Most patients know the core contract of the doctor-patient relationship . (we use doctor-patient relationship due to the extensive literature in this area, but this applies to all the members of the patient care team.) The doctor/clinician is obligated to act in the best interest of the patient (not what is in the doctor’s best interest, the hospital’s best interest, the insurance company’s best interest, or the society’s best interest), and the patient follows the prescribed treatment after deciding that the diagnosis and treatment plan are sensible. The patient questions how the doctor knows what their diagnosis is, why this treatment is best, what are the alternative treatment options, and what the prognosis is and is educated about the issues of the problem they face. The doctor also encourages a second opinion in difficult cases or if there are unresolved questions. Once the patient decides to commit to a course of treatment, they are obligated to follow the treatment plan as best as they are able (take the medication, do the therapies, follow the restrictions, and keep the doctor informed of progress).

Some patients, however, do not understand the treatment contract. They may have had negative experiences with other clinicians or have cultural reservations about medical treatment and models, or have cognitive limitations, or have a temperament that pushes them to follow their feelings, or many other barriers. Following Treisman and Angelino’s (2004) articulation of role induction, integrative medicine teams sometimes need to teach some people how to become patients [1]. To be a patient is to accept that the treatment team is working on the patient’s best interest and that the education and expertise of the team means knowing more than the patient about the psychological, biological, and developmental processes of the patient. We do not endorse any “blind trust” but rather a commitment to following through on the prescribed treatment. In order to do this effectively, the team needs to communicate with one another, with the patient, and in a way that considers that patient’s history and future. At the core of integrative medicine are a few foundational activities upon which the system and process of integrative medicine rest: communication and collaboration, gathering records and complete case history, and advocating for the patient.

Communication and Collaboration

The most important element of integrative medicine is professionals communicating and collaborating about mutual patients. The patients who we feel need this kind of care have complex comorbidities that include issues outside of the scope of practice for one clinician, and treatment in one domain affects treatment in other domains. Communication is the foundation that allows integrative medicine to function, bringing a patient’s team together to effectively coordinate care and work in tandem toward the mutual goal of patient health. Too often, when care is not integrative in its approach, a patient sees multiple providers such as a primary care physician, a psychiatrist, and a therapist, none of whom are communicating with one another. This lack of communication places the burden of sharing information on the patient, who may be unable to retain or disseminate the appropriate information about the nuances of their medical care. Even a person who is not dealing with schizophrenia or the aftermath of a brain injury will not have the training in each of the fields that they interact with to know what small pieces of information can make a big difference in making important decisions about treatment.

Beyond removing the burden of coordination from the patient, communication among a treatment team compensates for specialized training each clinician has in their respective fields. It is undeniable that a psychologist may be able to differentiate between depression and bipolar disorder but likely is not able to speak fluently on which blood tests would best screen for hepatitis C; this task would obviously fall to a medical provider. More importantly, when psychological and medical services overlap, an integrative team is in the unique position to intervene in a meaningful and competent manner. For example, some psychiatric conditions interact with medical conditions such as heart disease. Patients who develop depression postmyocardial infarction are more likely to die than those without depression, and depression is a risk factor for behaviors (smoking, overeating, lack of exercise, poor adherence to medication) that increase the risks of myocardial infarction. These independent but interlocking conditions require diagnostic acumen that may be beyond the solo practitioner. Treatment of these interlocking conditions requires a team that can simultaneously approach the whole patient rather than individual clinicians trying to treat conditions that are unresponsive without collateral treatment.

In addition to the benefits of communication, a lack of communication may inadvertently lead to clinicians acting in ways that contradict one another, leaving a patient confused at best and being harmed at worst. For example, a patient who is in recovery from heroin addiction with his therapist might be suffering from chronic back pain. When he asks his primary care doctor what to do about the pain, he may not admit his addiction to the doctor because he did not believe psychological treatment was relevant to physical pain. However, the seemingly appropriate prescription of a narcotic painkiller by the primary care doctor will trigger addiction issues due to being in the same class of drugs as heroin. As will be illustrated in later chapters of this book regarding opioid addiction, intentionally seeking out medications from multiple doctors who are not coordinating is a common way for an addict to feed their addiction, thus increasing the demand for communication with such difficult populations. Providers who are in close contact and work together in the treatment of their mutual patient can avoid scenarios such as the above to best care for their patients’ health overall. Effective communication is vital to integrated and coordinated care.

