are some key benefits of a Wellness Plan. It can be used to: • Schedule appointments • Set wellness goals • Review progress against goals (self and clinician-review) What the Patient Takes Home at the End of the Consultation 309 Scheduling of appointments When it is likely that patients will be seeing several doctors and allied health practitioners who are working in a team to assist a patient with cancer, keeping track of appointments can be difficult for patients. For example, a patient may have an initial consultation with the oncologist and integrative medical practitioner, then have appointments with a nutritionalist and exercise physiologist, plus appointments for high-dose Vitamin C therapy and hyperthermia. You can get the idea. Once you have a few practitioners in the mix, a Wellness Plan can assist the patient in keeping track of their various appointments. Setting wellness goals A Wellness Plan can also be used to set wellness goals—for example an exercise physiologist may set particular exercise goals, and the patient may use the plan to document their own progress. A nutritionalist might ask a patient to complete a five-day diet diary initially, then suggest modifications to their diet which could be incorporated into the Wellness Plan. The clinician may suggest some sleep hygiene measures—again, these may be included in the Wellness Plan. Reviewing wellness goals The patient may use these goals as a way of reviewing their progress or commitment to the goals. The clinician may review progress towards these goals at subsequent appointments, and use the feedback to suggest modifications to the plan and/or offer encouragement. Key Points A Wellness Plan can be used to: • Schedule appointments • Set wellness goals • Review progress against goals (self and clinician-review) Suggestions for a Framework for the Wellness Plan To create a Wellness Plan for your clinic, you need to decide firstly if the purpose is simply to provide a schedule of appointments or whether you want it to be more comprehensive, for example covering the seven key health strategies that we have included in this book. The Wellness Plan could simply provide an introduction, then topic headings with spaces left blank to be filled in during or after the consultation, then a list of contacts. Some suggestions of what could be included are set out in Table 8.1. 310 8 Bringing It All Together Table 8.1 Suggestions of what to include in a wellness plan Welcome and introduction to the clinic Stress reduction Diet Sleep Vitamin D and sunshine Exercise Additional therapies This section could be subdivided into several sections, for example: • High-dose IV vitamins • Oral vitamin supplements • Complementary medicines and therapies • Innovative technologies and therapies High-dose IV vitamins This could be a one-pager that welcomes the patient to the clinic, provides an explanation of the philosophy of the clinic and the modalities offered, a brief introduction to the clinicians, and contact details of the clinic including Emergency Contact phone numbers This could include space to write down different strategies to reduce stress. Where meditation classes are recommended, the contact details of a meditation teacher might be included, for example This might include space to list foods to incorporate into diet and foods to avoid Where sleep has been identified as an issue, this section could include some suggested sleep hygiene goals and details of some sleep enhancing therapies that could assist e.g. acupuncture, homoeopathy. Where supplements that might assist are recommended, these could be listed here This section might list some goals for getting adequate sunshine, and an appointment schedule for assessment of vitamin D levels (if this has not been done) and re-assessment. Where Vit D supplements are recommended, this section should include recommended dosage and date for re-assessment to monitor vitamin D levels. Where IV vitamin D is recommended, the Wellness Plan should also include a re-assessment date If the clinician is skilled in exercise therapy, then this section could list some types of exercise that can be incorporated into the patient’s lifestyle. However, since many patients have co-morbidities that might preclude some of the simple exercise suggestions such as moderate walking or yoga, for example in a cancer patient with arthritis, an exercise plan is best handled by an exercise physiologist. Such professionals are trained to consider the various factors that need to be taken into consideration This section of the Wellness Plan should include a schedule of appointments, taking into account when the patient might be having other therapies. For example, in an integrative clinic in Hong Kong, (continued) Working in an Integrated Healthcare Team … 311 Table 8.1 (continued) Oral vitamin supplements Complementary medicines and therapies Innovative technologies and treatments patients who are having IV Vitamin C therapy also have acupuncture whilst they are sitting with the IV drip in their arm. In the National Institute of Integrative Medicine (NIIM) clinic in Australia, patients having hyperthermia may also have high dose IV Vitamin therapy delivered at the same time This section will include those recommended supplements including dosages This section might simply include the contact details of the allied health/complementary medicine practitioner(s) (e.g. Chinese herbal medicine practitioner, acupuncturist, Western herbalist, homoeopathy practitioner, massage therapist) who are recommended by the integrative medicine doctor. The complementary medicine practitioner can then discuss the schedule of appointments with the patient, which could be inserted into the Wellness Plan as an attachment Where an integrative medicine clinic provides additional, innovative diagnostic techniques e.g. circulating tumor cell