Penny George spoke at the Eighth Annual Symposium on Predictive Health at Emory University in Atlanta, GA.
Integrative Medicine and the Transformation of Healthcare
Predictive Health Institute Annual Conference
IMAGINE for a moment...that you have been diagnosed with cancer and you want to be dealt with as a whole human being, connected in body, mind and spirit. But your treatment considers you only as a disease and a compromised body part.
Imagine...you have not been diagnosed with cancer but you are from a family that has a long history of it and you want to avoid going down that path. But your doctor tells you that there is absolutely nothing you can do to prevent cancer.
Imagine...you are committed to being responsible for your own return to health. You want to know the best way to do that, given your body type and lifestyle. But none of your care providers knows anything about such personalized care.
That was my story, and trying to change that reality has become an animating force in my life.
I’d like to share with you what I have learned about disease care in America. About the work of a small group of philanthropists dedicated to the improving “downstream care” while also helping move the country “upstream” toward the prevention of illness. And about how one health system is improving care - in both directions - through integrative medicine.
My message is that healthcare reform must be about health reform. Let me repeat that... healthcare reform must be about health reform. That we must each become the principal agent of our own health. That integrative care for illness is more effective than devices, pharmaceuticals and other conventional interventions alone. To get to this reality we will all – physicians especially – need to learn to collaborate in ways that are more inclusive and empowering. And that involves a consciousness shift for all of us.
I didn’t come to these conclusions on logic alone. I was diagnosed with invasive breast cancer in 1996. Given that my treatment plan was a mastectomy followed by chemo and hormonal therapy, it was not a day at the beach. And I was not assured of survival. I had very good conventional care. But I quickly realized that was incomplete. It didn’t address what mattered most to me: Preventing a recurrence. Helping me live fully with what could possibly be a chronic illness. Or dying whole, depending on what would be the outcome.
My father was a surgeon and like a good “shoemaker’s child”, I knew it was my job to take care of myself. So I set about finding my own answers, including ways to improve my quality of life during treatment. What I found was that my life was transformed by doing that. Yes, I found acupuncture helpful for hot flashes. Yes, I found guided imagery helpful in imagining myself growing old. But it was not the complementary therapies that were transformative, but rather feeling empowered. Regaining some sense of control over my life. It was reestablishing the connection between my body, mind and spirit that brought me back to wholeness. And wholeness meant a lot more to me than just whether or not the cancer cells were gone for good.
I would not call my relationship with my oncologist teamwork. He knew only what he’d been taught, and I didn’t choose to use my time with him to educate him about what I was learning. He did know about it though and was generally supportive. I put together my own healing team, which included, of course my husband Bill and also a psychologist colleague I called my healing coach. I found support too from my sons, my women’s group, and from
1a couple’s group Bill and I have belonged to for 30 years. I even went on a Vision Quest in the desert of southwestern Utah. I did not go through the valley of the shadow of death by myself.
This whole experience led me to talk to Bill about using the resources of our family foundation to try to change medicine. In the beginning I just wanted doctors to see how much their patients would benefit from having support to create their own healing path. Bill thought I was naïve, based on his experience with medicine from his work at Medtronic, the company he was the head of at the time. But he was supportive of me and we went for it.
Initially we worked on pursuing our vision within the hospital whose board he had been chair of and whose board I was currently on: Abbott Northwestern Hospital in Minneapolis. I will talk about that shortly. This vision was at the time called Complementary and Alternative Medicine. Since then, recognizing that people want the best of both approaches to care - Western and what is called Eastern - it has become known as integrative medicine. One day I hope it will just be medicine. And of course, health is not synonymous with medicine.
Let me define integrative medicine, or the term it is even is now morphing into: integrative health and healing: It is an approach to care – a set of principles and practices – that centers on us as whole human beings connected in mind, body and spirit. It takes into account all of the influences on our health (after all, only 20% of health outcomes are directly affected by healthcare professionals). It is personalized to our unique circumstances rather than simply following an algorithm in which we are all to be treated alike.
As you probably know, integrative medicine draws from a wider array of scientific approaches than are typically found in Western medicine. Those differ according to where in the continuum of care the person might be. For example, for prevention it will usually involve stress-reducing mind-body approaches that are easily learned and cost next to nothing. Movement and nutritional consultation are foundational tools, because they empower the person to do what they can for themselves.