Gather and Share Available Records

The second most important activity is gathering and sharing all available care records. To the surprise of no one who works in healthcare, and to nearly everyone who does not, the thicker the chart, the fewer professionals who have read it. Decisions are made about a person’s care daily without full knowledge of whether those approaches have been attempted in the past, if there is something in the history that could be contributing to the current situation, and that might give clues as to the origin or progression of difficult cases.

The integrative medicine team not only seeks out as thorough a medical record as possible, requesting records from every provider that a patient has seen, but takes the time to actually read and review past records in order to best inform current care. Understanding what a patient has done in the past, and whether the results were successful or not, provides important information that may guide the treatment team to make well-informed decisions. It may also allow the team to avoid repetitive or redundant procedures from being done. For example, a patient seeking treatment for hepatitis C may require certain blood work or a liver evaluation for fibrosis in order to obtain approval for antiviral medication. Discovering that a patient had a liver biopsy done previously may allow the clinician to move forward in acquiring the appropriate treatment more quickly.

Another example is a patient who has a long history of depression and is seeking psychological and psychiatric care. Knowing which medications have been used in the past, both which ones may have decreased symptoms and which ones were harmful or ineffective, allows the prescribing physician to make better decisions. In the case of antidepressants, which can take up to 6 weeks to start having an effect, this is particularly important in helping to expedite results as much as possible. Furthermore, by sharing this information with the therapist, the therapist may help the patient to understand why the medications aren’t working immediately and help to start therapeutic work in the meantime that may alleviate symptoms of depression as well.

Another common integrative care situation is the patient who has substance use disorder and suffers from low back pain. Having access to previous records of imaging scans and what has been tried previously, including steroid injections and physical therapy modalities, helps the clinician to come to a decision regarding treatment planning more rapidly and efficiently. Patients often have received fractured care in the past, and many of the initial evaluative and diagnostic tools have already been completed despite the fact that no one has reviewed the comprehensive records of all that has been done. Alternatively, it is also possible that the patient saw a clinician looking for a quick and easy fix who prescribed only medication. In the latter case, a full evaluation including careful history and examination and imaging modalities will be necessary. We have found that a comprehensive approach to treating pain, including multiple modalities and a team-based approach to care, is more effective than any treatments the patient has received previously.

Taking the time to collect and actually review records may be typically avoided because of its time-consuming nature. However, when at least one person on the team is able to gather these records and someone takes the time to read them, care of the patient becomes more streamlined and effective, helping the clinicians to provide better care, and the patients are less frustrated at unnecessary redundancies in their treatments.

Advocacy for Patients

Finally, the third key integrative medicine activity is advocacy for the resources to help the patient succeed in treatment. In addition to interventions, it is vital to set up our patients to succeed, helping them in gaining necessary tools such as insurance and public benefits. With this level of directiveness comes additional demands on the integrative medicine team to ensure that proper care is provided. For example, clinicians often struggle with the medical system to get patients access to specialists, medication, and resources that assist in accomplishing patients’ treatment goals. Insurance companies may be reluctant to pay for treatments, and it is often up to the integrative medicine team to convince the insurance companies that their medications or treatments are necessary. This role may fall outside of what medical physicians or psychologists are used to considering in treating patients, but it is important for the team as a whole to consider and meet this need. This is covered in more depth in a chapter on compiling the ideal integrative medicine team.

We assist our patients in navigating available public benefits not only because addiction has created poverty in our patients but because benefits are important resources for nearly everyone needing chronic care services. Chronic medical and behavioral health disorders put those affected at highest risk for treatment nonadherence, hospitalization, homelessness, and incarceration and relapse. Even for patients from an affluent background chronic conditions are the largest social determinants of poverty and additional physical and mental health problems. Although our public safety net is badly frayed, public benefits remain available to alleviate the worst of poverty. Too many do not take advantage of available benefits. In our area (Philadelphia), one out of five who are eligible for food stamps is not enrolled [2].

Patient Demands—and Satisfaction—Should Not Dictate Treatment

Patient-centered care is often confused with patient-directed care. Disagreeing with a patient about what to do is not the same as not hearing the person or not advocating for them. Patients must be reassured that the clinicians will keep working to get them better if they keep coming and engaging in treatment. Ironically, the desired medications often act in ways that may cause problems to get worse instead of better. When patients complain that they are not being heard because they aren’t getting the medication that they want, it is important to remember that advocacy for the patient is not giving them what they want; it is getting them better. Often one must say “I am listening to you and have heard what you said but I disagree with you.”

