Improving Patient Outcomes and Creating Solutions through Practitioner Collaboration

I recently read a blog post titled “How to talk with your patients about alternative medicine.” I got really excited and thought Yes! Another physician who gets it. Well, no. The blog really should have been called “How to convince your patients why you think alternative medicine is bogus without offending them.” 

The reality is, more and more patients are turning to complementary and alternative medicine (CAM) each year, between 40-70% depending on the age group. There is some indication that patients who use CAM have lower overall mortality, meaning they are less likely to die, and many studies show that they cost the healthcare system less money each year with outcomes that are just as good, if not better, than patients who stay conventional. In 2007 alone, Americans spent almost $38 billion out-of-pocket on CAM therapies, from supplements to yoga to chiropractic. 

$38 billion is a lot of moola. 

Because of the negative way alternative medicine is portrayed in the media, I had the misperception that the great majority of conventional practitioners were against it. I started digging, though, and happily found out, that is not necessarily the case. An older study surveying physicians found that more than 50% of them would support their patients’ desire to seek out CAM therapies. Other surveys of physicians range from 13-40% in support for CAM therapies, depending on the therapy. The more a conventional practitioner knows about CAM, the more likely they are to suggest it, and upwards of 85% of physicians want more education about CAM therapies.

The problem is, few of us are working together for the greater good to collaborate with other practitioners and offer patients what they really want.

It’s safe to assume that patients would welcome collaboration between practitioners, but only 30% of patients tell their conventional physicians when they are using CAM therapies. Many people are concerned that their physician will not support it.

Barriers to Collaboration

There are several barriers preventing collaboration between conventional and CAM practitioners. 

1. Most medical research is funded by pharmaceutical or medical device companies because that’s where the money is. Complementary and alternative therapies such as herbs, homeopathy, and chiropractic care are not financially lucrative and therefore do not receive adequate funding for research. I would love to see someone fund a study where newborns receive an osteopathic treatment within 48 hours of birth, because it would change lives.
2. Partially because of the “paucity” of controlled studies evaluating the effectiveness of many types of CAM therapies, there is a bias against them. Just take a look at the blog I mentioned at the beginning of this post. However, the lack of scientific proof does not mean these therapies do not improve patient outcomes, it simply means that the evidence is more empirical in nature. We’ve all heard stories about the cancer patients given a few months to live who actually survived for years after diagnosis due to the non-conventional steps they took to improve their health, but these patients are not being tracked or studied so that we can learn from them.
3. In addition, there is a scientific double standard that is used against CAM therapies. There are many conventional treatments that have never been thoroughly evaluated for evidence of safety and efficacy before being adopted into practice. These include some of the most universally accepted conventional treatments such as the current CDC schedule of infant vaccinations, radiation therapy, and low-fat and reduced sodium diet recommendations. One need only look at the recent decision to rescind 40 years’ worth of recommendations limiting dietary cholesterol, which were based not on patient outcomes and studies but rather a theory that ultimately could not be proven beneficial. This does not even take into consideration the current research-practice gap that exists in medicine, which you can read more about here. 
4. Physicians who speak in favor of CAM therapies and/or against conventional treatments are often ostracized by their peers. We should be embarrassed by the criticism heaped upon Suzanne Humphries, MD, and Jack Wolfson, MD, when they questioned the dogma behind current vaccination policies. That has to stop.
5. Unless specifically designed as an integrative program, most medical school education does not cover non-conventional treatments. It is human nature to criticize that which we do not know or understand. For instance, only 13% of physicians said they would recommend herbal treatments to their patients, and yet in a survey among family practice doctors, over 75% of the respondents said that doctors were “poorly informed” when it came to herbal medicine. Of course they shouldn’t be prescribing herbal therapies for their patients! But they are doing them a disservice by not recommending a knowledgeable herbalist to patients who want to pursue plant-based therapies. According to Dr. Robert Martines, a chiropractor in Campbell, California, holistic practitioners often experience “a basic ignorance of the scope and training of non-medical natural health care practitioners [from MDs]. There is a lack of professional respect, trust, and authority” which undermines collaboration across the disciplines. 
6. There is currently no financial incentive to collaborate. Although the original Affordable Care Act provided support for CAM therapies, most of the reimbursement policies were gutted during negotiations between the House and Senate. Insurance reimbursements for CAM therapies currently vary from 0-$30 per service, with no referral fees for practitioners.

