Bridging the Gap:

Integrating Arts in Medicine (AIM) into a Comprehensive Health Care Program

By Gena McLellan

INTRODUCTION:  History tells us that, at the dawn of civilization, humanity needed to understand its origins, its meaning, its surroundings, and how they all interacted with one another.  Art and medicine both arose from primitive man’s attempts to understand the world around him and to appease the gods responsible for shaping his harsh world (1).  Primitive art was an attempt to access the spirit world, while early medicine was a blending of art, spiritual rituals and herbalism (2).  As civilizations flourished, as knowledge increased, people were able to specialize--to ask specific questions about the world until we have the various academic disciplines we recognize today.  Each culture has its unique art forms and its unique healing methods.  Many, if not most, traditional healing techniques employed both art and spirituality, and continue to do so to this day.  So how, then, did we in the United States get to a place where “conventional” medicine is at odds with “alternative” medicine?  What is this division?  Why does it exist?  And what can we do to bridge the gap?

HISTORY OF MEDICINE IN THE UNITED STATES:  Up until the early 1800’s, medical care was pluralistic in this country (3).  There were many different health care systems available, and most patients employed more than one system at any given time.  Each group of immigrants, as well as the Native Americans, had their own healers who responded to the needs of their communities. Although medical schools existed since 1765 (4), they were a far cry from the organized, conventional health care system we see today.  Even formally trained doctors used the various techniques employed by “folk healers.”  However, when medical schools started to organize and standardize themselves during the first decade of the 19th century (3), a shift in the paradigm was felt throughout the country.  Fueled by the scientific method espoused by the Enlightenment, medical schools and the doctors they trained began to look at the “folk healers” as “charlatans”, “quacks”, and “mongrel homeopaths” (3).  Training in a formal medical school was becoming increasingly more elite; traditional healers responded by viewing the conventional doctors with distrust.  Folk medicine was seen as the “medicine for the people”, while standardized medicine was viewed as for the aristocracy and the well-to-do.  As the elitism grew, the medical establishment continued to look at anything other than “formal” training with disdain, lobbying for laws forbidding folk practice in any “reputable” medical establishment and denigrating folk medicine in the literature (3).   In time, the medical schools and the institutions staffed by their graduates became the dominant medical model; anyone who sought any other treatment was seen as superstitious and ignorant. 
            In its commendable goal of self-scrutinization, the medical establishment established codes of conduct, regulatory boards, and methods for disciplining those doctors who broke the code.  Unfortunately, one of the side effects of ensuring quality healthcare by policing unprofessional behavior of physicians was the infamous physician detachment (5).    By contrast, folk medicine continued to value the close, personal relationships between the healer and the patient. 
            Today, conventional or “allopathic” medicine continues to be the dominant medical system.  As such, the elitism and political dominance of the allopathic system still exists and is seemingly entrenched.  However, complementary, traditional, and alternative systems of healings are growing rapidly in popularity.  Although the mutual distrust still exists between “folk medicine” and conventional medicine, a truce of sorts has been called.  Younger allopathic practitioners generally are more open to the incorporation of CAM practices than are their older counterparts, who insist (often to the contrary of existing research) that CAM is not evidence-based, therefore it is worthless. Mainstream medicine is realizing that the growth in these systems reflects a failing of their patients; alternative medicine practitioners see the value in research and self-scrutinization. The paradigm is once again shifting, and the country is slowly moving back to medical pluralism.  It will, however, take some time and effort in order to achieve this. 