testing and therapies such as hyperthermia, this section could include a schedule of appointments in relation to these Working in an Integrated Healthcare Team: The Integrated Care Model of Practice It’s very difficult to be an expert in everything, even for an integrative medicine doctor. An integrated care model is one in which a team approach to patient care is taken, one involving several practitioners of allied health and complementary medicine who work together with the general integrative medical practitioner and oncologist. An integrated care model is not one doctor trained in western medicine who is also trained in some additional form(s) of complementary medicine trying to manage the patient on their own. Most patients with cancer have an oncologist and they also have a regular general practitioner or family doctor who plays an important role alongside the oncologist. If this general practitioner is an integrative medicine doctor, so much the better but it’s certainly not essential for the integrated care model. What is important is an open-mind and respect for other health professions. Other members of an integrated healthcare team include: nursing staff, nutritionalists, naturopaths, Chinese medicine practitioners, exercise physiologists, psychologists, meditation teachers, massage therapists and others. Whilst some integrative medicine doctors have trained in additional complementary modalities, in particular nutrition/nutritional supplements, it is a rare one 312 8 Bringing It All Together that knows the lot and is skilled in several forms of complementary medicine. It really does make sense to co-manage in a team and utilise the expertise of colleagues. The integrative medicine doctor or oncologist is in the ideal position to be the central pivot of the patient’s care. Team Meetings The ideal model is for a team to meet face-to-fact to discuss the patient’s case and agree on what different modalities may best help the patient. Then a range of options can be discussed with the patient who can make decisions about what they want to do, taking into consideration affordability, distance to travel and other practical considerations. In the end, it’s the patient’s decision—they may gravitate towards some therapies more than others, and that’s okay. In practice it is sometimes difficult to get practitioners together, in particular if they don’t work in a multidisciplinary practice. However, you can work around this by using phone conferencing at a designated time. At this meeting, each person can discuss what their modality can contribute, and how frequently they might need to see the patient (for example, a nutritional medicine practitioner may want to see a patient every 3–4 weeks to monitor how they are doing with supplements and diet modifications, whereas an acupuncturist might want to see the patient on a weekly basis). The integrative doctor is ideally placed to coordinate and can monitor the patient’s progress. Orthodox therapy may take precedence at certain times because of the time intensiveness of therapies such as radiation therapy. This needs to be considered in planning their care. If your practice is very organised and it is possible, having a designated Patient Liaison Officer for each cancer patient is ideal. The Patient Liaison Officer can be the first point of contact for questions in relation to the Wellness Plan, various therapies, appointments and other topics, and where necessary, the Patient Liaison Officer can refer medical questions quickly as appropriate. If it is not possible to bring a team together at the one time, then ideally the integrative medicine doctor will have a referral network of allied health/complementary medicine practitioners that they can refer the patient to, and who can provide regular reports to the doctor. The Wellness Plan would therefore include the contact details of those allied health/complementary medicine practitioners whom the doctor may recommend. At the end of the day, there is much that complementary medicine can offer patients in conjunction with orthodox medicine. Expanding Integrative Medicine 313 Expanding Integrative Medicine Integrative Medicine will be the medicine of the future. The public are already practising integrative medicine—they are seeking their own answers to health and healing through a variety of means. We already know that a substantial percentage of Australians, Americans and those living in other Western countries are using complementary medicines, with or without the knowledge of their general practitioner. In other parts of the world, forms of ‘natural medicines’ such as herbal medicine, acupuncture and others, are not ‘alternatives’. In their countries of origin, such medicines are the original medicines. In fact, when western medicine was introduced to many countries, such as China and India, each of which had their own medical systems, western medicine was at one point the ‘alternative medicine’. The use of such labels such as ‘alternative’ and ‘complementary’ is a western one and an epistemological claim, one that asserts the pre-eminence of western medicine over other forms of medicine. Like many of the problems in this world, the problem of illness will not be solved by competitiveness and warring factions within and outside of medical communities, however you define medicine. It will be solved by the spirit of cooperation, open-mindedness and mutual respect between the many different groups involved in healthcare and the communities that they serve. It will require political leaders with a deep understanding of public health—real public health— who are willing to make the changes necessary to enable the practise of integrative medicine, because that is what the public are practising and clearly wanting. This may require a fundamental change in health funding models, away from one that enables