The COVID pandemic highlighted the disproportionate risk for poor health outcomes for people suffering from poverty and other inequalities. We are witnessing an alarming increase in mental distress, healthcare expenditure, burnout, and workplace attrition. A growing body of research provides evidence for the mind-body connection and the essential role of equity in advancing integrative healing for all. The Integrative Medicine in Residency brings the unique opportunity to learn and practice whole person medicine while supporting the well-being of healthcare workers.
Shifting the Health Paradigm: Moving from Treating Disease into Creating Health
Across millennia, ancient healing traditions considered the mind, body, and spirit in the pursuit of health and well-being. By early 20th century, scientific and technological advances brought forth a more reductionist approach to the teaching and practice of medicine. The Flexner report of 1910 established the biomedical model as the gold standard of medical training, contributing to an imbalance in the art and science of practicing medicine.1
The U.S. health and medical education systems invest heavily towards acute and end of life care whereas only 3-6% of healthcare expenditure is allocated to primary care and health promotion. Despite staggering costs, U.S. health outcomes are lagging when compared to other developed nations. Our system is effective at treating disease but has been unable to reverse the epidemics of cardiometabolic disease, chronic pain and mental distress affecting patients and healthcare workers alike.
By end of the 20th century, thought leaders and academic organizations were proposing a more holistic approach to health and wellbeing. In 1994, Dr. Andrew Weil established the field of integrative medicine and founded his eponymous Center for Integrative Medicine at the University of Arizona in Tucson. In 1998, Martin Seligman, PhD, founded the field of positive psychology while the Office of Alternative Medicine became part of the NIH, ultimately renamed the National Center for Complementary and Integrative Health (NCCIH). The following year, the Accreditation Council for Graduate Medical Education (ACGME) would establish a set of competencies to help define the foundational skills every physician should possess, emphasizing patient-centered care and interprofessional collaboration.
A healing-oriented medical specialty, Integrative Medicine encompasses evidence-based Western and Ancient therapeutic modalities and the partnership between patient and healer. Along with the concept of treatment, health promotion and the prevention of illness are paramount. The Veterans Health Administration was one of the first U.S. institutions to provide integrative care under the leadership of Benjamin Kligler, MD. An integrative approach to healing is proving to be beneficial in the treatment of complex disorders, such as chronic pain. Veterans who used Whole Health services have reported improvement in perceived stress, engagement in life, and decreased opioid use. In addition, the VA Whole Health initiative is demonstrating benefit in improving employee health and well-being with increased engagement and decreased reported burnout and voluntary turn-over.2
Integrative Medicine in Residency Is Growing a New Generation of Interdisciplinary Healers
Since its founding in 1994, the University of Arizona, Andrew Weil Center for Integrative Medicine (AWCIM) has trained thousands of physicians. In addition to fellowship training, AWCIM offers a wide variety of educational programs including elective rotations for medical students and residents, online courses, health coach certification, and the Integrative Medicine in Residency (IMR) program. Founded in 2008, the IMR program provides 200 hours of competency-based, online curricula designed for flexible incorporation into primary care residencies. The modules include topics on nutrition, mental health, clinician well-being, and integrative approaches to pain management—all designed to support the learning and practice of integrative medicine in a variety of settings. A majority of residents use CME funds to cover the tuition cost which ranges between $800 and $1,200 per resident (based on content specific to each specialty). A one-time payment provides access to the curricula for the duration of the residency program plus an additional year post-training.
Since its inception, the IMR has trained more than 1,700 residents and expanded to more than 116 sites within the United States and several international programs. The residency programs include internal medicine, family medicine, obstetrics and gynecology, prevention medicine, and psychiatry. Pharmacy residents are now participating as part of a new multidisciplinary IMR pilot. Under the guidance of a faculty leader, each cohort of residents engages in diverse educational activities which might include clinical training, interactive online learning, formal presentations, advocacy work, and experiential learning. Faculty leaders have opportunities for professional development through monthly leadership meetings and an annual faculty development conference. A shown benefit of the IMR program is enhanced recruitment into participating residencies.3
IMR for internal medicine residents at UT Southwestern was established at the safety net resident clinic in fall 2018. A total of six internal medicine residents participated between 2018-20. In response to the need for safe opioid prescribing and a whole person approach to the treatment of chronic pain, a novel bimonthly clinic was created providing opportunities for interprofessional collaborations between internal medicine and pharmacy residents and faculty. The patient and clinician experience at the pilot clinic culminated in the founding of a new service, the Integrated Pain Healing Center. The multidisciplinary collaborations have now grown to include integrative medicine, clinical pharmacy, social work, psychiatry, addiction medicine, nursing, and acupuncture.
In September 2020, a new integrative medicine and pharmacy clinic was designed to address the high prevalence of uncontrolled diabetes at a dedicated medical home for employees of the safety net hospital. The weekly clinic was staffed by the IMR faculty leader and a Pharm D resident training in ambulatory clinical pharmacy. Patients with a baseline Hgb A1c greater than 9% were referred by their primary care physicians to receive a whole person approach to care which included food insecurity screening, patient-reported PHQ-9 screening, lifestyle counseling, and optimization of care. During the supervised resident clinic phase, patients with a baseline Hgb A1c of 8% or higher had an average 2.2% reduction after 3-4 monthly visits. After completing residency training, the Pharm D resident was recruited to join the Employee Health clinic. One year after implementing integrated clinical pharmacy services at the employee clinic, 69% of patients with diabetes had a Hgb A1c below 8% with concomitantly increased utilization of GLP-1s and SGLT2-i among clinic providers.
The first multidisciplinary IMR pilot was established in December 2021. At the time of publication, the residency programs represented include internal medicine, pharmacy, psychiatry, neuro-psych and med-psych, for a total of five IMR learners. The interprofessional collaborators span a variety of disciplines including psychology, contemplative care, integrative nutrition, nursing, acupuncture, and non-profit organizations. Residents and faculty engage in a variety of mind-body interventions including virtual meditative movement and mindfulness workshops. We incorporate ceremonial methodology in the design of experiential workshops which include centering exercises, patient case discussions and opportunities for reflection—all provided in a psychologically safe environment conducive to collaborative learning and integrative healing.
The past 50 years have brought forth previously unimaginable advances to humankind. From landing on the moon to genome sequencing, our knowledge continues to expand exponentially. However, despite major scientific progress, our society continues to face tremendous challenges that threaten the survival of humanity and our planet. To effectively address the complex challenges of the modern world, we need to think holistically and act collaboratively. An integrative, whole person approach to healing is proving to be beneficial in the treatment of complex disorders, such as chronic pain, cardiometabolic disease, and employee burnout. The Integrative Medicine in Residency program provides the unique opportunity to learn and practice integrative medicine—mind, body, spirit and community—while supporting the wellbeing of healthcare workers and healers.