At this point in healthcare, outcomes and physician effectiveness are often measured by overseeing bodies via patient satisfaction ratings [3]. Patient satisfaction may work against effective healthcare as it emphasizes patients’ subjective perceptions of their treatment and health and ignores efficacious medical interventions and actual best practice. A subset of patients goes to the doctor with a unitary problem and the clear goal of getting better, and for them patient satisfaction relates to their improvement and, can be a fair assessment of quality. For these patients, the goals of the doctor and of the patient are the same. In vulnerable patients with complex comorbidity, the goal of going to the doctor is often to feel better or to be more comfortable; for these patients, patient satisfaction is a destructive measure. When the patient’s goal is feeling good and the clinician’s goal is improving health and function, the goals are not aligned, and patient satisfaction will reflect this disconnect between provider and patient. However, this does not mean that the clinician should just give the patient what they want. Furthermore, recent research has indicated that this system of outcome measurement is not reflective of patient care nor predictive of patient health (e.g., [3,4,5]). When patients rate satisfaction, they are influenced by a number of factors unrelated to outcomes. For example, factors such as wait time lead patients to report lower satisfaction rates, even if those wait times are caused by physicians providing comprehensive exams [3]. Given research around the poor correlation patient ratings have with actual outcomes or quality of care, it is bewildering that patient satisfaction ratings continue to make up such a significant portion of quality measurement in healthcare. This is in part because it is easy to measure. In the words of William Bruce Cameron (though often misattributed to Einstein), “Not everything that counts can be counted, and not everything that can be counted counts” [6].

An unfortunate side effect of these patient satisfaction ratings is that poor ratings can actually lead to worse care. Community clinics may depend on payments from insurance companies that provide the lowest premiums and are therefore the most restrictive. These companies may use patient satisfaction ratings to determine the amount of reimbursement. Thus, when patients rate their care poorly—despite the true efficacy of treatment—reimbursement decreases. When funding goes down, clinics can no longer afford to have as many clinicians or services available because of a decreased budget. As a result, the quality of care decreases. When sources of funding use patient satisfaction as a determinant, they inadvertently cause the quality of care for patients to decrease, ironically possibly leading to even lower satisfaction ratings.

Beyond the ineffectiveness of patient ratings in judging quality healthcare, there is evidence that higher satisfaction ratings are actually correlated with higher mortality rates. Fenton et al. conducted a national study analyzing the link between patient satisfaction and mortality rates and ultimately discovered that higher patient satisfaction ratings are actually correlated with higher mortality rates [4]. This data was criticized because sicker patients are more likely to die and may give better satisfaction scores because of their dependence on the doctor. The link between patient satisfaction and mortality is greater when the data were stratified for the healthier patients. In fact, when a follow-up was conducted years after the study’s conclusion, there was a 26% greater mortality rate in the most satisfied patients over the least satisfied (Fig. 3.1).

Figure 3-1.
figure 1

Increased patient satisfaction correlates with increased mortality. (Graph based on data from [4])

Full size image

Some patients tend to rate their satisfaction based on what they want rather than what is actually advisable or evidence-based. The desire for an antibiotic for cold or bronchitis symptoms is well documented as an issue for patient satisfaction. In one study of almost one million patient satisfaction surveys in primary care settings from 7800 primary care practices in England, antibiotic prescribing was the number one prescription-related factor in patient satisfaction. Based on that study, any effort to decrease overuse of antibiotics would negatively affect patient satisfaction [7].

Many patients bring Internet-based opinions or advice from friends or family to appointments with strong beliefs about what treatments they should or want to get. However, a patient’s ability to assess their own need or know what treatment is best is often very limited, even when the patient is well-intentioned [3]. For example, a patient may walk in believing that they need a certain medication or a surgical procedure; if the physician assesses and does not agree with these expectations, patient satisfaction decreases. It is further important to note that patient expectations often greatly impact physician prescribing and behaviors, both overtly and in subtle ways [5]. First of all, physicians feel pressure to increase patient satisfaction, both from patients and from overseeing bodies that emphasize this system of measurement. Second, patients express preference for interventions exclusively provided by medical providers, such as medication or surgeries [5]. In the case of chronic pain, for example, patients express great dissatisfaction when offered alternative treatments such as exercise, yoga, or deep breathing instead of opioid pain medications. In this situation, a patient is likely to rank their satisfaction much lower. If this influences physician prescribing, it only further increases in cases of addiction where the patient may be seeking certain medications for themselves or to sell to others and thus will be particularly demanding in appointments and potentially punitive in satisfaction ratings if demands are not met. Given the influence of patient expectations on physician behavior, it is important not only to be aware of pressures from patients but to enact systems of care that protect physicians from the harmful power of patient satisfaction ratings as sole measurements of service provided.

