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Nancy Sudak, MD, ABIHM: Hi. I'm Dr. Nancy Sudak. I'm the Executive Director at
the American Board of Integrative Holistic Medicine. We're here with Dr. Dave Rakel.
Thank you, Dr. Rakel, for taking the time to meet with us. Dr. Rakel is on the board
of directors of the American Board of Integrative Holistic Medicine. He's a founder and director
of the University of Wisconsin in Madison Program in Integrative Medicine, and also
an Associate Professor in the department of Family Medicine. So, Dave, is it possible
to teach how to facilitate healing?
Dave Rakel, MD, ABIHM: I believe so. It is a controversial subject. Some people
would say, "No, we can't." Others would say, "Yes, we can." Some people believe that we
just have this innate personality that's hard to change. In fact, in Europe in medical education,
they will often bring in acting coaches to try and teach empathy and compassion. That
actually works pretty well. What bothers me is it's inauthentic. If we are trying to act
a certain way without being a certain way, another human being can pick up on that. If
we are going to really be authentic, in order to teach how to facilitate health and healing
in another person through our presence, that we have to first do this for ourselves.
Dr. Nancy Sudak: What are some of the ways that we can learn how to do that
for ourselves? Dr. David Rakel: In creating this curriculum
of how to really create a... I don't want to sound trite, but a healer. It sounds a
little trite. Really, what we are trying to do is, in the future we're going to have this
big mega computers that will tell us the differential for everything we want to know. But that computer
will never be able to really be present and understand through our intuition in understanding
of a complex story and be able to attach a lot of various bits of information into a
conclusion that will lead towards a path towards health.
There are our opportunities to help understand. In order to do this well, we have
to do it for ourselves. That's the main key. That's why the American Board of Integrative
Holistic Medicine focuses on this so much. We need to first start with ourselves in order
to be best prepared and train ourselves to best help someone else, because it's really
hard to sit with another suffering human being if we are suffering more than they are.
Dr. Nancy Sudak: [2:35] Yes. Well, can you talk about how integrative medicine has changed
or will change the shape of research in the future?
Dr. Dave Rakel: Yes. It's been really exciting. This whole field we always hear, "OK, where
is the evidence for that?" Now we are starting through NIH support and other funders to realize
that we can't do research the way we did in the past, that the randomized double‑blind,
placebo‑controlled trial is really good for a supplement or a medication. It really
doesn't work well to understand how complex systems heal.
If we are going to really look at the endpoint of what we want to achieve, which
is health for a complex human being or even a community, we have to say, "OK, what does
health look like at the end products? What do I want to achieve? If I want to achieve
better health in my community, so I have more resilient, healthy human beings who are kind
to one another, what type of intervention would I need in order to facilitate that outcome?"
We are starting to realize the importance of more of a pragmatic or practical randomized
controlled trial where we decide what we want to achieve, which hopefully is health for
our community. Then we're not so concerned about the drug or the pathophysiological process,
but we might include a number of different variables into that, maybe through the Patient‑Centered
Medical Home and primary care. May be by incorporating a team approach to
say what does this community need to be healthy and how can I achieve that? That's really
encouraging us to do research in a new and exciting way that is really expanding our
awareness into how to study complexity. Dr. Nancy Sudak: Well, would you be willing
to give an example of a research project that you did?
Dr. Dave Rakel: Well, one that comes to mind that we did not do, but is a really
good example of a pragmatic controlled trial is one of neck pain. We might just look at
acupuncture or we might just look at a muscle relaxant for a neck pain, but they did a pragmatic
trial where they had different groups of therapy. One was just education for the neck pain.
One was a physical therapist who was able to not just follow a protocol based on the
research direction, but they've really matched the therapy to the unique individual and what
they needed. Then there is also yoga therapy for that.
It wasn't just the yoga therapy that was combined also with an emotional awareness process of
how stress can be held in the neck. Then you look at those three different arms and you
say, "Which one works best?" Then we tried and reproduce that. We're not so concerned
about what chemical it is that we are influencing. Now that research is important too. Well,
we're more concerned about the outcome in helping that person with neck pain. How can
we improve their quality of life, so they need us less?
It's not that we don't want them to come see us, but we meet them in a different
way. This is what we are trying to do in the American Board of Integrative Holistic Medicine.
Educate people to feel more prepared to really appreciate and shift their complexities, so
we can move in a new direction and we need research as our guide.
This whole evidence‑based medicine process is transforming to evidence‑informed medicine.
