A Glimmer of Hope.

Abstract

For me, hope is serious business – something with substance that I rely upon daily. It's with that belief I pursued my medical career, leaning into the difficult situations, waiting confidently to be surprised and awestruck by something beautiful. More than ever, we physicians are in dire need of real hope for our professional and personal futures. Eventually, we all become patients and want compassionate physicians caring for us. I know change starts with us and within us. It explains how I found my way into an integrative medicine (IM) fellowship at age 60 and then sitting for a national integrative medicine board examination this year at age 70. After my fellowship training, I decided the best way to add integrative medicine to my private family medicine and geriatric practice was as a consultant.1 For the next 6 years, I combined my services as a family doctor and geriatrician with my newly acquired notions of integrative medicine. Not surprisingly, there was not one consultation request from a fellow physician. They were all patient-initiated. Word of mouth and current patients who wanted more time, advocacy, coordination, and holistic care kept me busy. These were poignant cases: a 69-year-old educator and his family struggling with his diagnosis of multi-system atrophy and rapidly progressive dementia, a 64-year-old engineer with terminal amyotrophic lateral sclerosis, individuals with vasculopathy and multiple comorbidities, and frail elderly adults fighting to stay independent – all seeking customized guidance and genuine understanding, none of which was forthcoming from their center city specialists or their luck-of-the-draw hospitalists. I did receive encouragement from several of my specialty colleagues who enjoyed my old-fashion dictated consultation letters, but what was missing was board certification; it was the necessary next step if my colleagues were to take my integrative medicine practice seriously. After my congratulatory letter from the American Board of Physician Specialties this year, I paused in relief to reminisce over my journey. There was no sudden epiphany, but what occurred to me gave me hope. It was just a glimmer, but it was real. Most physicians do not know what integrative medicine is or what a fellowship-trained, board-certified integrative medicine clinician can do. Considering there are only a dozen or so approved integrative medicine fellowships and fewer than 700 integrative medicine specialists in the entire country (unpublished data), it is understandable. Integrative medicine is fundamentally a comprehensive, holistic (body, mind, spirit), healing-oriented approach to health care that is deeply rooted in a strongly collaborative doctor–patient relationship. It uses all appropriate therapies, both conventional and alternative. It neither rejects conventional medical science nor unconditionally accepts alternative therapies.2 Only proven and effective natural remedies from modern and ancient healing arts are offered. These therapies are often less invasive, less expensive, and better tolerated than conventional medicine, but to truly understand the multiple advantages I discovered in my integrative medicine practice, one must dig deeper. The deterioration in physician morale and the complaints from patients about the dehumanizing intrusion of technology, insurance, and government policies into their dealings with physicians have been widely publicized.3 Many physicians have lost the joy of practicing medicine and their days are filled with drudgery. Increasing rates of physician burnout, depression, and suicide are troubling examples of this demoralization.4 Dehumanization in healthcare is sometimes unavoidable but has reached endemic proportions.5 Because we are witnessing the slow but steady erosion of the humanism and professionalism that have rooted medical practice for millennia, any plausible hope of countering the enveloping darkness around patients and physicians warrants serious consideration and study. The dignity of the doctor–patient bond is not automatic. It relies heavily on the physician striving to understand the whole individual, their family of origin, core values, and what gives their life purpose and meaning.5 It requires physician diligence and expertise to cultivate the trust, affection, and loyalty that result. These positive attributes are acquired throughout a physician's training and mature over a physician's lifetime. Their embodiment requires practice and humanistic mentors in training and in future workplaces. As for medical professionalism, this can be traced back to the time of Hippocrates, on whose name physicians swear to subordinate their own interests to better serve those of their patients. This pillar of medical professionalism also promotes patient autonomy and shared decision-making.6 Hopelessness within the medical profession seems to be directly related to the burgeoning demand by government and third-party payers for more metrics and more standardized care of patient populations. These dynamics, along with corporate medicine and physician employment, produce an underpublicized moral hazard that confronts physicians daily and threatens the primacy of medical professionalism and medical humanism.7 After years as an integrative medical consultant, I contend that the affirming humanistic principles of integrative medicine offset this subversion. To some, integrative medicine simply reestablishes the importance of a healthy lifestyle and reconnecting patients with their innate healing powers. For others, these time-consuming efforts, although commendable, seem unrealistic, but the legacy of integrative medicine when practiced as a component of a hospital- or community-based medical team will be its ability not only to restore the medical professionalism and medical humanism being lost every day, but also to lessen the dehumanization that patients experience and the rampant burnout among physicians. This 2-for-1 phenomenon of restoration and remediation is the unanticipated and underappreciated benefit of interjecting integrative medical consultations into the patient care equation. That was my “aha” moment – that physicians and patients benefit when integrative treatments and recommendations are applied across the human lifespan whether in primary or specialty care. I witnessed this as a hospital-based geriatric consultant and as a community-based integrative medicine specialist. Either way, my consultation letters explain in detail the importance of diet, sleep, physicality, resilience, relationships, and spiritual values in addition to my physical findings and recommendations regarding their various geriatric syndromes. There will be limitations to these ameliorating effects. The circumstances in which integrative medicine is practiced and the degree of acceptance and communication that the specialists and primary care physicians involved have will determine the extent of IM's value-added service. Integrative medicine physicians conducting research or teaching will be limited because of their relative isolation from the rigors of high-volume patient care. Other practitioners in the integrative medicine community who are neither fellowship trained nor board certified and practice a brand of integrative medicine based on merchandising vitamins and dubious therapies will have the least effect, but having fellowship-trained, board-certified integrative medicine physicians consulting on complex medical and surgical cases will, by its very nature, counterbalance the dehumanizing effects of today's healthcare system. Their consultation letters will illuminate treatment plans, keeping them on-track and person-centered. Time pressures on other physicians involved will be lessened; unwanted potentially dangerous testing and treatments can be appropriately averted and unnecessary costs thereby curtailed. With the integrative medical consultant onboard, patients will finally enjoy a relationship with physicians who advocate for treatments consistent with what is truly meaningful in their lives. Physicians want this twofold effect from integrative medicine. They want back the awe and humility of entering the lives of patients in a professionally intimate, deeply satisfying way.8 They wish for specialty-trained physicians to whom they can refer the “holistic management” of certain patients.9 The integrative medicine consultant as a respected member of a multidisciplinary team is poised to fill the current void and restore the team's joy in caring for patients by having a deeper awareness of who these patients are and what they want. When the agendas of patients are acknowledged within the context of their spiritual and family values, dignity and true shared decision-making are reestablished. In my experience, the integrative medicine consultation sets the framework for this to happen. By skillfully combining the attributes of medical humanism with evidence-based clinical guidelines, integrative medicine consultants provide patients the opportunity to make informed medical decisions consistent with their life goals while regenerating the joy of practicing medicine for all involved physicians. At long last, a new way to hope for our collective futures. Conflict of Interest: None. Author Contributions: Joseph F. Mambu is the sole author of this article. Sponsor's Role: None.