For people living with chronic conditions integrative medicine offers improved quality of life. People with chronic low back pain may choose therapeutic yoga, massage and acupuncture. Currently these patients often end up with expensive steroid injections that often are frequently ineffective. For acute care it could mean offering the option of using less medication by incorporating hypnotherapy for pain relief.
At the end of life, integrative care emphasizes spiritual care, music, ritual and comfort care, over continuing curative attempts at chemotherapy. It is responsive above all to what the person and the family really want. Some experts have referred to integrative medicine as predictive, preventive, personalized and participatory care. Ken Brigham and Michael Johns in their excellent new book Predictive Health refer to this as “advanced common sense”. I think that is exactly right. While there is advanced science being brought to bear, the essential premise is common sense. If we continue to focus on disease care, we will get more disease. But if we want more health, we will get more health, we must focus on health.
Over time the George Family Foundation became more involved in funding programs around the country that shared our vision. Eventually, we realized that there was a lot of uncoordinated work going on to make integrative medicine mainstream. We decided to bring together physician leaders and the philanthropists who were funding their programs to strategize how we could be more effective. This decision led our foundation to host two meetings. The first included 20 leading integrative medicine physicians, including Andy Weil, Dean Ornish, Ralph Snyderman and Mehmet Oz, and a group of 20 prominent philanthropists funding integrative medicine programs, including Christy Mack and Barney Osher. We spent 2 1⁄2 days together looking for strategies that would be catalytic. One strategy the group unanimously agreed upon was to harness the power of philanthropy.
Historically, philanthropy at its best has been the engine of social change. In 2001 we created the Bravewell Collaborative to be that engine for the remaking of American medicine. Bravewell is a small group of philanthropists whose mission is to bring about optimum health and healing for the country. Integrative medicine’s principles and practices are the how of that. It is an operating foundation, which means that Bravewell decides what needs to happen, what people or organizations are best positioned to do it, then we do what it takes to make that happen. It is different in that respect from a grant-making foundation most people are familiar with.
At a second meeting six months later, attended by philanthropists only, we decided upon four strategies: Convinced that no change would be sustainable without it, we set about to change the way physicians are educated. At the same time Bravewell was being created, so too was a consortium of leading academic health centers committed to integrative medicine as the future of medicine. Harvard, UCSF, Georgetown and Duke were among the 8 founding members. We decided to ensure the Consortium’s survival and to fuel its growth. Ralph Snyderman, the group’s leader, believed that if they could grow to 25 it would be close to the tipping point.
The Consortium now has 55 members and it is growing fast. It has more than delivered on Bravewell’s investment. For example, the Consortium’s most recent bi-annual research conference on complementary and integrative medicine, which was held in Portland this past spring, was attended more than 1000 academic and clinical researchers from 30 countries. The Consortium is now admitting major hospital systems as members and continues to influence medical schools how to teach students about integrative medicine.
Another strategy was to champion the courageous physician leaders in integrative medicine. Every two years since 2003, Bravewell has given a $100,000 cash prize to a physician leader. It is part of a big celebration event in New York that gathers the growing integrative medicine community. This coming November we will be honoring two leaders: one is Tracy Gaudet, who built the integrative medicine programs at Arizona and at Duke. She is now the director of the office of patient-centered care and cultural transformation for the Veterans Administration Health System. The other is Miles Spar, who heads the Venice Clinic in Los Angeles. It is the nation’s first health, wellness and integrative medicine program at a free clinic.
Our third strategy has had to do with educating the public. We believe that medicine changes in part because the public demands that it change. We wanted to show people the care they should be asking for, care that was already being introduced in major medical centers across the country. In 2006, working with PBS, we conceived and funded an award-winning 2-hour documentary called The New Medicine. It was ultimately seen by more than 8 million people.
The final strategy was to strengthen the leading models of integrative clinical care. The consulting firm McKinsey & Co. has done two pro-bono studies for Bravewell. In one they suggested we create a network of the 8 leading clinical centers. we were working with. The idea was that a network would allow them to share best practices and survival strategies. We did that and all are now thriving. A few years later, McKinsey suggested we create a Practice-Based Research Network or PBRN. It is the first of its kind in the country, and we called it BraveNet. BraveNet has been working to collect clinical data on the emerging models of care. McKinsey also encouraged us to fund fellowships for practicing physicians to attend the Program in Integrative Medicine at the University of Arizona, Dr. Andrew Weil’s program. Through those fellowships more than 80 fabulous young physicians are on their way to becoming the field’s next-generation leaders.
