Nancy Gahles, DC, CCH, RSHom(NA), discusses our current healthcare system and explores integrative models for family caregivers, the aging “baby boomer” generation.

by Nancy Gahles, DC, CCH, RSHom(NA)

“The essence of medicine is a covenant between a doctor and a sick patient.  The term “doctor-patient relationship (denigrated in this age of autonomy) sums it up.  In an age of super-specialization, gatekeepers, and third party payers, a “covenant” may sound trite, but the existential angst of a life-threatening illness, demands unique human bonds.” – Patrick Guinan, M.D., Hippocrates and Christian Medicine, Sources of the Patient-Physician Relation.

This same quote fits the most common issue facing primary care providers, management of chronic diseases, particularly, those affecting a forgotten population, the family caregiver. As the baby boomers turn 65 in 2012, we, primarily first portal of entry physicians, will see more of the multidimensional health issues we now face with family caregivers.

Integrative healthcare has emerged as a means to facilitate the healing power of these unique human bonds to advance the concept of personalized medicine, individualized medicine or patient-centric medicine. All of these are rubrics for what thought leaders in the healthcare industry are proposing as a model for delivery of best practices in developing and applying guidelines to improve quality of care and deliver better clinical outcomes and to establish what Kaiser Permanente calls “care delivery excellence”.

Integrative healthcare can be seen as an approach to healing that honors the “covenant” mentioned in the first sentence of the Hippocratic Oath and one that is guided by philanthropia, love of mankind.

Why should I care? Because it is a moral imperative implicit in the “binding promise” of the doctor-patient relationship. It is the essence of good medicine to heal from the highest standards, to restore the sick to wholeness.  The integral wholeness of the human being can be restored by working in concert with practitioners whose specialty addresses the suffering of the patient.

The reductionist nature of our current health care system supports the organ-centric, end stage pathology philosophy of medicine. People come to primary care physicians when they are sick, in general, when one organ system is failing, presenting as acute or chronic symptomotology.  The person becomes the patient, is examined, tested and referred to the specialist trained in pathologies of the affected organ system. There is a standard of care for each diagnosis rendered and an ICD-9 code to identify and justify the treatment or procedure to be performed. There is a current procedural code, CPT, to submit to the insurance company and an accompanying fee schedule that allows a certain amount of payment for that CPT code.

This is our system as it now stands. In most instances, this is the substance of the doctor-patient relationship.  Most often, it is only when your treatment hasn’t “worked” that you refer the patient to another specialty.  In our prevailing health care system, we are limited to licensed practitioners if we want the patient to be reimbursed by insurance companies for their care.  People are most likely to follow through with referrals to other practitioners and thus continue their care if they are covered by their insurance. The determination of where and to whom you refer the patient is the conundrum facing the practitioner. Understanding this requirement as necessary in these days of high insurance premiums and recession induced lack of discretionary income, we are indeed fortunate to have licensed professions that can address the restoration of wholeness to the person, in an integrated manner, that is, through the doctor-patient relationship and through the doctor-doctor relationship.

We do know, through our scientific investigations, the same fundamental truths that the early philosophers of medicine, Hippocrates, Aristotle and Asclepius knew. Wholeness, or health, is the sum of the harmonious operations of the mind, body, emotions and spirit (soul).

Modern medicine allows for the incorporation of these principles in the practice of specialties such as chiropractic, acupuncture, homeopathy, Ayurveda, naturopathy and psychology. With the exception of psychology, they are called Complementary and Alternative Medicine (CAM), listed and defined on the National Center for Complementary and Alternative Medicine (NCCAM) website. We do have a plethora of practitioners with whom we can work in an integrated manner to combine the knowledge of conventional and traditional healing disciplines to develop a model of care that meets the needs of the individual in all their glorious diversity!

This approach to providing comprehensive primary care that facilitates partnerships between individual patients, their personal physicians and the patient’s family, is known as the medical home model and is the foundation of the health care reform delivery system that has the stakeholders in the healthcare industry up in arms with the charge to change the status quo.

Why should I care? Because an integrative medical home model will address the needs of individualized, patient-centric care. It will contribute to the body of best practices; produce real world clinical models; generate patient based outcomes for evidence-based medicine; develop research initiatives for comparative effectiveness and cost effectiveness; establish national and state policy, funding decisions and benefit design based on high quality data; expand primary care to collaborative models and primary prevention; add to world-wide clearing house web based information for consumers and practitioners to engage in online discussion and education globally.

