COMMENTARY

A Neurologist Makes the Case for Integrative Medicine

Kathrin LaFaver, MD; Indu Subramanian, MD

Disclosures

July 27, 2021

This transcript has been edited for clarity.

Kathrin LaFaver, MD: Hi. This is Dr Kathrin LaFaver, coming to you from Chicago. Today I have the great pleasure of talking to neurologist Dr Indu Subramanian. A native Canadian who studied at the University of Toronto, she has been living in Los Angeles for a long time now, where she serves as the clinical director of the Department of Veterans Affairs (VA) Southwest Parkinson's Disease Research, Education and Clinical Center (PADRECC), as well as a clinical professor at UCLA. We're here today to talk about integrative medicine. Welcome, Dr Subramanian.

Indu Subramanian, MD: Thank you so much, Kathrin. Great to see you.

LaFaver: It's especially fun to interview you, because you have been talking to many Parkinson's experts over the past year for a really nice series on holistic topics in treating this disease. That's a good segue to our topic of integrative medicine. Many of the neurologists watching this might wonder, why should we care about this? To start off, can you define integrative medicine?

Integrative Medicine: Moving Beyond Western Concepts

Subramanian: "Integrative medicine" is young term for what we used to call "complementary and alternative medicine." I think we've shied away from that latter term because the sense of "alternative" makes it seem like it's outside of the regular Western practice of medicine, and that patients would have to choose either Western medicine or this alternative type of medicine. So, the concept of integrative medicine is sort of bringing the two areas together.

It's a very welcoming space to me, because I grew up with a mom who is a Western-trained family physician. In our house, there was also a lot of practice of our Vedic traditions. My grandmother would cook for us when we were sick — bring us something that was gingery if we were having nausea, turmeric milk, and things like that. So, for me, those traditions were always integrated.

But when I went to Western medical school in Toronto, we learned a very set approach to treating and curing certain diseases. The patient comes in with the disease, we see them and take charge of their care, and hopefully cure them of disease. They go back out, live their lives, and come in again if and when they're sick.

The concepts of integrative medicine are more holistic. They operate with a sense that the body has ways to heal itself, which is adopted from Eastern practices that consider not just physical symptoms but also holistic concepts of health, including the patient's mind, body, spirit, and environment. That really appealed to me, and I think it lends itself well to a lot of neurologic diseases.

I started through a pathway of yoga and mindfulness trainings. Then I began looking more into traditional Chinese medicine. It was very natural in its approach to the disease that you and I both care a lot about: Parkinson's. Wanting to further my studies, I ended up taking an exam to become board certified and started going to meetings in the area. It was really a beautiful marriage for me in taking care of patients with Parkinson's disease.

LaFaver: I think it's so true that as we develop genetic cures for certain diseases, which always get a lot of attention, we tend to forget the importance of healthy living — or, for lack of a better term, lifestyle factors. They are a foundation for not just prevention but also treatment of such things as stroke, Parkinson's, Alzheimer's disease, and even migraine or epilepsy.

I'm curious: How do you apply principles of integrative medicine in your own practice?

It Began by Treating Myself

Subramanian: I think it starts with having been interested in some of this myself. In my daily life, I saw the benefits of these mind-body practices and wellness approaches in helping with the anxiety or insomnia I sometimes experienced. I saw that if I ate more healthily or slept better, I felt better. So, I think embodying this in oneself is the starting place.

Then a lot of patients were attracted to me as a clinician by knowing that I was open-minded to these things. I started learning from them about what their approaches were, what seemed to really resonate with them. I have had a lot of young women patients in Los Angeles coming to see me because of my interest in yoga, and I was trying to guide them with yoga poses.

There isn't any one cookie-cutter approach. You have customize it to the individual patient. But I do ask people a lot about lifestyle. That has to be a part of how we practice, even in Western training. I think it would be a little bit antiquated if we weren't talking about exercise and sleep in counseling a patient with Parkinson's. This is really the focus of some of these integrative approaches, even thinking about social connection as it relates to the mind-body connection.

