Hawai'i-Pacific Chapter
A quarterly e-newsletter for the Hawai'i Pacific Chapter of ACHE December 2016
In This Issue
Messages from Chapter Leadership
Message from your ACHE Regent, Winter 2016
Message from the Chapter President, Winter 2016
Message from Incoming President
Recent Events
2016 Hawai'i Healthcare Leadership Conference
Original Articles by ACHE Members
Overcoming Skepticism about Integrative Medicine in Health Care
Calendar of Events for Winter 2016-17
Calendar of Educational Events for Winter 2016-2017
News & Committee Updates
2017 Board Election Results
News from the Education Committee
Membership: New Fellows, Members, and Recertified Fellows
News from the Guam Program Council
Winter 2016 Financial Report
ACHE National News - Winter 2016
Opportunity for Diversity Learning
Career and Leadership
Career Corner
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Jen Chahanovich, FACHE

Art Gladstone, FACHE

Nick Hughey, FACHE

Chuck Tanner, FACHE

Selma Yamamoto

Nancy Wilson

Micah Ewing

Maj Charlotte Hildebrand, FACHE

Suzie So-Miyahira

Stefan Fedusiv

Tamara Pappas

Bobbie Ornellas, FACHE

Emiline Buhler

Gidget Ruscetta, FACHE


Original Articles by ACHE Members
Overcoming Skepticism about Integrative Medicine in Health Care
Sally Belles, RDN, MBA, CDE


Interview by Sally Belles, RDN, MBA, CDE, December 11, 2016

Hospitals, clinics and physician practices are somewhat skeptical about the role and value of Integrative Medicine in health care.  Although, many patients have never heard the term Integrative Medicine, they often desire and seek out alternative approaches to their health problems.  Awareness of Integrative Medicine will continue to grow as patients and physicians work to develop a collaborative relationship where shared decision-making is central to enhancing both the patient and physician experience.

To learn more, I conducted an interview with Dr. Kathleen Kozak.  Dr. Kozak is an internal medicine physician practicing at Straub Clinic and Hospital in Honolulu, Hawaii.  Some of her (candid) responses may surprise even the staunchest skeptics.

Belles:  What is "Integrative Medicine" (IM)?
Dr. Kozak:  Integrative medicine (IM) is a patient-focused approach that combines different treatment modalities in conventional medicine, alternative medicine, nutrition science, etc., which addresses the patient in a holistic manner and focuses on health and well-being, in addition to disease treatment.

Belles:  How is IM being implemented and in what types of clinical settings?
Dr. Kozak:  IM is just in its infancy in its acceptance into mainstream medicine.  Although many of the principles are identical to what most MD's learn in school, the field of IM includes other disciplines, such as chiropractic care, acupuncture, medical massage and more. Currently, IM is being used in major medical centers like Duke University, Mayo Clinic, Cleveland Clinic and more.  These centers have established IM departments that address the complexity of clinical care and allow for complementary medicine disciplines to be integrated into the care plan of patients being treated for their other medical conditions.

Belles:  How did you first become aware of and interested in IM?
Dr. Kozak:  I think all physicians are doing some form of integrative practice any time they send patients to do physical therapy, see a dietitian nutritionist, or address their psychological issues about their medical conditions.  However, these days, IM is taking it to the next level and with the Affordable Care Act, the nondiscriminatory payment for alternative care practitioners has made this approach to medicine come into the spotlight.  Medical research is being done to look at the efficacy of many IM treatments and as studies show statistically significant improvement in certain areas, such as chronic pain management, more and more conventional doctors are taking a second look at these approaches to patient care.

Belles:  What is the overarching goal and purpose of IM and is there a need to incorporate IM into hospital and clinical practice?
Dr. Kozak:  IM is already being used in many major medical centers, particularly in the areas where it has proven benefits. This includes oncology care, preventative care, and even something as simple as quiet time in our hospital in the afternoons is a way to recognize the patient-centered approach in healthcare that is becoming more mainstream.

Belles:  What is the potential for IM in enhancing the patient-physician relationship, as it relates to the patient and physician experience?
Dr. Kozak:  IM is at its core a patient-centered approach, which requires a strong patient-physician relationship.  However, it's not going to replace conventional medicine or alternative medicine, rather it is meant to connect the two to provide for a focus on wellness, instead of just disease prevention and treatment.

