Seeing the Holistic Picture
Integrative Medicine Program Treats Body, Mind, and Spirit
Birgit Rakel, MD, has heard it all. “Voodoo.” “Fringe.” “Weird medicine.”
Rakel is an integrative medicine specialist—a board-certified family medicine physician who uses complementary therapies to enhance the health and well-being of her patients. She practices at the Marcus Institute of Integrative Health at Jefferson’s Myrna Brind Center in Center City, and is assistant professor in the Department of Family and Community Medicine, the Department of Emergency Medicine at SKMC, and the new Department of Integrative Medicine and Nutritional Sciences.
Rakel’s medical training in her native Germany incorporated botanicals, homeopathy, and mindfulness-based therapy as part of the curriculum, and her upbringing included herbal remedies prescribed by her family doctor.
“In Germany, we did not call it ‘integrative medicine’; we just called it ‘medicine,’” she says. After medical school, Rakel completed a residency in family medicine at a university hospital in London, and a fellowship at the Royal London Homeopathic Hospital, “so none of these concepts were foreign to me.”
What was foreign was the attitude she encountered when she arrived in the United States in 1996 to undertake a three-year residency at a New Jersey hospital.
“As part of the residency, I regularly gave lectures on yoga, meditation, and homeopathy,” she says, adding wryly, “My colleagues and peers thought I was really weird.”
Rakel says the very concept of using complementary medicine in a professional healthcare setting was frowned upon at the time. But a lot has changed over the past two decades. What was once looked upon with skepticism—and even scorn—in this country is now starting to be viewed in a new and positive light. Integrative medicine is increasingly becoming part of the mainstream as physicians prescribe complementary therapies in conjunction with traditional protocols.
Integrative healthcare brings conventional and complementary approaches together in a holistic, patient-focused approach to wellness—often including mental, emotional, functional, spiritual, social, and community aspects, and treating the whole person rather than one organ system.
Institutions such as the Mayo Clinic, Brigham and Women’s Hospital and Harvard Medical School, Duke University Health System, Johns Hopkins Health System, and Stanford Health Care are offering complementary wellness programs, as well as incorporating integrative medicine courses into their medical school curriculums.
As usual, Jefferson is ahead of the curve and continues to lead the way, says Daniel Monti, MD, MBA, CEO of Jefferson’s Marcus Institute of Integrative Health and the Ellen and Ron Caplan Professor and Chair of Integrative Medicine and Nutritional Sciences.
Not only has Jefferson been a key player in bringing integrative medicine into the mainstream by building a comprehensive program over the past 21 years, but in February of 2019, SKMC became the first medical school in the country to create a Department of Integrative Medicine and Nutritional Sciences as an equal peer to the other clinical departments in the medical school.
“It’s a historic first,” Monti says, proudly. “Establishing this academic Department of Integrative Medicine is a natural evolution of Jefferson’s long-standing leadership in the field.”
He credits Mark L. Tykocinski, MD, provost and executive vice president for Academic Affairs, Thomas Jefferson University, and the Anthony F. and Gertrude M. DePalma Dean, SKMC, for making it happen. “He saw the value in what we had done to date and realized that creating a department was important.”
Tykocinski explains that “granting academic department status to the field of integrative medicine as a first in the American medical academy is in synch with our broader push within SKMC to expand the boundaries of physician training and practice, to embrace cross-cutting disciplines and knowledge domains with open arms.”
From Humble Beginnings to Blazing Trails
Jefferson began its integrative medicine program in 1998 as a part-time clinical practice with limited services such as a mindfulness-based stress reduction course. At the time, Monti had just begun his career at Thomas Jefferson University Hospital as co-director of the consult service in psychiatry. He also conducted research in a scholars program in mind-body medicine with research focusing on stress physiology because “the interest in the mind-body component of health and illness was always there,” he says.
Over the years, the program slowly gained footing, but took off in 2004 with an endowment by Ira Brind, who was chairman of the Board of Trustees of Thomas Jefferson University Hospital at the time. He established an expanded integrative medicine center in memory of his wife, Myrna, who was treated for cancer at Jefferson and was an advocate of integrative medicine. Her motto was: “The soul heals and science cures.”
When the center received Brind’s endowment, then-president and CEO of the hospital, Thomas Lewis, thought Monti was a natural to fill the position of medical director. But at the time, integrative medicine was still considered “fringy,” so Monti sought the advice of his mentor as to whether to accept the position.
