C O L U M N S:
N E W S x I T E M S:
University presidents call for restructuring of UCSF Stanford Health Care
Q: Does complementary medicine differ from alternative medicine?
KUSHNER: Yes, because we are not an alternative to traditional medicine. Ninety-nine percent of our patients are under the regular care of an allopathic physician.
SPIEGEL: In fact, the bulk of our practitioners are physicians.
Q: So how would you define yourselves?
SPIEGEL:
We really specialize in a certain interface of mind and body problems, providing
high touch in Stanford's high-tech environment. But we are careful to screen
in only those programs which have been proven in well-conducted studies to
be effective. We consult closely with our advisory board and our physician
colleagues.
Q: How did you choose which modalities to offer?
SPIEGEL: I was asked about three or four years ago by Peter Van Etten to set up this clinic. I started pulling together members of the medical staff here who were interested in practicing in the clinic, as well as formulating an advisory board largely composed of physicians who were interested but were not themselves practitioners (see "Fact" 4 on page 7). I started meeting with them. I had my own picks of treatments that I thought were good, ones where we had expertise, where there was empirical evidence that they helped patients. I started recruiting practitioners and running various concepts by interested parties. For example, the pain service provided acupuncture and supported its inclusion in our clinic. Indeed two of our three medical acupuncturists are faculty in the Department of Anesthesia. On the other hand, orthopaedics and neurosurgery said "no way" to chiropractic, where there is reason to be concerned. It's a complex task to sort out the potential benefits of lower back rearrangements to relieve pain from a vast menu of other claims that may or may not be valid. This was compounded by the fact that we had no in-house expertise in chiropractic. In general, sorting out what services to offer generally pointed out to us the extent to which we really are an interface program, linking various departments and medical disciplines.
Q: Is your program self-sustaining?
KUSHNER: Our volume has consistently grown each month. Our patient visits for the month of June were over 500. We are not in the black at this time but hope with continued program expansion that we will be.
Q: Who are your typical patients?
GOLIANU: Probably our most typical patients face complex medical problems, such as cancer, which result in physical and emotional consequences. I can think of a breast cancer patient who has received standard chemotherapy; she's had a mastectomy and she sought us out for a breast cancer support group, acupuncture and massage treatments. She found those treatments very helpful in getting through the predictable side effects of chemotherapy, and subsequently the radiation therapy, as well as helping to support her emotionally and physically.
KUSHNER: Brenda's example is useful because it illustrates that we are supporting traditional treatments. We're certainly not telling patients to drop their chemo. We want to help them cope with their treatment. Incidentally, 50 percent of our patients are seeking pain treatment, and 80 percent are women.
GOLIANU: It seems women are more proactive about seeking treatment for pain and pain-related conditions.
Q: What else beside pain do you commonly treat?
SPIEGEL: Another large group of patients suffer from aggravating, chronic medical conditions that are less clearly defined. An example would be chronic fatigue syndrome. We can help provide solutions ranging from self-hypnosis to traditional medications.
KUSHNER: Here's an example: a paraplegic taking narcotics for severe shoulder pain. He didn't want to be on narcotics, had tried everything else, so he came to us for biofeedback. What came out was that the pain started when his wife left and divorced him. Part of the process was to find what triggered escalated pain. Eventually the patient's pain resolved and he stopped pain medications.
Q: How might physicians sort out whether to send their patients to your clinic?
SPIEGEL: We can become involved when there is anxiety, pain or depression related to a serious medical illness. Even if it doesn't reach the threshold of psychiatric illness, we can help patients address the anxiety and depression that is a logical outcome of a life-threatening illness. I try to approach these problems on two parallel tracks - first, we address the symptoms and how to deal with them, and second, we address the coping, stress and exacerbation issues that are interacting with the symptoms. For example, I worked with a woman suffering from pseudo seizures. She couldn't drive. On one level we used hypnosis to actually bring on these seizures. She'd practice inducing the seizures, and they'd get milder and milder. On the other hand, we needed to address the exacerbation issues. She was in the middle of a really vicious three-generational litigious family fight. We got her to ask herself, "Why am I the shock absorber for my father's battles with everyone?" She gradually extracted herself from the situation and she's a lot happier. Instead of allowing herself to be yelled at by her father for an hour every day, she calls him a few times a week, and if he starts to get nasty, she just says, "Goodbye, I've got to go." She has far less stress in her life and she's not having seizures anymore.
