Lise Alschuler, ND, FABNO discusses the most important component when thinking about your practice; the patient.

by Lise Alschuler, ND, FABNO

I begin the first of a series of monthly columns on integrated medical practice in the only way conceivable, by spotlighting the star of the show, the patient. Despite the fact that helping people is the raison d’être for our work, it is amazing how easy it can be for healthcare practitioners to neglect the patient. Under the pressures of time constraints, economic bottom lines, paperwork avalanche, and information overwhelm, we too often forget about the patients we are here to serve. Patients become a means to multiple ends, a commodity of our trade. And, as one would suspect, after a time, we practitioners lose our way. The end-of-month profit margin, the completion of daily dictations and charting, getting home in time for dinner and sleeping uninterrupted become the hallmarks of successful practice. Meanwhile, the reality of the patients’ experience in our collective hands becomes a consideration farther and farther in the distance.  Sitting even further still is the patient’s wishes for more fulfilling healthcare.

There is, however, a growing exception in this otherwise dim scenario. Some of us have caught an alluring whiff of a different way to practice. Following an aroma infused with the distinctive perfume of integration, we have nosed our way out from the otherwise crushing weight of typical practice. Merely intrigued or downright captivated with the idea and intention of practicing integratively, these practitioners are oriented in a different direction than the typical healthcare provider. The allure of holism combined with a compelling sense of rejection of the dominant paradigm fuels this movement towards integrated healthcare. There is, however, one cardinal rule which must inform our work, and which is, ultimately, the only real measure of our success.  This rule is: it is all about the patient.

Let me first be clear that by ‘integrated medicine’, I am referring to the concept of coordinated multidisciplinary care practiced by integratively-minded, and in some cases, trained providers. Integrated healthcare relies upon providers with significant competence in their area of practice expressing a primary motivation to collaborate with other highly competent providers for the good of the patient. It is my contention that integrated healthcare can only be successful with this main objective. Historically, healthcare centers that operate with profit as the primary motive for adopting an integrated model have failed spectacularly. Additionally and unfortunately, many conventional providers, who, tired of the burdens of conventional practice, adopt integrative practices as a way out, but do so without clear commitment to the ideals of the patient, become marginalized and minimally effective.

In contrast, providers and institutions that focus their integrated practice around the question, “What do my/our patients want?” stand the best chance of success. Orienting everything from office layout, fee schedules, protocols, staffing and decision-making around serving the expressed needs of the patient creates cohesive momentum and direction. Following the lead of the patient’s best interest surmounts roadblocks and becomes the medium through which every decision, conflict and compromise are filtered. In so doing, patient-centered integrated healthcare remains the primary directive above all other competing directives. Let’s look at a hypothetical example in several ways to illustrate the power of this simple and yet powerful concept.

Background:  An outpatient gastroenterology clinic has recently added a dietician, naturopathic physician, acupuncturist and massage therapist to the medical staff.  The conventional providers, disenchanted with the procedure-driven practice that their professional world has become, welcome the change. The clinic has dedicated a portion of previous profits to establishing the integrative services.  One of the lead physicians has even completed some coursework in mind-body practices and has begun to incorporate these techniques into his work with his patients.  All providers meet at the start of each day for case review discussion. Advertising the added integrative services has created a strong initial influx of patients to the clinic and business is booming.  A patient with a long-standing history of ulcerative colitis presents to the clinic. This patient states that he is transferring his care to the clinic because he wants a holistic and integrated approach to his disease. He has avoided surgery to date and describes his primary goal as “I want to learn how to create health in my colon so that I can avoid surgery.”