“When I went to talk to him about the offer, he said, ‘Don’t do that—it will be career suicide! Don’t get involved with those integrative people!’” Monti graciously declined the job.
Soon after, he walked into the new center as it was being completed and saw a portrait of Myrna Brind on the wall.
“She was one of my favorite people,” he says. “Seeing her picture moved me. I said, ‘Maybe it is a stupid move, but maybe there’s a really unique opportunity to do something special that a lot of people could benefit from.’”
He became the director of the center in 2005 with the goal of building a model for a successful, science-based program that incorporated research and patient care. That same year he was awarded a large National Institutes of Health (NIH) grant to develop stress-reduction programs in collaboration with the Sidney Kimmel Cancer Center (SKCC). Since that time, programs have been expanded at SKCC, and have been incorporated into the Vickie and Jack Farber Institute for Neuroscience and other departments at Jefferson.
In 2007, Monti obtained an Investigational New Drug (IND) license to study the effects of vitamin C in cancer patients. Three years later, he was given his first Marcus Foundation grant of $3 million and was able to conduct a clinical trial in conjunction with SKCC.
Over the years, the center has received numerous research grants from the Marcus Foundation. In 2015 it was awarded a $14 million gift to create a new, 14,000-square-foot satellite location in Villanova, Pennsylvania. Included was funding for a PET/MRI (positron emission tomography/magnetic resonance imaging), the first of its kind in the Philadelphia region. This hybrid technology combines an MRI with molecular imaging to give a complete picture with precise alignment of anatomy and metabolic activity in order to assess a wide range of diseases, guide innovative treatment protocols, and enhance research.
Four years later, the foundation made another substantial gift—one that enabled SKMC to solidify its place as a leader in integrative medicine.
Jefferson Leads With Courageous First Steps
In early 2019, the Marcus Foundation made its largest commitment yet to SKMC: a $20 million gift that has facilitated the creation of the Department of Integrative Medicine and Nutritional Sciences as a fully established, co-equal department in a medical school—the first of its kind.
Today, the department’s curriculum consists of clinical applications of integrative medicine with a focus on functional biochemistry, nutrient-based therapies, mind-body neuroscience, novel mechanisms of healing, and emerging therapies. The program will include a master’s degree and certificate courses, including one in integrative nutrition and mind-body medicine. It also boasts another first in the country: a fellowship program slated to begin in 2020. There will be two fellowship slots; Monti anticipates an abundance of applications.
“Jefferson took the first courageous step in creating an academic Department of Integrative Medicine and Nutritional Sciences,” says Monti, who has been contacted by numerous other institutions across the country regarding the logistics of setting up an integrative medicine department. “We can help set standards for the field, define what integrative medicine is—and what it is not—so that all of the misunderstandings can be clarified.”
Those “misunderstandings,” he says, are rooted in semantics. While the terms “integrative,” “complementary,” and “functional” medicine are all appropriate, the term “alternative” is avoided.
“Integrative medicine is not alternative medicine,” Monti states emphatically. “Alternative medicine replaces traditional medical care, and that is not Jefferson—and that is not anyone who is involved in academic medicine. Integrative medicine supplements good medical care and adds value to treatment.”
Monti makes clear that all of the department’s doctors are board-certified in some field of conventional medicine, with additional training in nutrition-based therapies and mind-and-body therapies.
“If you look at what falls under the term ‘complementary medicine,’ you’ll find hundreds, even thousands, of modalities,” he explains. “But we incorporate only a small handful into our practice because we only use what we have done the work in, and what is based in science.”
Research is a key component of the center. The Marcus Institute of Integrative Health and the Department of Integrative Medicine and Nutritional Sciences at SKMC conduct pioneering clinical trials to test the efficacy and safety of complementary therapies.
The institute (which includes both clinical centers—Myrna Brind and Villanova—and the new department) has grown considerably since the early days: there are now 35 full-time employees, including physicians, nurses, researchers, and other staff, and Monti predicts growth in all three components of the department—academic, research, and clinical. Last year, the institute hired a new medical director, Anthony J. Bazzan, MD, board-certified in internal medicine and integrative and holistic medicine, and a fellow of the American College of Nutrition. The research director, Andrew Newberg, MD, is world-renowned for innovative imaging techniques and the neurological mechanisms of health.