How do I begin? The forgotten family caregiver is the perfect case example of how an integrated model can take shape. I use the term “ forgotten” because we forget to take the context of the person’s life into account when we treat the presenting symptom only.

Case Study: A 55 year old female presents at my office for chiropractic care of a chronic stiff and painful neck and low back pain. Examination and x-rays reveal subluxations and osteoarthritis and a treatment plan of chiropractic manipulation plus adjunctive physiotherapies, exercises and workplace ergonomic corrections is instituted. As treatment progresses we develop a relationship and while discussing the fact that her muscular tension is always quite high, she reveals that she has a lot of stress at home. Further inquiry reveals that she is the primary caregiver for her 93 year old mother who lives with her and is virtually blind and deaf. I asked how she experiences the stress of taking care of her and she said: “I lost my life. It’s a loss of flexibility. The ability to be spontaneous and independent. I was a loner before and now I crave time by myself and now I don’t even have that. I get angry. But I can’t feel my anger towards her so I take anti-depressants and my back…kills me! I feel guilty that I feel angry or resentful because she cared for me for 18 years. I have to stay in more and listen to audio books for recreation. I don’t invite people over as much because she can’t see or hear well and it confuses her.” I asked her how she manages her stress and she said: “Chiropractic for my back and medication for my depression. I also get up early to have the alone time I need and go to the gym to exercise.”

Comments: Co-morbidities such as depression along with the presenting ailment is a very common phenomenon.  Caregivers, in particular, are prone to anxiety and depression. Caregivers who are also parents may be putting their children at risk for adverse health outcomes. According to evidentiary studies reported in Depression in Parents, Parenting and Children, major depression in either parent can interfere with parenting quality and increase the risk of children developing mental, behavioral and social problems.

While evidence shows that primary care psychotherapy is as effective, if not more effective than antidepressants, the use of antidepressants has doubled in the U.S. between 1996 and 2005. Paxil and Prozac being the most commonly prescribed.  Medical Expenditure Panel Surveys done by the U.S. Agency for Healthcare Research and Quality involving more than 50,000 people in 1996 and 2005 found that individuals treated with antidepressants became more likely to also receive treatment with antipsychotic medications and less likely to undergo psychotherapy. The truth is that primary care clinicians are key in preventing major depression particularly in the elderly. Medscape medical News CME, 2009-11-04.

An integrative healthcare model can be proposed for the above case study by collaborating with a Certified Classical Homeopath, the psychologist and the chiropractor.  A recent prospective multicenter observational study, Aug. 6, 2009, evaluated the details and effects of an individualized homeopathic treatment in patients with chronic low back pain. The conclusion was that classic homeopathic treatment represents an effective treatment for pain and other diagnoses. It improves health-related QoL and reduces the use of other healthcare services. Homeopathic treatment of patients with chronic low back pain: a prospective observational study with 2 year’s follow-up. Institute for Social Medicine, Berlin Germany. Witt CM, LudtkeR, Baur R, Willich SN.  “Other diagnoses” can be represented by the feelings of suppressed anger, resentment and isolation that the patient feels. The beauty of homeopathy is that it takes into account all of these emotions along with the physical complaints and a homeopathic remedy is prescribed for the totality of symptoms. 

Homeopathy also showed feasibility of randomized controlled double-blind trials in Brazil where homeopathy is a medical specialty and depression is their most prevalent chronic disease. Homeopathic Individualized Q-potencies versus Flouxetine for Moderate to Severe Depression: Double-blind, Randomized Non-inferiority Trial. U.C. Adler et al.

In the case study, individualized patient centered care can be realized utilizing 3 practitioners, who working together can likely reduce the low back pain and the depression as well as increase quality of life. It can be assumed that there would be a reduction in the number of chiropractic treatments and the amount of prescription drugs needed. Hypothetically, this would represent cost effectiveness and comparative effectiveness, data that could be evaluated.

Why should I care? Because it is our moral imperative to deliver the best practice, do the least harm, and restore the patient to wholeness. And because it simply makes good sense to follow an integrative, individualized, patient centric model.

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