During the pandemic, we couldn't see our patients in person or really do these massive medication adjustments on Zoom. We were worried, what if the patient gets sick and has to go to the emergency room, which is full of COVID? So, we sought out practices that were relatively safe and easy to prescribe. This entailed such things as going for walks, setting a schedule, trying to get good sleep, maybe meditate a little bit with these popular apps, mixing in some of these practices. I think that happened in part because we ourselves were feeling a little bit of the benefit from such approaches during such a crazy time.

I really do try to listen to the patient and understand their cultural background and what appeals to them. For somebody, it might be prayer, which is a way to incorporate mind-body approaches in certain cultures. For some people, it might be cooking with their family on a Sunday and dancing in their kitchen to a Latin song on in the background. It's really about what brings people joy, what they can incorporate in baby steps to feel like they're on the pathway to really getting better and thriving with whatever disease state.

LaFaver: That's a great example. This doesn't have to be separate from what we're doing in taking care of people with Parkinson's. We're already asking about so many of the nonmotor symptoms, and this is a nice extension of that.

That's also a good segue, because you mentioned loneliness and fostering social connection during this time of COVID-19. You recently published the results of a survey that was part of the CAM CARE in PD study. Can you give us a little of the background around that?

Subramanian: Absolutely. CAM-CARE in PD is a study run out of Bastyr University by principal investigator Laurie Mischley, a naturopathic physician and a PhD. We worked in close collaboration and have presented these findings at integrative medicine meetings together.

That's another thing that's kind of cool about integrative medicine. It's not just all MDs with a certain training. There's other types of practitioners: yoga teachers, naturopathic physicians, and all kinds of different people who come to these conferences. You're really able to talk about a disease and find out different approaches and what works.

Laurie has been tracking a number of patients through a survey over about 7 years now, and it's grown. Participants are asked to respond to a survey every 6 months asking about modifiable variables. I went into the survey data to look at how such things as yoga and exercise benefited patients. We saw a lot of things that were beneficial in terms of exercise.

Measuring the Toll of Loneliness in Parkinson's

Subramanian: I knew from integrative medicine meetings that I attended that there had been some significant research looking at loneliness and its effects on people. It's as bad for you to be lonely as smoking a half-pack of cigarettes a day or being obese. This is a real risk factor just in populations in general. I hadn't really learned about that in medical school, so it was something that opened my eyes.

We started interrogating the data and found that loneliness was a significantly negative risk factor in terms of quality of life and progression of disease. It was as bad for you to be lonely with Parkinson's as the beneficial effects of exercising 7 days a week for 30 minutes a day is good for you.

It's a very profound risk factor, and also something that we can modify and do something about. It's not just all doom and gloom. We have data going into the pandemic on a patient population that's been physically distanced and sheltering in place, and all the more at risk for these issues. It's really one of these things where we can be proactive in trying to help people get back into whatever the new normal is going to be. Providing social support and connection is a huge part of that. Our data has hopefully inspired people to start asking these questions, as I know we have.

Another interesting concept that I think has been historically overlooked is that an otherwise happily married couple can still be lonely. There are actually three spheres of connection that you need to have in order to not be lonely. You have this intimate sphere where you're with a partner at home or a confidant with whom you're in a relationship, but you also need to have these two other spheres. One is a tribe, a friendship circle of people outside of that intimate relationship that you're able to confide in. We really are trying to encourage people to look for that. And then the other sphere is where you're connected through a shared purpose or meaning to a larger community circle.

For example, if you suffer with migraine or neuropathy, it might be being in a support group for that. It also may not have anything to do with your neurologic disease. At the VA, I see a lot of vets whose group revolves around that shared experience. Some people have similar interests. You and I, for example, connected through a women in neurology group. It might be a cultural or religious group, something that connects you with this greater meaning, that really you look forward to and brings you purpose.

I've been encouraging my patients to think about those three spheres. Do you have a circle of friends? Do you have a connection with some greater purpose? What brings you meaning or brings you a purpose? Let's try to find you things.

When it comes to what else can we do, there's this new concept of social prescribing, which I think is kind of exciting. We've been dabbling a little bit in that at the VA.

When the Prescription Is More Social Interaction

LaFaver: I think social prescribing is absolutely fascinating. I've seen it used in pediatrics a bit to prescribe exercise, playdates, or whatever. We need to be more creative, especially in this time of COVID, when not all the same interventions have been possible. We can also think about how to adapt things as we go along. I'd be curious to hear a bit more of what you have been using in terms of social prescribing to your patients.