Monti looks forward to continued NIH and foundation funding, increased clinical trials, and growth across the board. He boasts that Jefferson’s program is setting the bar for integrative medicine today—and he credits the Marcus Foundation as well as Ira and Myrna Brind with making it all possible.
“It was through the love and dedication of Myrna Brind that we are here today,” says Monti. “That early support from the Brinds was pivotal to us being created and surviving the initial years. And then the support from the Marcus Foundation was critical to us taking the next step in becoming national leaders in integrative medicine by expanding our geographic footprint and creating a department.” A generous third donor, Ellen and Ron Caplan, established the Ellen and Ron Caplan Professor and Chair, which is held by Monti.
Everything Old Is New Again
The idea that healing is most effective when you consider the whole person rather than focusing on specific illnesses, body parts, or symptoms is not new. In fact, Socrates said in the 4th century B.C., “The part can never be well unless the whole is well.”
Some of the earliest known healing therapies came from Ayurvedic medicine, traditional Chinese medicine, and homeopathy.
Perhaps the oldest system of healing—going back about 5,000 years—is traditional Chinese medicine, which uses herbs, dietary therapy, and mind and body practices such as acupuncture and tai chi, which are the two most frequently used in the U.S. Almost as old is Ayurveda, originating in India more than 3,000 years ago. Practitioners prescribe individualized treatments, including compounds of herbs or other ingredients, diet, exercise, yoga, body manipulation, and lifestyle alterations. Joining much later, homeopathy was founded by Samuel Hahnemann and first practiced in Germany at the end of the 18th century. It is a medical system based on the belief that the body can cure itself; those who practice it use tiny amounts of natural substances, such as plants and minerals, to stimulate the healing process.
Monti explains that these forms of ancient practices were pushed into the shadows when the Flexner Report was published in 1910 because it put people in the United States into the mindset of only thinking about the new model of medicine—one in which the value of a holistic way of looking at a patient got lost.
“We have to recover from that,” he says. “When you think about it, the United States arguably has the best medicine in the world. We have the best technologies, access to the best pharmaceuticals, superb doctors—some of the most brilliant minds in medicine are here in the United States. And yet, the health status of our population is abysmal.”
The World Health Organization ranks the average life expectancy for men and women in the U.S. as 21st in the world; the Bloomberg Global Health Index ranks the U.S. 35th in healthiest countries.
“So there’s this disconnect between disease and wellness. We are good at targeting a disease, but we haven’t been so good at targeting the whole person,” he says. “Integrative medicine brings that component back into medicine as an ally and a value to the rest of the medical model.”
Integrative medicine saw a resurgence in this country about 25 years ago, as patients began to demand options to traditional care.
In 1993, the medical world was taken by surprise when an article in the New England Journal of Medicine revealed that a large percentage of patients were seeking therapies outside of what their physicians were recommending. It provided an even greater impetus to physicians to try to understand why patients were going rogue with outside treatments, some of which were unproven and ineffective, and some of which were not safe.
“People self-diagnosing and trying to self-treat with over-the-counter medicines and botanicals can be dangerous,” Monti says. “Yet, the need for something more was glaringly there, and so we decided to try to be of service to these people—to create a new subspecialty of medicine to fill an obvious gap.”
In response to the growing number of people across the country seeking nontraditional medicine to fill the gap, and institutions and medical schools trying to keep up with the demand, the NIH created an Office of Alternative Medicine in 1994, later renamed the National Center for Complementary and Integrative Health (NCCIH). The NCCIH conducts rigorous scientific investigations to determine the usefulness and safety of complementary and integrative health interventions.
In 2002, there was an additional push to bring integrative medicine further into the mainstream when philanthropists from around the country formed the Bravewell Collaborative, a foundation that supported and funded research and training in the field. More than 50 leading medical schools in North America were part of the consortium, including Columbia University, Georgetown University, Harvard University, University of Pennsylvania, Stanford University, and Yale University. The collaborative disbanded in 2015, as its leaders felt the organization had succeeded in its mission.
Further evidence that integrative medicine is gaining acceptance is that a board certification process for the specialty was established through the American Board of Physician Specialties (ABPS) in 2014. Since that time, the American Board of Integrative Medicine has certified approximately 1,000 diplomates, according to Lauren Henrichsen of the ABPS.
Monti says integrative medicine is making great strides in winning over skeptics.