quick medical consultations with too often limited health outcomes, to one that facilitates an integrated care model that includes evidence-based complementary medicines along with evidence-based orthodox medicine—real integrative medicine. The ultimate aim is to deliver the best possible care to the patient. Education Medical education, and education more broadly, will need to shift gears. At the level of primary and secondary schooling, at least in Australia, we are not doing enough to teach our children how to cope with stress, nor the effects of stress on mental, emotional and physical health. Children need to learn how to communicate about stresses and how to unload. We are not recognising in our work practices how much we are damaging ourselves through a lack of work–life balance. We are not educating our young people, at school where much of this education (but not only there) should take place about the pressures of the workplace, the insidious culture to conform to 314 8 Bringing It All Together overwork, and how to create balance. Instead we promulgate a culture of overwork and wear it like some badge of honour. It’s a very stupid and dangerous practice. Clinicians have an important role to play in educating their patients and often, the families of those patients consequently. However, education must start much earlier than that, in primary and secondary schools and colleges. In the clinic, as clinicians we need to be paying far more attention to talking to our patients about stress, and how they can unload stored stress and emotions. There is plenty of ‘scientific’ evidence of its role in pathogenesis of chronic diseases such as cancer. We need to help our patients understand what their stresses are, and how to reduce them or ‘unload’ them. To do this, we need time to talk with our patients and listen. Environment According to Professor Sali, the single most defining word that describes the behaviour of humans throughout history is ‘killing’. Fortunately, since the loss of over 50 million people in the Second World War, in the Western world at least killing has become far less popular. But we are doing other things to kill ourselves, albeit more slowly. We are poisoning our waters and our food supply and our air, and we are wondering why the proportion of people with cancer and other chronic illnesses are so high. We are running around throwing money at research to find cures for the very diseases that we, as a species, are creating. It’s not rocket science. We are confusing the issue of poisoning our environment when we talk about things like carbon trading schemes, as these are meaningless to most people, and they are not addressing the root causes of environmental damage, which is our behaviour. Redefining Integrative Medicine At the beginning of this book, we described Integrative Medicine as follows: Integrative Medicine combines conventional medicine with evidence-based complementary medicines, therapies and lifestyle interventions for the treatment and prevention of disease. The patient–practitioner relationship is collaborative and supportive, empowering patients to take control of their health and wellbeing. Integrative medical practice makes use of all appropriate therapeutic approaches, healthcare providers and disciplines to achieve the best health outcome for each individual patient. Integrative Medicine empowers patients and health practitioners with a wider range of treatment, screening and prevention options, a collaborative relationship, and an emphasis on preventative medicine. It is a form of medicine through which the clinician can deliver health to the public; in a sense it enables public health. Expanding Integrative Medicine 315 This definition has a heavy emphasis on what has caused disease at the individual or personal level, in contrast with orthodox medicine. It’s not a bad definition, at first glance. However, Integrative Medicine will need to include more than this. Health cannot occur in isolation to our environment and the way we live. To be truly integrative in medicine, we need to go back to the wisdom of many ancient cultures which understood the human as existing as one part of the environment, affected by and capable of affecting the world around it. Our health is intimately interwoven with our food supplies, our industries, and our ways of living and interacting with others. Our health is also interwoven with our spirituality, which is something beyond religion, and something we have chosen not to address in this book. Nonetheless, this is a very important part of health. Those are only a few factors that impact on our health. If we want to see changes in population health, we need to make changes to how we approach living on this earth. The ancient cultures including the North American Indians understood this. They are warning us again right now about the potential devastation of rivers and waterways in the US. Integrative medicine in the future must involve more than practitioners of medicines, whatever the form these ‘medicines’ may take. We need to come back, like a council of elders, to reconsider the many factors inherent in how we live our lives as societies or nations that are adversely impacting on our environment and consequently, ultimately on our health, and we need to make changes to these. Discussions about public health will need to involve various industries, environmental experts, town planners, educators and many other sectors of society, because the actions and behaviours of these many sectors all impact on health. We need to learn to cooperate as a species, or we face extinction. We also might need to better define ‘health’. Black Elk said: I could see that the Wasichus [white people] did not care for each other the way our people did before the national’s hoop was broken. They would take everything from each other if they could, and so there were some who had more of everything than they could use, while crowds of people had nothing at all and maybe were starving. ‘They had forgotten that the earth was their mother’. (John G Neihardt, Black Elk Speaks: The Complete Edition) Conclusion This book has sought to capture an approach to conducting an integrative consultation, with a focus on patients with cancer. Whilst we have chosen cancer for the purposes of this book, the principles described in this book equally apply to other chronic diseases. The impact of stress, nutrition, sleep, vitamin D, exercise and additional therapies could easily apply to cardiovascular disease, or rheumatology, for example. 