Bravewell set some guidelines for how we would operate. We agreed we would take on only things that Bravewell alone could do, projects that we could deliver on and do so in a timely manner. One of our older members had said to me when I asked him to join Bravewell, that at his age he didn’t want to buy any “green bananas”. We took him seriously.
Another principle was that we would partner with those better positioned strategically to make change happen. The Consortium is the best example of that. We wanted to change how physicians are trained, and they are the ones that do that. Then in 2009 we partnered with the Institute of Medicine to host a two-day Summit on Integrative Medicine and the Health of the Public. The head of the IOM recently told me it was the best attended and most energetic convening the IOM has ever had.
We didn’t get everything right, and not all partnerships in the end make sense. For example, we thought we could partner with the US Army. On behalf of all the military, the Army had put together a task force on comprehensive pain management. When we read the task force summary, we realized that what they had committed to do was exactly what our clinics were already doing to treat pain. We thought we could help them implement the task force’s recommendations. In fairness, the task force’s leadership thought so too and they wanted our help.
We held a briefing for the Army Surgeon General and his staff that was enthusiastically received. But over time we realized that the military has its own timeframe, and it is considerably slower than ours. We are now working on a smaller scale to coordinate BraveNet’s research metrics with the Army’s. I mention this in part because it is important that you know the military is strongly committed to integrative care for the treatment of pain for both warriors and their dependents. This transformation is underway also in the Veterans Administration.
While Bravewell was growing, the program Bill and I had co-founded back in 2003 at Abbott Northwestern Hospital was evolving as well. Abbott Northwestern is one of the largest and most respected tertiary hospitals in the Midwest. It is also the flagship hospital of the Allina Health system. We had chosen to invest at Abbott for three reasons: because it has strong nursing leadership, because we had support from the hospital President, and because the culture of the hospital was already patient-centered.
Initially, the program was called the Institute for Health and Healing, of which there are several now around the country. In 2009 it was renamed the Penny George Institute for Health and Healing. The George Institute is the largest hospital-based integrative medicine program in the country. The inpatient work came first. The way it started, under the radar, is one of the reasons it’s been so successful. Bedside nurses were, and still are, trained through a program called Transformative Nurse Training. The TNT program teaches nurses to offer healing therapies at the bedside. It reconnects nurses to why they went into medicine in the first place. The program has been tremendously popular – 500 Abbott Northwestern nurses have been through the program, as have nurses from Minneapolis Children’s Hospital, the Mayo Clinic and the LA-area VA and others. It generates some profit for the hospital, and it reduces turnover.
The George Institute’s therapies, whether offered by nurses or our other practitioners, are targeted especially for patients dealing with pain, anxiety or nausea. Any nurse, physician, patient or family member can ask for a consult. Patients do much better, and as a result physicians strongly support the program. Physician support is why acupuncture is built into the rehab process for the joint replacement program. The hospital covers the cost of the inpatient services out of its operating budget.
The outpatient center was built in 2005. It brings in a small revenue stream through a combination of insurance coverage and self-pay and it brings large numbers of new patients to the hospital system. At last count, 25% of its patients were new to Allina. Eighty percent of acupuncture appointments are covered by insurance, as required by Minnesota law, and integrative physician consultations are covered as well.
It was always the intention that the Institute would move “upstream” to include prevention as soon as possible. First, though, it needed to show the hospital that it could improve outcomes. How many of you have heard of the Triple Aim? It seems to be the holy grail of healthcare, and it has to do with improving patient outcomes, patient satisfaction while lowering costs. These are measured as part of the acute and chronic illness part of the care continuum. Cost effectiveness in prevention is still pretty difficult to demonstrate.
The response from the hospital – patients, physicians and administration - has been enthusiastic. Integrative approaches are now fully embedded in cancer care. The Institute has been asked by the remaining 7 clinical service lines to help them add integrative practices and consults into their care for their patients as soon as possible.
I would like to share a few findings from the George Institute’s clinical research: The Institute’s eight week Resilience Training (or RT) Program focuses on people suffering from depression. There are three components: mindfulness meditation practice, diet and nutrition, and exercise. In a pilot study funded by Allina, 40 employees with major depression were enrolled in a controlled trial using a wait-list control. The results were that employee depression scores decreased by 71% without any additional medications, compared to a 10% reduction in the control group. Quality of Life improved by 71% in the Resilience Training group, compared to a 19% improvement in the control group. Both of these results are statistically and clinically significant. Looking at presenteeism (being at work but not functional), the study found cost savings of over $1,700 for each Resilience trained participant. The clinical impact of the training remained through the 1-year follow-up.