Subramanian: It's a cool concept, which I think may be the wave of the future. We were recently quoted in a New York Times article about this. It feels like such a novel idea, but it's been around in the United Kingdom and other parts of Europe, which have different healthcare systems that are a little more conducive because they're not based on private insurance and everyone sort of has access to the same things.

In the United Kingdom, they've placed so-called "link workers" in the community, who are like a social worker but maybe not as extensively trained. These link workers ask people about their needs, learn if they're lonely, and then try to connect them with social support resources customized to them and in their community. For example, this could be a gardening group for an elderly patient with Alzheimer's disease that might be starting to have cognitive issues but is otherwise capable.

In the VA system, we've started to roll out an intervention called the Compassionate Contact Corps. This was a pivot that happened very quickly during the pandemic. There were a lot of volunteers coming into the VA. If you've ever been to the VA, you probably were greeted by one in the lobby. These volunteers were told to stay home so as not to expose themselves to COVID. Many of them lost their ability to volunteer, which is a hugely beneficial lifestyle that I encourage for anyone who has the time.

So, the VA redeployed these volunteers in this proactive social prescribing kind of mechanism called the Compassionate Contact Corps. This allowed us as clinicians to ask patients about loneliness and then write a prescription, essentially clicking on a consult with the Compassionate Contact Corps. Then the patient and the volunteer are matched through a survey of like interests. The volunteer proactively reaches out on a weekly basis through phone calls, or a video visit if that's technologically feasible for the patient. This created a beautiful sort of beneficial effect, hopefully not only for the patient but the volunteers as well.

We're trying to help promote and grow this. There's been a lot of interest in these small, out-of-the-box ideas for volunteers outside the VA, including in the Red Cross, the AARP, and other organizations.

If you're a clinician watching this in a relatively rural setting, you may be interested in finding an idea of connecting patients in your own practice through some mechanism. It might be having a picnic once a week at the beach, or something else. I know of some clinicians who have even paired two patients in their practice with similar interests (of course, after getting permission). I think it's kind of a beautiful way to act as a link worker in our busy practices.

Researchers have observed a positive effect, given that so many people visit their doctor with complaints because they're sometimes lonely themselves. If they're given somewhere else to have that connection, it allows the doctor to focus more on the things that we should be doing in our clinical spaces and not just addressing these sort of basic human needs, such as loneliness and social connection.

LaFaver: There's definitely so many opportunities. I was previously involved in the Parkinson's Disease Buddy Program. Patients with Parkinson's disease were paired up with first-year medical students in a monthly program to meet and do social activities together. Surprisingly, it was not only the people with Parkinson's who found it very enjoyable, but the medical students also loved it. Oftentimes, they were new in the city and formed long-lasting relationships. There are many opportunities to be creative and actively foster social connection as another dimension of medicine.

Interested in Integrative Medicine? Here's Where to Start

LaFaver: This is such a rich topic, and we could probably speak for another hour. But to conclude, if there are physicians or neurologists interested in learning more about integrative medicine, what are some of our resources or courses you would suggest?

Subramanian: I know that you had gone to the conference run by the Andrew Weil Center for Integrative Medicine at the University of Arizona, and I think that's a good way to start. They're definitely starting to drizzle in some areas of neurology.

I attend conferences, even if they're not specific to neurology, because I've found a lot of interest in the types of topics covered. I went to the conference for the San Diego-based Academy of Integrative Health & Medicine (AIHM). They have a fellowship there with Dr Weil and a number of part-time 2-year fellowships that can be done as you're practicing. There's also online courses, such as about herbs or supplements, or other specific topics. I'd recommend people start with conferences or those, get a taste of that, see if it appeals to them, and then start to learn more.

It's definitely a growing movement in neurology. I saw that you posted something in our women in neurology group, and there was something like 20 people who said, "I love this topic and I wanted to do a fellowship. What do you think?"