CAM:  Definition, Disciplines, and Strengths:  Complementary or Alternative Medicine, or CAM, has come to mean anything other than allopathic medicine.  The Cochrane Collaboration defines CAM as such:
“Complementary and alternative medicine (CAM) is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period.  CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being.  Boundaries within CAM and between the CAM domain and that of the dominant system are not always sharp or fixed.” (6)

Disciplines classified as CAM include traditional medicine of any ethnic group, such as Chinese medicine, Ayurvedic, and shamanism; herbalism, energy medicine, art therapy, music and sound therapy, and even using trained animals to diagnose pathology (7).  Many disciplines, such as nutrition, osteopathy, and chiropractic, are well-grounded in evidence-based science and are well-regulated; these types of disciplines tend to be more readily accepted by conventional medicine (8).  Others, such as crystal work or color therapy, are still considered “on the fringe”. 
Much effort and progress is being made to expand CAM into the scientific arena; such entities as the National Institutes of Health and Biomed Central have well-developed websites detailing background information, current research, and/or funding opportunities for evidence-based CAM therapies (9, 10, 11, 12, 13).  CAM is being taught at more and more medical schools (14).  Integrative (or integrated) medicine, which seeks to incorporate CAM therapies into a holistic healthcare regimen, is seen with more frequency in conventional healthcare settings.  CAM as an industry is booming, with consumers spending approximately 24.6 billion dollars on point-of-service treatment (not including books, classes, or equipment) in 1997, up 86.4% from 1990; when the self-help items are included, this number jumps to $34.4 billion (15).  Each of the various disciplines, even when similar (for example, the energy medicine disciplines incorporating the Chinese system of Qi and the Indian system of chakras), have their own customs, rituals, and procedures.  However, there are certain similarities among disciplines that make it an attractive option to the healthcare consumer.  What is it about CAM therapies in general that people are responding to?
Zollman and Vickers have identified seven features of CAM therapies that patients find valuable.  These are:  1) time and continuity; 2) attention to personality and personal experience; 3) patient involvement and choice; 4) hope; 5) touch; 6) dealing with ill-defined symptoms; and 7) making sense of illness (16).  While it is true that these features are also found in conventional medicine, the approach taken by CAM therapies is much different.  CAM tends to focus more on the patient as a whole, emphasizing the mind-body connection and the role that the patient himself plays in disease etiology and progression.  Conventional medicine, on the other hand, tends to focus more on the biochemical pathways involved in disease pathology and treatment of symptoms.
CAM practitioners usually spend longer periods of time with their patients.  As mentioned above, CAM practitioners concentrate on the person as a whole, how they react to and manifest the disease, rather than on symptoms individually.  CAM patients are empowered by the amount of choice and control they receive in treatment, as opposed to the passive role a patient tends to play in the physician-centered-responsibility model that is the norm in conventional medicine.  CAM practitioners seem to be more optimistic even when dealing with a negative diagnosis.  This optimism often benefits the patient; a positive state of mind is very important when dealing with illness.  There is typically more physical contact between the CAM practitioner and the patient.  This is partly due to the nature of the CAM treatments themselves, and partly because the CAM practitioner is not bound by the same rigid codes of conduct as the conventional physician. 
Although many, if not most, CAM-seeking patients seek out allopathic doctors for acute conditions, CAM therapies often offer better relief of chronic, ill-defined illnesses and disease than does conventional medicine.  Often, allopathic doctors do not prescribe treatment, minimize symptoms, or imply psychosomatic etiology to symptoms when tests are inconclusive, as with chronic or hard-to-diagnose illnesses or disease.  The validation and treatment of symptoms as the patient perceives it is often just as valuable as treatment in and of itself (17).  CAM focuses on the person as a whole, attempting to address a patient’s spiritual, emotional, and interpersonal needs as well as the symptoms.

Bridging the gap:  CAM and conventional medicine together are frequently seen as part of an integrated healthcare regimen.  However, as this partnership is newly-forged, those practitioners who espouse and/or facilitate this partnership are often unsure of how to progress.  Some advocate total separation (18), while some advocate total integration (19).  Boon et al. proposed a continuum of integration where levels of cooperation between allopathic physician and members of the integrated healthcare team increase as one moves from left to right along the continuum (20).  The left of the continuum is better suited to treat acute conditions, while the right side of the continuum is optimal treatment for such chronic conditions as autoimmune disease, hard-to-diagnose illnesses, and pallative care (see Figure 1).