To evaluate the impact of integrative care for pain management in six inpatient settings across the hospital, the team studied the medical records of 1800 patients seen by our team over an 18-month period. The average reduction in pain scores was 1.9 points (on a 10 point scale) and the average percentage in pain reduction was around 55%. These results led to a $2.4 million 4-year study under way now, funded by the National Institutes of Health. In this study, researchers will find out how long the pain relief lasts and see if there are specific integrative therapies are more effective than others in relieving pain in specific patient populations. The researchers also found that when pain scores were reduced, there was a corresponding decrease in total charges by more than $2,700 per person per hospital stay.
There are also numerous research groups exploring the biological impact of these therapies in hospitals and universities across the country. Evidence is accumulating that demonstrates changes in neuroplasticity, shown by functional magnetic resonance imaging, as well as changes in gene expression, and increased telomere length, one important factor in the aging process.
Allina is one of 32 pioneering Accountable Care Organizations in the nation. Its leadership understands the importance of the Institute’s work in delivering higher value care. Proof came last spring, when the Penny George Institute for Health and Healing was designated as a Clinical Service Line, with responsibilities across the Allina Health system. It is both a horizontal service line, in that it has been asked to integrate the care models of the other service lines, as I mentioned, starting at Abbott. And vertical, because it serves people directly, across the continuum of care. It is also responsible for innovation in the areas of prevention and wellness and for improving population health in 13 outstate communities in Minnesota through the Healthy Communities Partnership.
Here’s what I have learned through my journey with cancer and through the work of the George Family Foundation and the Bravewell Collaborative. Our goal as leaders in the health arena is to bring about flourishing of the people whose lives we touch. I love the Buddhist notion of flourishing. In our context, it means not just curing people of disease, but also partnering with them to achieve fullness of health in mind, body and spirit.
I believe the clinical care of the future will be team based. Not just because it is all we can afford, but because it is better suited to address the diverse and changing needs of the people to be cared for. Nutritionists. Mind-body therapists. Chinese medicine practioners. The exercise physiologists who know how to help us move our bodies. Behavioral health specialists, psychologists, and health coaches who help us do the hard work of personal change. They actually have more to offer than physicians do, if health is our goal. These health professionals, and the physicians of the future, will be taught to work together collaboratively and to operate comfortably in teams. In time, we will succeed in weaning people from the expectation of a doctor visit and the semi-totemic prescription at the appointment’s end.
We are in the midst of a great collective consciousness shift. As I said, integrative medicine is not about modalities. That is the part Western medicine focuses on, because interventions are what modern medicine does. But if we simply substitute supplements and herbs for pharmaceuticals and medical devices – or heaven forbid we market a new pill to make it unnecessary to move our bodies, or we find a drug to cure obesity - we will still be operating out of the same old “Fix me, Doctor” consciousness. As Albert Einstein said, “We cannot solve our problems with the same thinking that we used when we created them”.
Bravewell will sunset next year. It has done what it set out to do. But Bill and I are not leaving the field. There is still a lot of work to do. The remarkable partnership between Emory and Georgia Tech is one of the most promising ventures in this new world we are moving toward. We are eager to help it fulfill its potential.
Now, let me ask you again to imagine... that you have developed a personalized plan for optimum health. A plan that will help you avoid or significantly delay the cancer and heart disease that runs in your family... that you know what kind of food is best for you. What kind of movement too. You have a regular mind-body practice that works for you that includes mindful eating. You have a sense of purpose and meaning in your life that you are part of at least one community in which you experience love and acceptance. You not only have health, but also a deep sense of wellbeing.
Imagine... you are no longer overweight. Your joints don’t hurt anymore. You feel joy and a sense of equanimity in your daily life.
Imagine... that you have a wellness team to turn to when you need it. A physician is part of the team, but not the primary person you see. If you have a chronic illness, you have science based options for ways to live fully. You feel empowered to make the right choice for your own situation.
Finally, I ask you to imagine... that you are in a position to make this vision a reality. In your lifetime. To make America healthy again. Because I believe that by virtue of your being in this room, you are. I hope you will think about what your unique contribution might be.
Thank you for being here, thank you for listening to my message.