GOLIANU: Often our patients are looking for something more than medical treatments. Maybe they have headaches and have been offered the standard medical regimens. But perhaps they would like to use less medication or would like to look at alternatives.
KUSHNER:
We've found that patients and physicians often don't know we exist. I
think we need to make sure that they know we are an option.
Q: In a specific case, how should doctors decide whether to refer, say, to a complementary medicine clinic, or alternatively, to a pain clinic?
GOLIANU:
For oncology patients, for example, I'd refer them to the pain clinic
first if they are suffering pain believed to be related to their oncologic
condition. Unfortunately, many pain medications have side effects which
are either undesired or not tolerated by the patient. Or sometimes the
pain control is not complete. We see many patients who come to us at that
point. Many patients would prefer to find a way to lessen medication,
say, by using acupuncture. I have a patient who has Hodgkin's disease.
She said, "I don't want to go on methadone. I'd rather just have acupuncture
three times a week." Now she's off methadone. I think it's a minority
of patients who say, "just give me a pill."
KUSHNER: Being interdisciplinary as this points out has insurance implications. Biofeedback for a pain related diagnosis is a good example. It's a psychiatric treatment, so its not readily covered under a medical clause in a health policy. On the other hand it's being applied for a medical diagnosis, so it's not readily covered under a psychiatry clause. If it means dollars, no one wants to own it.
Q: Are your services reimbursable?
SPIEGEL: Sometimes. Much of our business is self pay. This is a relatively new area for many insurers, and we are often faced with inconsistent responses even from the same insurance company for a similar group of patients. This is a major issue that needs to be addressed.
KUSHNER: Some are, some aren't, it depends on the modality and what their insurance is. For instance, acupuncture is at least partially covered 75 percent of the time. Services such as massage, "Mindfulness Meditation" and forgiveness are not covered.
SPIEGEL: The bottom line here is that we should be reimbursed because we offer treatments that work, sometimes when other, often more reimbursement-friendly, approaches have not been effective.
GOLIANU: Patients want our services. They are pushing insurance companies, and I think we are seeing movement. For example, two years ago acupuncture was hardly ever paid for by an insurance company and now it often is.
Q: What are some physician obstacles to helping patients receive complementary services?
SPIEGEL: I think when a patient asks about complementary approaches there is a tendency among physicians to view it as something of a challenge. There can seem to be an implicit message to the physician, "I'm not satisfied with what you're doing and there's something better out there." I would ask doctors to view it more as an opportunity to encourage their patients to be proactive and get something more. Most patients who come here are receiving treatment from their regular physician and are happy with it. That may surprise many doctors because many patients are not telling their doctors that they're seeking complementary treatments. We certainly don't want to undermine the relationship with doctors. We're encouraging docs to say to themselves, "Okay the patient has asked for that. Good. This is a sign that I have a patient who is going to devote energy and resources to help themselves get better. And I'll help them do it." I would view it as an opportunity to collaborate with a patient, not as a challenge to the doctor's authority.
Q: Is there any research to validate a mind/body approach?
SPIEGEL: Let me offer an example. Classic immunology said it was absolutely absurd to think the brain could have any effect on leukocytes. Well, how do they study leukocytes. They take them out of the body - they take blood samples and study them. You have immediately made it impossible to see any relationship between the brain and the lymphocytes. But when you study them in context, when you look at cytokines and how the sympathetic nervous system affects lymphocytes in the spleen and how cytokines affect the brain, we discover that yes, indeed, the brain and the immune system have an effect on each other. I also think as physicians we often have a certain biotechnological bias about what constitutes real medical treatment. We have a surgical intensive model; you identify a problem in the body then you go in and fix it. In this model, the patient's involvement is minimal. Therefore, we sometimes tend to be overcritical about practices that involve some kind of mind/body interaction that enlists patient self-management. We need to apply the same standards of efficacy to complementary techniques, and when we do, we'll get the right answers.
Q: Brenda, can acupuncture pass rigorous scientific screening?