There are a lot of cool topics, and it's really out of the box. The loneliness conversation has been talked about for the past 5 years or so. But other things include the effects on health of global warming, what ZIP code you are born in, and some of the trauma-related topics around early childhood adverse events that we're both interested in. There are a lot of topics that we may not exactly see in a neurology meeting or even in a neurology-specific integrative medicine meeting. But I think it's okay to kind of open our minds a little bit.

I've had conversations around being a physician, wanting to realign our practice a little bit, and thinking about new ways to bring joy and meaning to our own everyday life. That's really sort of reinvigorated me and my arena of practice.

The pandemic has shone a light on the inequalities and disparities, and how some of our practices may not have been exactly been representative of how we would like to practice. We can hit reset on what is important to us in our patient care and what our purposes are. That can come about through meeting people who may have had the same thoughts in their own practices from different fields, and it can be quite invigorating.

A lot of free content has been made available during the pandemic that people can access to learn more. I think there's a weekly or monthly seminar offered through the AIHM, including one I presented on neurodegenerative disease. The world is our oyster in some ways because of the abundance of virtual meeting spaces.

I'd urge viewers to do what I and others have done, which is to send an email to someone who's presented something you're interested in and connect with them. Usually, those people are pretty amazing and very like-minded, out-of-the-box thinkers. It's another way to socially connect.

LaFaver: The Andrew Weil Center for Integrative Medicine does offer a formal 2-year fellowship for people who want to really dive in deeper and earn a degree. If people are interested in lifestyle modifications like exercise, diet, sleep, stress, there's also the American College of Lifestyle Medicine. They focus more on modifiable disease risk prevention and offer another board-certified opportunity to get specific training in these areas.

Wellness Doesn't Have to Be an Expensive Pursuit

LaFaver: You briefly mentioned inequalities, which is a big topic. Because you're practicing in two different areas of Los Angeles, I'm wondering if you had any thoughts of making integrative medicine more accessible to people regardless of their ZIP code?

Subramanian: I think there is a movement to address this. At the meetings I've attended, I've met acupuncturists-in-training in colleges that are operating free clinics here in Los Angeles. They're trying to get into places that are maybe not otherwise accessing such things.

There's a sense that wellness or some of the things I have been trying to be the cheerleader for are expensive or inaccessible. There's this branding with yoga and with wellness, that you have to go to a spa, buy pricy mats and yoga clothes, and adopt a very expensive diet. Really, it's about lifestyle choices that people can integrate into their daily lives on this pathway to really thriving and getting better.

I think when you meet people where they are culturally, you've actually started part of the dialogue to really help with breaking down some of these disparities. That lifestyle choice has to be culturally specific. Something I'd prescribe at UCLA for a 40-year-old White mom who has a lot of resources is going to be very different from what I would prescribe for a Latinx veteran who's in his 60s and might be a new grandfather, as it would for somebody in their 90s who might be in assisted living and may be Black. I'd recommend finding out what brings patients joy and meaning, understanding the cultural context, learning the things they like to do, and then figuring out ways to build those into their daily life.

So much of medicine has become "take this pill" or "have this surgery" that we've kind of forgotten about all the things that actually make us feel better when we're sick. For different people, this is my mom and her hugs, a nice bowl of chicken soup, baking cookies with your grandchild. It's about understanding that these lifestyle things that we all probably do in our day-to-day and gravitate towards when we're feeling not so well, are a part of wellness. It's about bringing in those lifestyle choices and helping guide patients to feeling better. When they feel like have self-agency in their own wellness, then they actually feel much better.

It's not just giving them a pill and saying come back in 6 months or prescribing surgery. It's really about asking, "What do you do every day? What makes you wake up in the morning? What do you want to do to really fill your plate with things that bring you joy, meaning, and a good quality of life?"

We have the ability to hopefully guide that. I think in medicine, we've forgotten that a little bit. And it can be accessible even in the face of disparities. We just have to find cultural ways to make these accessible.

Of course, there are systemic problems. But if we can at least start conversations, we understand people and they can understand that we understand them, I think we can start breaking down these barriers where there's mistrust, or a sense that the doctor doesn't get what I'm doing at all and has no clue where I live. We can start the conversation there.

LaFaver: Bringing the joy back into medicine. I think I'm all for it.

Thank you so much for taking the time and joining me for this conversation. And thanks everyone for listening.

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