Integrative Medicine's Pragmatic Mission

David Rakel, MD


J Participat Med. 2013;5 

In This Article

Abstract and Introduction


"By far the most frequent drug used in general practice was the doctor himself. It was not the bottle of medicine or the box of pills that mattered but the way the doctor gave them to his patient."
–Michael Balint, Introduction to the Doctor, His Patient and the Illness.


Integrative medicine was not born from the medical establishment but from public interest. In the mid-1990s, there was a growing frustration with health care's overdependence on the use of therapies to suppress symptoms while not recognizing self-healing mechanisms. Public surveys found that many viewed complementary and alternative medicine (CAM) to be more aligned with "their own values, beliefs and philosophical orientation towards health and life than traditional medicine."[1] This started a growing interest in CAM and encouraged the medical establishment to not only focus on what is wrong with the body, but to also recognize what is right with it.

Definition of Integrative Medicine:
Integrative medicine is defined as healing-oriented medicine that takes account of the whole person (body, mind and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative. [2]

This "salutogenic" (saluté=Italian word for health, genesis=creation of) approach[3] requires robust research models to look at the outcome we want to achieve. The traditional randomized placebo controlled trial (RCT) that controls for belief and expectation (placebo) is good for measuring the intrinsic effect of a drug, herb, or diet plan. But, if we want to know how to influence patient outcomes, we have to include the nonspecific variables that these trials try to remove. A nonspecific variable is the context from which the pill (specific effect) is prescribed. It includes the importance of relationship, expectation, and belief. The pragmatic controlled trial (PCT) looks at how all the variables (specific and nonspecific) affect the outcomes we want to achieve.[4] This requires the participation of complex human beings and recognizes the parts of the therapeutic ritual. This is true for both CAM and conventional treatment.

Approximately 38% of Americans use CAM treatment. Low back pain is the most common condition for which CAM therapies are used.[5] Low back pain is also the most expensive condition in primary care practices.[6] Despite a significant increase in spending to treat this condition, there has been little improvement in outcomes over the past decade.[7] We will use low back pain as an example of how a particular CAM therapy (eg, acupuncture) could be used to its fullest potential as we explore the contextual effects of the therapeutic ritual.