GOLIANU: An NIH consensus conference in 1997 encouraged acupuncture for a number of problems, including pain and nausea, and there's a number of studies that have clearly shown the benefit. I think the problem that we still have with acupuncture right now is that the theoretical background and understanding of the mechanism of action is still not understood. I think that's why it is sometimes seen as an alternative practice rather than a mainstream practice that we should all be doing. Current research has shown that acupuncture needles trigger an endorphin release. Also neurotransmitters appear to proliferate after acupuncture. The other very interesting work comes from MRI, where it's been documented that stimulation of the small toe leads to changes in the visual cortex. That leads to almost every patient receiving acupuncture asking, "Why does a needle in my little toe affect my headache?" We still need to cross that theoretical bridge. Until we learn how that needle is affecting things, people are going to have a hard time understanding acupuncture. We need more basic science on the mechanism of action.
Q: As an analogy, how do you think patients would feel if you, Brenda, as an anesthesiologist, told your allopathic patients that you weren't sure why the anesthesia put them to sleep?
GOLIANU: I don't think that is a perfect analogy because in fact we don't know why many anesthetics work, even though they do work every time. With acupuncture, a patient might get better, but others don't get better. We don't really know about our technique or about the diagnosis process, or why it isn't effective 100 percent of the time. Because we don't know the mechanism of action, it's difficult to perfect the practice. Right now we're basically basing our practice on a traditional model that was built hundreds or thousands of years ago. A practitioner learns at the side of a more experienced practitioner. It's basically an apprenticeship. So, as I've said, we need the basic science.
Q: Is spirituality a part of the program?
SPIEGEL: We haven't done anything with that yet, unless you count the forgiveness classes, which certainly touch on the spiritual realm. I've been a little cautious about it because, on the one hand, I have respect for people's religious and spiritual beliefs and practices, and I don't want to interfere with that. On the other hand, we've had people come talk to patients, and I think sometimes too much is promised. It is a delicate area. If there is something spiritual we can do that meets our general criteria for safety and efficacy, we'll explore it. Certainly on one level we can find efficacy in something that will comfort people and help them feel and cope better. The tougher question is, does it really affect the course of disease? Our goal is what we might call truth in advertising. We will present treatments that work for what they claim to work for and we won't offer treatments that claim more than they can deliver.
Q: How do you screen for contraindications in your clinic?
KUSHNER: A patient called recently, a 70-year-old woman saying she had irritable bowel symptoms and wanted biofeedback. She mentioned she had a weight loss of 10 or 15 pounds. Her doctor wanted her to have a sigmoidoscopy but she didn't want that. I told her that based on what she told me, I would need a letter from her primary care physician approving the biofeedback. The woman never did come in. For migraines, we would need to see a workup before starting a treatment such as biofeedback.
Q: Have you thought about offering primary care services?
SPIEGEL: Yes, we've thought about it, but for practical reasons, including lack of space, we really haven't done it. It's also true that our clinical model at Stanford tends to be super specialized, so we thought a specialized complementary clinic might fit more naturally here at the beginning, but a comprehensive clinic is something to look at in the future, maybe. UCSF does this under the name of an Integrative Medicine Clinic. In any case we hope that this idea will help physicians to view their own practices more comprehensively.
Q: Breast cancer support groups are a major staple of your program. Yet haven't these groups operated for decades here?
KUSHNER: Pat Fobair, who leads cancer support groups for the clinic, has run a breast cancer support group at the hospital for many years, serving breast cancer patients the first year after diagnosis. These continue and are free to patients through the Department of Radiation Oncology. But we are offering two new groups. One serves patients' continuing needs after the first year, and a second group is for patients with recurrent breast cancer.
Q: The cancer supportive care program, how does it work?
SPIEGEL: This is primarily an informational program. We're trying to answer commonly asked questions by cancer patients around issues that range from nutrition to coping with pain to spirituality, meaning of life, sexuality. We also have an exercise class for cancer patients and others with physical limitations. We support their physical needs to exercise in a nonthreatening social environment of similar individuals.
Q: What new programs are on the horizon?
KUSHNER: We are considering a formalized fatigue clinic, because that's one of the main complaints of cancer patients.
SPIEGEL: We're also starting a headache pain program. We're going to do evaluations of patients with headaches and make recommendations about what combinations of treatments might be most helpful. It's primarily pain management for patients without clearly identifiable and treatable diagnoses to avail themselves of a program that doesn't place a high priority on medication as the primary treatment of choice.
Q: What's the overall future of complementary medicine?
SPIEGEL: My hope is that in a few years the effective interventions we offer under the rubric of complementary medicine will just be considered good medicine.