Patient satisfaction rates can be maintained without caving to patient demands by addressing concerns in a patient-centered way that provides information and correlates with the preferences of the patients [4]. This not only improves patient satisfaction but is correlated with better health outcomes as well. However, this type of care introduces its own obstacles as it takes much longer because of the conversations required and can be difficult for physicians to implement, particularly given billing and the current level of demand on scheduling of physicians [4]. Regardless, a model of integrative medicine allows for the physician to meet with the patient in the time that they have and for other members of the team to supplement and assist in providing information and providing support for the patient in a way that not only helps the patient to feel supported but produces better outcomes in health.

Example: Discussing Benzodiazepines with Resistant Patients

The idea of advocating for the patient can be misunderstood in ways that are bad for patients, such as providing them with whatever they want. Such patient-determined prescribing ignores the expertise that clinicians have in knowing the risks and benefits of various alternative treatment options and therefore the healthiest treatment choice for patients. As is clearly described above, patient demands and/or satisfaction should not be the hallmark by which clinician effectiveness is ranked. A common example of allowing the patients to dictate treatment is the long-term prescription of benzodiazepines in the treatment of anxiety disorders. These medications have quick and/or “easy” results in temporarily reducing anxiety in patients. There is, however, rebound anxiety with long-term use as the brain adapts to the presence of the drug. Additionally, benzodiazepines impair learning, hindering patients from developing coping skills to deal with ordinary life stresses. The relief of the symptoms produces a psychological dependency on the drug, and ongoing use produces physical dependence. In fact, by shielding the patient from their anxiety, they are unlikely to develop coping skills for anxiety and instead depend more on medications for problem-solving. The medications can ultimately cause more problems by covering up the anxiety instead of creating meaningful change and simultaneously preventing the patient from truly engaging in therapeutic work that would be most beneficial in the long run. In the case of the example below, the patient may demand benzodiazepines, but the clinician, especially one working in an integrative medicine setting with a therapist, must help the patient to understand what is truly best for their well-being.

Consider the example of Darla. Darla is a 45-year-old woman who has been prescribed benzodiazepines, namely, Xanax (alprazolam is the generic name, but patients often use the trade name, and in this case, we will use Xanax because that is the name she used) for the past 20 years by her family doctor; she came into treatment because her anxiety remains severe and her husband’s cancer is exacerbating her experience of fear in her life to the point where she is afraid to leave the house most days. She has been taken off her Xanax briefly in the past, but finds herself feeling so sick from withdrawal that the idea of stopping is terrifying. Furthermore, she feels that she cannot tolerate living without the drug and was able to get her doctor to prescribe it again right away. In one of the first sessions in our clinic, the following conversation occurred to help Darla understand that the prescription she had been given for so long was not helping her.

[This conversation picks up after Darla has been describing her anxiety and her continued need for her Xanax repeatedly]

Darla: You don’t understand. I need my Xanax so I don’t feel anxious.

Therapist: Let me explain to you how these medications work, and you can tell me if this sounds familiar. Xanax is a benzodiazepine, which is a class of drugs that all work similarly. It is essentially alcohol in a pill in terms of how it impacts your brain. At first, it works very quickly, making you feel euphoric, more social, more uninhibited. Xanax initially increases your mood and decreases your anxiety. Most people like this experience. Does this sound right?

Darla: Oh yes, I always feel better right after I take it.

Therapist: Ok, so just like alcohol, Xanax is a depressant, a sedative. Their primary action is to decrease brain functioning. You might find yourself getting sleepy, maybe lightheaded, and many people want to go to sleep after that initial period. Some people even use benzos to help them go to sleep. However, they find that after they fall asleep, alcohol and benzos work the same way. In the body, what goes up must come down. There is a rebound effect because the brain is always working to find balance. When the brain is slowed down by a drug, it must speed up after. You don’t get a good night’s sleep because your mind is racing and you wake up groggy. It actually disrupts sleep! It might be good for a nap, but it’s bad for a night’s sleep and really bad over time. Did you have more problems with sleep before or after you started taking Xanax?

Darla: Well, I have more problems now…

Therapist: And this is why.

Darla: But it still helps with my anxiety!

Therapist: Like I said before, it does initially make you feel better. But, as that dose wears off, you are more anxious for the same reason. Your brain is pushing against the sedation, trying to balance out, so you feel even more anxious than before. We use benzos to try to push down the anxiety, but it always comes back. Over time, benzos make people more anxious across the board. Has your anxiety gotten better since you started taking them?