Belles:   What is the potential for IM in the area of physician engagement?
Dr. Kozak:  Physician engagement is an ever-increasing problem. The Mayo Clinic published a study looking at the rates of physician burnout and tied these to the use of electronic medical records.  Over half of physicians reported symptoms of burnout in a recent study because of the increasing demands of paperwork and also the expectation of higher volumes of patients to be seen each day.  IM helps to make the patient feel like they are the center of their care but requires more time.  Being that there is a current shortage of primary care doctors nationwide, it's unclear if physicians are going to be able to give patients all that they need while still being able to run their practice.  That's where the coordination with alternative practitioners such as naturopathic physicians, chiropractors, etc. may be able to help provide the care needed while not defining this as all coming from one practitioner who is already feeling the symptoms of burnout themselves.

Belles:  What is the role of the physician in IM?  Is the role specific for primary care providers (PCPs)?
Dr. Kozak:  PCP's are central to the function of an IM practice.  When I ask my patients where else they go for care, they tell me all sorts of places, bashfully, as if they have been found cheating on their doctor.  But these other places can be good for them.  Chiropractors can do wonders for low back pain and their therapies are superior to me prescribing lots of anti-inflammatory pills.  Acupuncture treatments can help with a lot of different muscle and joint pains.  Even some of the herbal treatments that patients use are often helpful to promote wellness.  In an IM practice these other practitioners can be part of the clinic or they can be solo providers but engaged cooperatively to help care for the individual patients and share their expertise with the other doctors involved. I t doesn't have to be "either/or".  It can and should be "and".

Belles:  What is the evidence to support IM? Is there a mind-body-spirit connection?
Dr. Kozak:  Even the NEJM has published research regarding the use of techniques such as mindfulness based stress reduction on the treatment of low back pain, lowering the use of addictive narcotic medications, and also improving overall pain levels.  For some of the IM practices, it is about the mind-body connection. However, for others, it's just about taking a different approach to some of the more complicated conditions in medicine that don't have an easy solution or one simple cause.

Belles:  Are there controversies surrounding the incorporation and use of IM?
Dr. Kozak:  Because published data is limited, there are controversies with certain components of IM. Traditional medical studies look at a comparison between two groups; one receives a treatment and the other group a placebo, or no treatment to prove that the treatment works.  Patients often don't know which group they are in.  However, it's quite difficult to do in certain types of alternative medicine.  It's really hard to fake massage, or acupuncture, or chiropractic care.  Even if there are studies where it’s done, the overall healing might be multifactorial, and so it's really difficult to isolate one treatment and its benefit from any other possible mechanisms of action.  If taking an hour out of the day to have a massage helps to lower stress levels, this can help overall wellbeing.  But was it the massage; was it the hour to relax?  It's hard to tell. In conventional medicine, if it isn't proven, it doesn't work, but life is much more complicated than that.

Belles:  Explain the differences between Conventional Western Medicine, Alternative Medicine, and Complimentary Medicine as approaches to patient care.
Dr. Kozak:  I'm confused too.  Some people use these terms interchangeably.  Alternative or complementary medicine usually describes the different modalities of treatment like herbs, massage, chiropractic, acupuncture, etc.  IM puts them all together and includes both conventional medicine learned in medical school with the other modalities.  I do know that when I call what I do "traditional medicine" I'm usually reminded that it's only been in the past 100 years or so that medical schools even existed, and truly traditional medicine is that from places like the middle of the Amazon, not the medication I prescribe from the local pharmacy.

Belles:  What infrastructure, training and resources are required to incorporate and implement IM in the primary care setting?
Dr. Kozak:  Many doctors are integrative in their practice.  Combining nutrition, counseling, stress management, exercise, all of these things are integrative.  When patients see other practitioners, like aryuvedic doctors, working with their treatments, even talking to their other doctors can make any practice integrative.  Sharing patient notes with permission, keeping the lines of communication open, and making referrals to these types of healers when appropriate can make any doctor the "and" doctor and not the "either/or".  Some major medical centers have integrative clinics that actually combine the physical offices of acupuncturists, chinese medicine and more in one location.  Those types of clinics are usually hard to find with regular doctors in the same place.  However, with the increasing focus on wellness, patient demand will drive what the medical offices look like in the future, and maybe one day there will be a stress management coach who works down the hall from me with my patients to help them cope with their lives and their health, while I treat their hypertension, diabetes, high cholesterol, etc.  When that day comes, I will be the first to try it!

Belles:  Thank you Dr. Kozak.  There is a clear opportunity for clinics to explore how to create a sustainable mechanism to provide IM.  Your insight into identifying and partnering with reputable alternative health care practitioners in the community does support a team-based, patient-centered approach to providing care.


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