Scenario 1 “Power is Me”:  The patient, Mr. Star, seeks integrated care at the newly established clinic A. He is scheduled with the lead gastroenterologist (who performs all colon resections), the acupuncturist, the massage therapist and the naturopathic physician. Mr. Star is given recommendations from each provider.  Additionally, the naturopathic physician and acupuncturist inform the patient that it is possible, with significant lifestyle change, acupuncture, nutritional supplements and medications to save his colon.  The gastroenterologist informs Mr. Star that, given the extent of his disease, surgery is the only viable treatment option. Mr. Star is confused. He decides that he must align with the providers who are telling him what he wants to hear. He re-schedules with the naturopathic physician and the acupuncturist only. At case reviews, the naturopathic physician and acupuncturist report, with great satisfaction, on his commitment to their recommendations. The surgeon, convinced that Mr. Star needs surgery, openly dismiss the naturopathic and acupuncture approaches as being without sound evidence and accuse the N.D. and L.Ac. of denying the patient appropriate care. With each report, the rift deepens. The surgeon begins to think of the naturopathic doctor and the acupuncturist as dangerous. The naturopathic doctor and acupuncturist begin to see the surgeon as close-minded and focused only on conventional care. Referrals between providers cease, patients stop coming to the clinic as they experience the same triangulation under one roof that they were seeking to escape with previous providers. Within a year of opening, the clinic closes.

Scenario 2 “Follow the Money”:  Mr. Star presents to clinic B with the hopes of securing an integrated treatment plan to bring health to his colon in order to avoid surgery.  He undergoes evaluation by a gastroenterologist, a hypnotherapist, a psychotherapist and a naturopathic doctor.  The provider team meets.  Each provider has recommendations for Mr. Star.  In particular, the hypnotherapist and psychotherapist are impressed with Mr. Star’s revelations of early childhood abuse and significant anxiety.  They feel that a concentrated program of sessions over the next 3 months would significantly augment his health and possibly avoid the need for surgery.  After considering these interventions, the gastroenterologist and clinic director determine that the best course of action for Mr. Star is to obtain surgery first and then to utilize these mind-body techniques to support post-operative healing.  Of note, the clinic’s revenues are below target this month.  The clinic manager notes that having the surgery this month and delaying the other services to next month will support the clinic’s overall operations. Upon learning of this plan, Mr. Star expresses his disappointment and confusion. He decides to pursue hypnotherapy and psychotherapy elsewhere prior to surgery and says he may return in a month or two for the surgery.  The clinic posts another deficit at month’s end.

Scenario 3 “It is All about the Patient”:  A beleaguered Mr. Star makes an appointment at a clinic C, his third integrative clinic.  He is evaluated by a gastroenterologist, an acupuncturist, a naturopathic physician, a physical therapist and a dietician. The team meets to discuss their evaluations. The first question asked is, “What are Mr. Star’s goals and how can we best meet them?”   They agree that Mr. Star’s goal is to support the health of his colon and try to avoid surgery. The team agrees that Mr. Star may need to obtain surgery eventually, however they do not feel that his need for surgery is imminent. The team decides that intensive naturopathic and dietary programs along with regular acupuncture and visceral manipulation by the physical therapist for 6 weeks can be instituted first. At the conclusion of this time, they will evaluate Mr. Star for improvement and for the necessity for surgery, to be followed by more integrative care. They present the plan to Mr. Star who readily agrees to the services. Within a week, Mr. Star has referred two other friends to the clinic. Business is booming and everyone – providers and patients – are enjoying the process.

Integrated care that is centered with, and for, the patient will succeed. Patients originally sounded the clarion call for integration and, as providers, our efforts to respond to this call must continue to place them first and center. And, the wonderful thing is, as healthcare providers, we will re-discover our passion for medicine in the process.


*Lise Alschuler, ND, FABNO is a naturopathic physician with board certification in naturopathic oncology.  In practice for over 14 years, Dr. Alschuler is the current President of the American Association of Naturopathic Physicians, member of the American Board of Naturopathic Oncology Board of Medical Examiners, and is in practice at Naturopathic Specialists in Scottsdale AZ.  Her website is www.DrLise.net.


Additional articles by this author:

Additional articles from The Journal of Medical Practice Management:


 IHS speaker To see Lise Alschuler, ND, FABNO in person, attend Breast Cancer: An Evidence-based Review of Naturopathic Supplement and Herbal Strategies, Update on Women’s Health Plenary Panel and National Policy and Integrative Practice: Building the Road at the 2009 Integrative Healthcare Symposium. Integrative Practitioner members get 15% off Symposium registration when they enter discount code 7470.