Figure 1:  A continuum of team health care practice models (20)

            Who are the members of an interdisciplinary healthcare team?  What are the skills that members of such an interdisciplinary team would find helpful?  How can we teach these skills in an academic setting? 

Groups involved in interdisciplinary healthcare team and their needs:  Here is a description of the members of a typical team, along with some needs.  It is by no means inclusive, but it serves as a starting point to identify what issues such teams need to address.

  1. Patient and family/friends:
    1. Need quality care
    2. Need to be validated (signs, symptoms are real)
    3. Need to be involved in their care; autonomy
    4. Need to have their worldview respected
  1. Artist-practitioners, CAM practitioners, Spiritual care providers
    1. Need to be validated (they are valuable contributors to the healing process)
    2. Need autonomy to perform their duties (within constraints of patient’s needs)
    3. Need to interact with patient
    4. Need to have their worldview respected

 

  1. Healthcare professionals
    1. Need to know this won’t hurt the patient
    2. Need to be able to take charge when needed
    3. Need to work within the constraints of the institutional system
    4. Need to have their worldview respected

 

  1. Healthcare managers
    1. Need to comply by existing institutional rules and regulations
    2. Need to see a “bottom-line” benefit
    3. Need to have their worldview respected

Note how all of these groups need to have their worldview respected.  A successful member of a team needs to be able to communicate with other members of the team, needs to be aware of and sensitive to the needs of the other members, and needs to be able to respond to the needs of the patient.  Some skills that all members of a team may find helpful include:

      1. Communication skills
      2. Empathy skills
      3. Multicultural awareness
      4. Enough background info to communicate effectively

Teaching interdisciplinary skills in an academic setting:  Many of the classes taught by CAM or AIM curricula in other institutions are specialized courses, but fortunately the University of New Mexico has a number of courses that can be selected as part of a comprehensive curriculum.  The following list is not all-inclusive, but serves to illustrate the wealth of resources available to the AIM program in teaching these skills to potential team members.
COMMUNICATION SKILLS

  1. Introduction to Communication, Non-Verbal Communication, Cross-cultural communication—these classes provide training and awareness on the different methods of communication
  2. Critical Thinking—a philosophy course; this course requires students to be able to formulate and defend arguments without resorting to name-calling or attacking the person
  3. Technical Writing, Proposal & Grant Writing—tech writing is required for nursing students; these classes offer insight to how allopathic professionals communicate with one another.  Also, Proposal and Grant Writing will prove helpful in the event that students want to write grants to support their own AIM projects

EMPATHY SKILLS

  1. Introduction to Nursing—basic skills and issues involved with nursing are covered.  Provides both empathy training and common background knowledge among team members
  2. General Psychology—awareness of how emotional states can impact physical health; awareness that there are issues underlying people’s behaviors
  3. Introduction to Philosophy—philosophy was categorized here because this class challenges students to look past their personal assumptions and to consider other people’s assumptions
  4. Mind-body awareness physical education classes, such as NIA, Feldenkrais, Pilates, martial arts—focusing on one’s own mind-body connection facilitates understanding and respect of other people’s mind-body connections

MULTICULTURAL AWARENESS

  1. World Religions—oftentimes, a person’s religious background shapes his or her worldview in profound ways—whether the person realizes it or not.  This class teaches respect for all different faith systems while striving to recognize how they view the world around them and why
  2. Professional ethics—provides awareness of the code of ethics that must be maintained by allopathic practitioners
  3. Introduction to Political Science, World History—understanding of any historical tensions among different groups may facilitate dialogue among group members
  4. Intro to Anthropology, Intro to Sociology—awareness of different cultural groups, their concerns and their priorities and how these affect interpersonal  patterns

BACKGROUND INFO/DOMAIN KNOWLEDGE

  1. Biology core classes or Biology for non-majors, Anatomy and Physiology—provide background information all students
  2. Art History, Art Appreciation, Foundations of Music—provide background information for all students
  3. Intro to Nutrition—provides background information to all students

Most of these courses fulfill the UNM core.  Some options for implementing certification of completion of an AIM curriculum include a stand-alone major offered through the University Studies program; a distributed minor option, with curriculum distributed in the Fine Arts, Biology, and Nursing departments (similar to the manner in which premedical courses are offered); and a graduate/professional level concentration.  This option, of course, would require more specialized classes.