If all we did was practice evidence‑based medicine we wouldn't be able to prescribe
much, because we just don't have enough evidence for that. Evidence informed medicine says,
"Hey, this is really important. It's going help guide us towards not harming and really
helping that individual". Dr. Nancy Sudak: What are some of the resources
that you would recommend for individuals wishing to learn more about this kind of research
approach? Dr. Dave Rakel: The research approach
is evolving as we speak. The National Institutes of Health, the National Center for Complementary
and Alternative Medicine is probably the best resource for us to understand how we are using
more of this practical outcomes research to really understand how we can add value to
healthcare delivery. Dr. Nancy Sudak: In addition, what about
resources for teaching Integrative Medicine in academic setting? What would you recommend
for that? Dr. Dave Rakel: Sure, yeah. Lots of
different resources were biased right? We really believe strongly in the American
Board of Integrative Holistic Medicine and we have our syllabus that is quite expansive
in regards to what it offers. after starting my fellowship in 1999, I felt that there was
a tremendous need to create a resource for primary care docs specifically to understand
how to use the evidence that we have to help guide us towards really integrating books
both traditional and non‑traditional methods. We just published a third edition of "Integrative
Medicine," which I edit but a lot of my friends including you have contributed to and it's
really a work of love - I'm going to say it! Dr. Dave Rakel: [07:38] We hope it really
acts as a guide. It is divided into three sections. First is the art of what we do.
It's the healing encounter. It's the philosophy of this field and that's just three chapters.
But the majority of it is a reference text. What if you want to use an integrative approach
for neck pain? What's the evidence for yoga for neck pain? What's the evidence for acupuncture?
We also have a little icon that rates the evidence, the weight of the evidence but also
the weight of harm. That is something you don't always see in traditional medical text.
What we have going for us in integrative holistic medicine is we are using therapies that may
be matched to the patient's belief and culture better. They have less harm in regards to
some of the other therapies that we are more used to prescribing in conventional medicine.
After each chapter, there is a therapeutic review and there is an evidence versus harm
icon which is an arrow. The more up it is, the better evidence
with the least harm. The more down it is, the worst evidence with the more harm. It's
a really quick icon that helps guide the reader. If they are seeing someone with hypertension,
they can just turn right to it and just skim the summary. It is meant to really be a guide
in their practice. The last section is tools for your
practice. These are educational quick chapters to help us learn how to do an elimination
diet. Or, "How do I do self hypnosis for abdominal pain or headaches? What can I learn about
reducing the toxins in my environment?" These are really practical how to chapters that
we just wan to really give guidance based on research.
Lots of these authors have years of clinical experience. We want to share that
with other physicians, healthcare practitioners and clinicians to really help us move towards
creating more of an excellence in salutogenesis. This excellence in how complex systems heal
and that's what we are doing together. This whole organization is creating an excellence
for health, which we already have a pretty good excellence for disease in acute and catastrophic
care, but we need a better balance and if we are going to add value to healthcare where
we have improved outcomes with reduced cost. This is what we have to explore.
Dr. Nancy Sudak: Dave, what are some of the factors that you think will have an
impact on our current disease focused model of healthcare?
Dr. Dave Rakel: You have to focus too much on payment, but it really doesn't drive what
we do. We need a currency for health. Right now, we have a currency for disease. Once
we can figure out how to pay healthcare teams to really reach out and create help for our
community, we're going to create a focus for us to do this together. The team of the future
will be physician led, but not physician dominant. We're going to have other professionals in
here. We're going to choose that profession to best serve the needs of that specific community.
If I have a community that has a lot of obesity, I'm going to maybe choose a psychologist and
a nutritionist, maybe an exercise sociologist, and we're going to work together to create
these programs. But how do you pay for them is the key.
If we can figure out how to reward health or the outcomes that we want to achieve,
that's ideal. Now, some businesses are starting to do that. They're saying, "Hey, my healthcare
premiums are too high. I can't make my business work out, because I'm spending all this money
on healthcare." They're saying, "Hey, I'm not going to pay
these high premiums. I'm going to give money directly to a patient centered medical home
or a health clinic to manage my population and my business. Not just to treat their disease,
you can do that, obviously that's needed, but to also facilitate their resiliency and
their present‑ism at work and their creativity. Give me what I want for my employees if I'm
spending all this money." If we do that, if we continue to pay for acute
and catastrophic care through the third party payer, through the insurance, but directly
allow money to flow into the community clinic. We have a resource to bring in these teams
of professionals to reduce the cost, because they don't need to go in for dialysis, they
don't to go into the hospital or urgent care as much because we're really focusing on what
that unique individual needs to be well. We're just exploring how to do that but through
businesses, is a really low hanging fruit there. That's if businesses want this for
their employees, we'll give it to them. But give us the money to do it because we need
that support to create these teams. That's how we'll create this currency for health.
Dr. Nancy Sudak: That's an excellent and hopeful answer. It does suggest that integrative
medicine, in many ways, is the solution to our healthcare crisis.
Dr. Dave Rakel: Well, you and I are biased, so we would agree with that. But it's just
good medicine right? And drop the adjectives, and this should just be what we do for our
friends and our communities and the people we care for. It's not the deal that the model
was wrong, it's the best we could do, but now we're starting to be insightful, and to
understand we need to do it a little differently. We need to start to pay for what we want.