316 8 Bringing It All Together Such an approach to conducting an integrative oncology consultation does not reduce the person to a diagnosis. It seeks to see the human being as they are, a person living with cancer. This book has sought to give some guidance to clinicians working with cancer patients about the many factors that can contribute to cancer, some health strategies that can contribute to wellness and some of the scientific evidence associated. It is based on Professor Avni Sali’s approach to working with patients with cancer and other serious diseases. There is a massive amount of data on integrative medicine and its application to cancer. We have made reference to some of this, and have we presented some of the key evidence in relation to what we have discussed. We have not covered all complementary medicines and innovative therapies that may show promise in the treatment of cancer. Instead, we chose to focus on particular ones and present some of the scientific evidence in relation to those. One of the underpinning premises of the Ultimate Consultation is that the Ultimate Outcome requires the Ultimate Patient, one who is empowered and proactive in making positive changes to adopt a healthier lifestyle. Another key premise is that a healthy person with cancer will do better than an unhealthy one. Stress is one of the most important factors in illness and healing from conditions such as cancer will require identifying and alleviating stress, through the unloading of stored emotions and stress. Better still if we can prevent cancer in the first place by addressing life stresses. Happiness is very important to nurture. It is hoped that this book may give those interested in working with people with cancer some ideas of how they might construct their own approach to an integrative oncology consultation, and some of the evidence behind many of the integrative medicine approaches that may be used. Importantly it is hoped that it may help clinicians help empower their patients to harness the power of their minds to make necessary changes and provide the necessary fire to maintain the discipline needed to form new and healthier habits. This notion of harnessing of the mind is not just wishful thinking. We have enough ‘scientific evidence’ to now understand the physiology behind it. We just don’t really know what the mind is… Finally, we would like to end this book with a story about a well-respected Australian athlete who faced his own challenges with health, and in many ways, exemplifies the power of human will and the necessity of discipline in turning a difficult situation around. Nothing New Under the Sun? A Tale of an Australian Athlete There are numerous stories of individuals who have reversed severe health problems by changing lifestyle, diet and physical fitness. Kylie’s father recounts one such story from his adolescence in Shepparton, Victoria in the middle of last century and this story illustrates in many ways what can be achieved with intention, willpower, and importantly discipline. Conclusion 317 Her father spoke of meeting a man named Percy Cerutty who, approaching 50, had a life-threatening health breakdown. He refused to die, adopted a strict vegetarian diet, and took up long distance running. Percy began training to tackle an Australian 50-mile record, the attempt which was to finish at a big sports gymkhana being staged by Kylie’s grandfather Bill O’Brien, a well-known boxing trainer who trained several Australian boxing champions. Her father, Les O’Brien, describes the experience thus: He stayed at a local pub, but had many of his lunches with us. My mother would simply cut up the largest variety of fresh, raw vegetables and fruit that she could muster on his plate. He would begin running from the pub, in his sparse uniform of short shorts and running shoes (there’s your vitamin D!), eat his meal, then head off to knock up as many training miles as the afternoon would allow. He was an excellent conversationalist, and indulged my adolescent curiosity about his change in lifestyle and ambitions. Did he break the record? I’ve forgotten. But he did write me a letter later, which I kept for many years, in which he explained what he called the philosophy of his new lifestyle, which he called ‘Stotanism’, a cross between Roman stoicism and Spartan self-discipline. Instead of an early demise, from those early years, ‘Stotan’ Percy embarked on a long career as an athlete’s training coach, mentoring such famous Olympic runners as Herb Elliot and Betty Cuthbert and countless others, and not just runners, at his training camp in Portsea, on the coast, where he ran his trainees up and down sand hills and preached his philosophy of healthy living. There are numerous books written about Percy Cerutty, including one of his own entitled ‘Why Die?’. Percy certainly would have to be Professor Sali’s ultimate ‘Ultimate Patient’. Quod Erat Demonstradum (That which was to be demonstrated) Reference 1. Ford ES, Bergmann MM, Kroger J, et al. Healthy living is the best revenge: findings from the European Prospective Investigation into Cancer and Nutrition-Potsdam study. Arch Intern Med. 2009;169:1355–62.