It is exactly because of these barriers, particularly #5, that we need to start collaborating on behalf of our patients. To do otherwise jeopardizes the concept of “consent” in medicine. If patients do not have all of the information they need to make an informed decision regarding their health care, how can we say they have truly “consented” to treatment, especially one that might cause them harm?

A New Model of Care

Imagine a patient complains to his primary care provider that he is experiencing chronic head, neck, and back pain. This patient is 40 pounds overweight, does not exercise, is depressed, and works 50 hours a week as a computer programmer. In the traditional setting, this patient might be counseled briefly to lose weight, start exercising, and receive a prescription for medications such as anti-depressants, ibuprofen and/or narcotics such as oxycodone. Six months later, when the patient returns, he is now 60 pounds overweight and in severe pain, so the PCP refers the patient to an orthopedic surgeon or neurosurgeon. Being found to have disc degeneration, the patient then receives three injections of corticosteroids to reduce inflammation and finally, ends up having spinal fusion surgery 12 months after he initially sought care from his PCP. He experiences a slight improvement in pain at first, but his mobility has now been limited, and 6 months after surgery, he finds himself 80 pounds overweight and prediabetic, with the accompanying negative cascade of events that follow.

In a collaborative setting, imagine that the primary care provider recognizes the root causes of the problem: 1) the patient is overweight, which puts a strain on his posture and spinal column; 2) the patient does not exercise, which affects joints, muscles, circulation, and mental health; and 3) the patient sits for long hours at a computer in a non-ergonomic position, which causes further damage and misalignment to the spinal column. The PCP then refers the patient to a clinical nurse leader (more on the CNL in a minute), who arranges for the patient to see a holistic nutritionist to educate the patient about food choices and weight loss, a chiropractor to adjust any spinal subluxations, a personal trainer to teach the patient about exercise, and a trained occupational or physical therapist to make sure the patient’s computer station at work follows OSHA guidelines for ergonomics. After 6 months, the patient has lost 30 pounds, visits the chiropractor monthly, exercises 4 times per week, is no longer depressed, and has a work station that supports his physical needs. He is now pain free.

If this collaborative model seems expensive and idealistic to you, think again. Spinal fusion surgeries run anywhere from $60,000 to $200,000. In fact, a 2012 study found that annual medical costs for patients who used CAM therapies for spine problems were $424 lower for spine-related problems and $796 lower for overall health care costs compared to patients who did not use CAM. 

A similar paradigm could be applied to diabetes, heart disease, autoimmune disease, and even cancer, although in those cases, the patient should also be seeing a holistic practitioner experienced in using whole food nutrition and herbs to help address the physiological problems brought on by disease and inflammation.

Clinical Nurse Leader as Team Leader

In my Patient Empowerment series, I discussed a nursing role called the Clinical Nurse Leader. Specifically designed as a change agent, the Clinical Nurse Leader is poised to be one of the major players in the evolution of our health care system. 

One of the principal roles of the CNL is as a leader of an interdisciplinary health care team “that deliver[s] treatment and services in an evolving health care system.” Not only can the CNL advocate for and educate patients regarding informed health care decisions, we are actually trained to coordinate and manage care across the continuum, collaborating with the various disciplines of health care as best serves the individual patient. Here’s an excerpt from the AACN White Paper:

“The CNL provides and manages care at the point of care to individuals, clinical populations and communities. In this role, the CNL is responsible for the clinical management of comprehensive client care, for individuals and clinical populations, along the continuum of care and in multiple settings, including virtual settings. The CNL is responsible for planning a client’s contact with the health care system. The CNL also is responsible for the coordination and planning of team activities and functions.”

— White Paper on the Education and Role of the Clinical Nurse Leader

This is the health care system of the future. Health care practitioners need to set aside our egos (myself included at times!) for the benefit of each patient. We need to put our expertise to work and at the same time recognize that while we don’t have all of the answers, our esteemed colleagues in other areas of health care just might be able to provide what we can’t.

Imagine the lives we could change for the better by working together instead of fighting amongst each other. Health care consumers, start demanding that change now. Insist that your health care practitioners start collaborating with others so that you can have the best possible health care, the health care that you deserve.

This is the health care system of the future, and it starts now.