Darla: No, it’s gotten worse.

Therapist: Because a doctor prescribed it to you, people think of it as different than alcohol. However, they are doing the same thing in numbing you to your anxiety instead of helping you to deal with it. Those doctors aren’t doing their job to get you better; they are trying to be helpful, but they’re not. You’re sick and that’s unfortunate, but I am here to get you better. This is a unique and special program; we believe in working really hard to help people deal with their anxiety without just numbing you from it like your Xanax is doing. If you choose to be a part of this program, we can help you with this.

Darla: I don’t know. I think I just need a higher dose of Xanax.

Therapist: Benzodiazepines, like your Xanax, are a poison. They are interfering with how your brain is functioning. It impairs how you can think and, while it might be enjoyable or feel good, it is not how it is supposed to be used medically.

Darla: But my doctor gave it to me.

Therapist: True, but if you look at the insert that comes with your prescription, the FDA even recommends that benzos are only used for a short term. Eight to 10 weeks max. Alcohol makes you feel similarly; would you drink several shots of whiskey every night before bed? How would that work out?

Darla: Well no, I wouldn’t do that!

Therapist: This is what you have been living with, and why you have been getting more anxious over time so that you actually need more of the medication. I get that, but we have to get rid of the bad to start to fix the anxiety.

Darla: I guess that makes sense, but I have gotten so sick when I have tried to stop it before.

Therapist: You’re right that you can’t just stop like you have tried before. Unfortunately, now that you’ve been on it and your brain has been pushing against it, you’ve changed your seizure threshold. A seizure is when brain is so overwhelmed that it short circuits and shuts down for a few minutes. It is not just unpleasant, but it’s dangerous. The doctor here will slowly decrease your dose over months; this is the safe way to taper off the drug and keep you healthy while your brain adjusts back to a normal level.

Darla: I guess…

Therapist: This is scary. I know that benzos have been a safety blanket, something you have turned to for help, and giving that up is scary. I am not asking you to do this all today. Trust us and do this over time, allow us to help you. Your anxiety will peak when you take the last dose, but then will go down over time.

Darla: That makes sense, but it helped me when my brother and I stopped speaking 10 years ago.

Therapist: When you told me about that huge fight with your brother, you said that the Xanax helped you forget about it. But you recounted the whole thing now. Seems terrible, but also unresolved. We want to actively deal with these issues, rather than not deal with them in the moment.

Darla: That’s true. I still feel bad when I think about that. I guess I’m just worried about how I will deal with things without the Xanax. It really has been a help, even in just getting through my day-to-day.

Therapist: When you were talking to me about how you use Xanax, you said that there are real uses for it and also that you sometimes used more than you should have or snuck some sometimes. I gave you a physical explanation. But more of what is going on with you is battle with fear that is being played out over use of Xanax. You are afraid you can’t deal with life, sleep, or problems with your family, without Xanax. Remember that you have slept or done things before Xanax. And you can do it again after. You are capable. You have survived all these things in your life. You’re a survivor. You are strong enough to do all this without Xanax. You can prove this to yourself over time by doing what we ask you to do.

Darla: Okay, I’ll give it a try. But I need you to help me so I can deal with my life!

The above conversation covers a number of topics that come up when talking to someone about making a change like discontinuing the use of benzodiazepines . Our patients will fight our suggestions when they are not in line with what they want or seem scary to try. Acknowledging these fears, as well as providing information about misconceptions they may have, allows you to express empathy while still advocating for the patient’s best interests. Patients respond well when they understand the rationale behind intimidating interventions, which increases buy-in and willingness to consider these treatment options. Despite our patients’ resistance, this does not mean that we should sacrifice best care to maintain our patients’ short-term satisfaction with us as providers. In the end, as this example shows, advocating for best care may not be what the patient wants, but it is still the necessary route for clinicians to insist upon.

Conclusion

The implications of the foundational assumptions of integrative care lead to an entirely different experience for the patient seeking medical care than anywhere else in healthcare. The patient is talking to someone whose default assumption is the patient will be served by the team for many years. All information about the patient’s life is potentially clinically relevant and part of the careful detective work needed to provide the highest level of care. Problems that arise for the patient are not the patient’s problems to solve alone, but issues that the team wants to see resolved so everyone can be as healthy and happy as possible. This method of conceptualizing care, based on coordination, seeking out a thorough medical history, and truly advocating for the patient to get the best care possible is what make integrative medicine so unique and transformational in providing the best patient care.