“Some of the things that have been seen as a bit fringy 20 years ago—like mindfulness and an emphasis on nutrition—are embraced with open arms by healthcare systems across the country today,” he says. “Our job is to continue to push the science and make sure that we’re validating our model as we go along.”
Monti still gets some pushback on the concept of integrative medicine from colleagues, but for the most part, “that’s a thing of the former generation.”
“What I find is that the newer generation of physicians is exceedingly open-minded and ready, willing, and able to incorporate many of the concepts that are part of what we do every day,” he says.
One member of that newer generation, Mariah Cicioni, MD ’18, says that integrative medicine provides her with a “greater number of facets” in patient care.
Now in her second year of a pediatrics residency at Duke University Hospital in Durham, North Carolina, Cicioni was introduced to integrative medicine in her first year of medical school with a course taught by Rakel called “The Healer’s Art.”
The class, which Rakel has taught for the past 15 years, uses principles of contemplative studies, humanistic and transpersonal psychology, cognitive psychology, formation education, creative arts, and storytelling to present and explore the human dimensions of medicine.
Cicioni says she gleaned a great deal of information from the course, but she didn’t get to see integrative medicine at work until a clinical rotation in Florida during her fourth year, when her mentor used it in his pediatric practice.
“I loved how he was able to talk with the family, take more time with them than most traditional visits, and how he talked about their goals and how he partnered with the parents to come up with a plan to achieve those goals,” she says. “For example, when a patient came in with anxiety, we did a breathing technique in the office to help with relaxation, then talked about steps that can be done at home, like meditation done as a family.” Still, she faces resistance when she mentions incorporating integrative medicine into everyday care.
“It’s a constant struggle; I often get criticism. People call it voodoo,” she says, sighing. “That word really frustrates me.” But instead of getting frustrated, she says she tries to educate her peers and her patients to let them know everything she does is based in science and rooted in research.
“There will always be medical problems we can’t fix with traditional therapies, so there will always be a need to answer the question: ‘What else can we try?’” she says. “Doctors and patients need to open their minds to other ideas.”
There Is Art to Medicine as Well as Science
Both clinics of the Marcus Institute (the Myrna Brind Center and the Villanova Center) are designed to invoke a sense of calm. Lights are low; soft, meditative music floats in and out on the pentatonic scale; people speak in almost a whisper.
Rakel places a small glass pyramid filled with sand and seashells on her desk, and traces the triangular bottom with her finger. “This is the tripod—diet, exercise, mind-body therapies. This is the basis,” she says. It is the basis that physicians build upon to help patients through conventional and complementary therapies.
“I tell my students, you need to become a really good MD before you can become an integrative doctor,” she says. “You have to look at integrative medicine as an expanded toolbox for the MD.”
That toolbox provides the means to collaborate efficiently to the benefit of the patient, says Monti, noting that the integrative medicine center is sometimes the first line of defense in getting patients to the appropriate specialist when they come in with concerning symptoms.
“For instance, when someone comes in and we diagnose them with cancer, we immediately get them to the cancer center for their primary treatment,” he says. “Then we take a step back, and are there for the patient to support them in any way we can to enhance the overall quality of life and healing journey of that patient.”
That support can come in many forms, including nutritional advice and supplements, a prescription for acupuncture, or mindfulness therapies, just to name a few. Monti says one of the center’s most successful treatments is the neuro-emotional technique (NET), a mind-body therapy that has been found to reduce the symptoms of traumatic stress in cancer survivors. A recent study conducted at the center looked at 23 patients who were feeling traumatic stress from cancer-related experiences. In just four to five NET sessions, patients who received the therapy reported much less distress, their overall emotional state improved significantly, and the way their brains reacted to stress cues normalized. The study was published in February of 2017 in the Journal of Cancer Survivorship.
“When a patient gets a consultation with us, the physician is thinking in almost a double model where they’re considering everything that has been done to date within their conventional treatment team, and also the value added in taking a more comprehensive approach—taking into account the totality of the person in terms of the healing process,” Monti says.
While integrative medicine still gets some resistance from colleagues, Monti says more and more are welcoming its benefits and calling him for consultations. And although the medical world is beginning to accept and appreciate it, Rakel warns that it needs to be incorporated slowly and carefully.
“The more studies and data we have, the more we can document our research, and the more our colleagues will embrace what we are doing,” she says. “I believe in integrative medicine—I believe it is the way of the future. And one day it will not be called ‘integrative medicine’—it will just be called medicine.’”