Integrative Medicine at Einstein

At the Continuum Center for Health and Healing on lower Fifth Avenue in Manhattan, you can find healthcare services that many medical practices provide: internal medicine, ear, nose & throat otolaryngology, gynecology & women’s health services, and orthopedic and sports rehabilitation. But comparison to a conventional medical practice ends there. Doctors and care providers at the center are more likely to prescribe acupuncture or aromatherapy than Ambien, and they prep patients for surgery with classes in biofeedback, guided imagery and energy healing.

Benjamin Kligler, M.D. This is not some new-age, fairy-dust facility; it is the front edge of a burgeoning trend in integrating non-conventional approaches to healing into medical practice and is being supported by a growing body of research that shows empirical, effective results from complementary healing arts.

Dr. Benjamin Kligler, associate professor of family and social medicine at Einstein and vice chair and research director of the Beth Israel department of integrative medicine, is the center’s founding medical director. He also is director of the student wellness program at Einstein.

“We’re seeing a sea change in terms of how complementary and alternative therapies are being integrated into the medical environment,” said Dr. Kligler. “A lot of what is driving that change is new, specific, science-based research.

“There are many approaches outside the realm of conventional medicine that we now know work. For example, fish oil, Vitamin D and St. John’s Wort,” said Dr. Kligler. “By taking a scientific approach to complementary therapies, we can more clearly define how they work and where they work. As these move into mainstream healthcare, we’re becoming more rigorous about knowing what parts work, and what to leave behind.”

He brings this approach to introducing complementary and alternative therapies to Einstein medical students. “Einstein has been very receptive and progressive in introducing an integrative medicine curriculum,” said Dr. Kligler. “There is a commitment to an evidence-based approach and critical thinking we take that fits into the Einstein ethos. Instead of teaching this as some esoteric branch of medicine, we’re saying, ‘look at the science.’ As clinicians and as doctors we have to learn how to make sense of what the science is telling us. It’s relevant to every dimension the students are learning about.”

Ellen Tattelman, M.D.He added, “It’s what I would call a skeptical open-mindedness. There are still people who feel it’s not appropriate to teach these types of medicine until there has been more definitive research. But we’re not asking people to accept this uncritically. We want the students to look at the evidence just like they would at anything in Western medicine.”

For Einstein students, that means the opportunity to take classes in Reiki, yoga, and meditation; to shadow students at the Pacific College of Oriental Medicine as they learn acupuncture; to attend an anatomy session with a chiropractor side-by-side with the presenting M.D. and to use evidence-based medicine skills to analyze a study using tai chi for fibromyalgia. There also is a personal wellness program, which addresses physician wellness, stress management, healthy eating and the mind/body connection.

“We want students to experience what patients are talking about and see how it feels firsthand,” explained Dr. Ellen Tattelman, who directs the department of family and social medicine’s faculty development fellowship, co-chairs the Einstein Wellness Working Group with Dr. Kligler and introduced the first alternative medicine elective course at Einstein in 1995.

“It was a different time then,” she noted. “People knew very little. But it was clear that patients were using alternative medicine a lot and were afraid to tell their doctors. That resulted in disjointed care and, at times, dangerous practices.

She continued, “The idea was to open up the conversation. And, with the support we received from the Jerry S. and Marilyn C. Handler Endowment for Integrative Medicine in 2000, Einstein was ready early on. We would bring in practitioners and have them present what they offer along with their philosophy of healing. Students would discover new approaches to health and illness while learning to ask their patients what else they are using and who else they are seeing. They then understood to make sure the care was complementary and safe.”

In addition, Dr. Tattelman advises a group, Students for Integrative Medicine, who organize a series of evening events featuring speakers in the field, and which hosts an annual symposium.

The approach is in stark contrast to what Dr. Tattelman learned as a medical student. “On the outside, people were talking about healing and keeping yourself well, while in medical school it was all about curing disease,” she explained. “Now there is more extensive information, and greater acceptance, and there’s much more evidence on how well some things work as well as on how some don’t.”

Diane McKee, M.D. A lot of that evidence is being collected by the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health. When NCCAM put out a call for proposals for studies of the effectiveness of alternative therapies, Dr. Kligler teamed with Dr. Diane McKee, co-director of the division of research in Einstein’s department of family and social medicine, to look at the use of acupuncture for pain management.

Dr. McKee’s foremost mission is to find better ways for providing primary care services to patients in the Bronx. “I do research and Ben has contacts in the complementary therapy world,” said Dr. McKee, who also is director of the New York City Research and Improvement Networking Group (NYC RING), the practice-based research network sponsored by Einstein. “This opportunity allowed us to collaborate.”

“What’s particularly unique is that it’s unusual for anyone in an underserved minority population to even get acupuncture,” said Dr. McKee. “We wanted to see if it could be relevant to urban practice and made sense for primary care.”

They conducted their study, at four Montefiore-run community health centers in the Bronx, with 270 patients, over two-and-a-half years. Their results showed a marked decrease in perception of pain from those treated with acupuncture along with an increase in the patients’ functional status.

“This was a real-world study of effectiveness, conducted among a population in very great need of something they weren’t getting,” said Dr. McKee.

She continued, “I don’t pretend to understand why acupuncture works. But, now I know it does. If the evidence says it works, we should use it. If it helps patients, physicians should be offering it routinely.”

Dr. Kligler and Dr. McKee plan to take their research to the next level by developing a predictive model for physicians to use when looking at pain management with their patients. “We already know acupuncture can make a difference; so, how does it work? Who does it work on? We want to begin to tease out the answers to those questions so doctors have a tool that’s validated for recommending this as a therapy,” said Dr. Kligler.

One of the barriers to the acceptance of complementary treatments in the mainstream medical community is the perception of benefit and cost. “For insurance companies and hospitals, there is a big imperative in research to show that employing these therapies saves money,” said Dr. Kligler, who recently examined this aspect in a broader study supported by the Urban Zen Initiative, a philanthropic effort aimed at improving the care of patients with cancer.

Students learn about complementary medical practices, such as acupunctureFor the study, one cancer-care floor at Beth Israel was converted into an “optimal healing environment.” The project included remodeling the physical space; training the nursing staff in holistic techniques, such as relaxation therapies and imagery; and the presence of yoga therapists on the unit to work one-on-one with patients. The research program investigated whether the intervention improved the patient’s quality of life as well as what impact it had on length-of-stay and medication use in relation to cost of care.

The study showed that, on average, the hospital saved $150 per patient, per hospital day. “There was a big cost savings for the hospital,” said Dr. Kligler. “Even factoring in the extra costs for care, the hospital came out ahead. We also found that patients had less pain, less anxiety, and an improvement in mood and quality of life,” said Dr. Kligler. “And, they used fewer medications — less sleep meds, less pain meds, less nausea meds.”

As the body of science-based research grows and evidence mounts, alternative and complementary therapies are becoming an important component of patient care — and an aspect of medicine that all aspiring and practicing physicians have to know about.

“The CDC estimates that 40 to 45 percent of our population is using some alternative therapy,” noted Dr. Kligler. “If nearly half of your patients are using these, you have to know about them.”

For Dr. Kligler, it’s simpler though. “A lot of these therapies have proven to be truly effective,” he said. “As a doctor, wouldn’t you want to know about that? Why would we not want to know about these things that might help our patients? You are a doctor. You have to know about what works!”