 

References:

  1. SHP History:  Medicine Through Time.  WWW Document.  URL: http://www.educationforum.co.uk/gcseSHPchron.htm
  1. History of Medicine Timeline.  WWW Document.  URL:  http://www.schoolscience.co.uk/content/4/biology/abpi/history/timeline.html

 

  1. T. J. Kaptchuk, D. M. Eisenberg. Varieties of healing.1: medical pluralism in the United States. Annals of Internal Medicine, 135:3, 2001.
  1. The Historic Background of Osteopathic Medicine.  WWW Document.  URL: http://history.aoa-net.org/Osteopathy/text.htm

 

  1. F. Davidoff. Weighing the alternatives: lessons from the paradoxes of alternative medicine. Annals of Internal Medicine, 129:12, 1068-1070, 1998.
  1. C. Zollman, A. Vickers. ABC of complementary medicine: what is complementary medicine?. BMJ, 693-696, 1999.

 

  1. C.M. Willis, S.M. Church, c.M. Guest, W.A. cook, N. McCarth, A.J. Bransbury, M.R. Church, J.C. Church.  Olfactory detection of human bladder cancer by dogs:  proof of principle study.  BMJ 329, 712-716, 2004.
  1. Complementary and alternative medicine?  What is it?  WWW Document.  URL:  http://www.mayoclinic.com/invoke.cfm?id=PN00001

 

  1. National Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health (NIH).  WWW Document.  URL:  http://nccam.nih.gov/
  1. Medline Plus:  Alternative Medicine. WWW Document.  URL:  http://www.nlm.nih.gov/medlineplus/alternativemedicine.html

 

  1. BMC Complementary and Alternative Medicine.  WWW Document.  URL:  http://www.biomedcentral.com/bmccomplementalternmed/
  1. University of California, San Francisco School of Medicine:  Osher Center for Integrated Medicine.  WWW Document.  URL:  http://www.osher.ucsf.edu/Resources/InternalResources.aspx

 

  1. The British Medical Association:  Complementary and Alternative Medicine.  WWW Document.  URL:  http://www.bma.org.uk/ap.nsf/Content/LIBAlternativeMedicine
  1. Courses on Complementary Medicine and Alternative Therapies (CAM) taught at Conventional U.S. Medical Schools.  WWW Document.  URL:  http://www.healthwwweb.com/schools/CAM.html

 

  1. D. M. Eisenberg, R. B. Davis, S. L. Ettner, S. Appel, S. Wilkey, M. Van Rompay, R. C. Kessler.  Trends in alternative medicine use in the United States, 1990-1997.  JAMA, 280:18, 1569, 1998.
  1. C. Zollman, A. Vickers. ABC of complementary medicine: complementary medicine and the patient. BMJ, 1486-1489, 1999.

 

  1. T.J. Kaptchuk.  The placebo effect in alternative medicine:  can the performance of a healing ritual have clinical significance?  Ann Intern Med. 136:11, 817-825, 2002.
  1. Coulter.  Killing the goose that laid the golden egg?  BMJ 326, 1280-1281, 2003.

 

  1. L. Rees, A. Weil. Integrated medicine. BMJ, 119-120, 2001.
  1. H. Boon, M. Verhoef, D. O’Hara, and B. Findlay. From parallel practice to integrative health care: a conceptual framework. BMC Health Service Research, 4:15, 2004.