An Integrative Approach to Gastrointestinal Health
Diarrhea? Constipation? Tummy Troubles? Well, then, this post is just for you! I originally wrote this piece for my old blog and loved it so much that I decided to recycle it. A little bit of an update… Dr. Yeh has now become a dear and close friend. Her enthusiasm for integrative medicine, dedication to patient care and teaching and generous spirit make her a truly special friend and colleague.
Last week I had the enormous pleasure of sitting down to breakfast with a new friend, Dr. Ann Ming Yeh. She is a Stanford trained pediatric gastroenterologist with a focus on integrative approaches to diagnosing and managing a variety of pediatric GI conditions.
Dr. Yeh is a warm, kindhearted and extremely knowledgeable physician with a holistic approach. If you are fortunate enough to live in the Bay Area, you can make an appointment for your child to be seen by Dr. Yeh. If not, though, don’t fret. Here is a slightly abbreviated version of our breakfast conversation that nearly collided into lunch. I’m hoping that this post will provide an introduction to integrative medicine and help us to better understand the role it can play in our family’s health.
What is Integrative Medicine?
It’s a way of treating patients that uses scientific evidence to figure out the best way to approach a patient’s problem, whether it be through alternative modalities such as acupuncture or mind-body medicine, botanicals, herbs, supplements and working with patients in a holistic, rather than a reductionist way. So, even though I am a gastroenterologist, from an integrative standpoint, I still may look at a patient’s sleep in terms of their abdominal pain to get a whole picture of might be going on.
So should integrative medicine be a part of medical training?
IM is good medicine. Ultimately, I don’t think that it should be seen as a separate entity but rather a part of general medical care. But the key is that it has to be evidenced based. Otherwise, there’s no way to know if a particular treatment is safe and effective. It has to be validated through research and not just anecdotal.
How do your integrative visits differ from your “regular” clinic visits?
I think because of my training, I do pull in some of the elements from IM for my regular clinic visits but the limiting factor is time. For a typical IM intake, it’s about 90 minutes for the initial visit, which includes reviewing their medical history but also diving into their social environment, stress, physical activity, nutrition and sleep. I evaluate all of those components. If I have the time, I will even delve into Traditional Chinese Medicine (TCM).
What does a typical patient in your IM clinic look like?
There isn’t necessarily a “typical” patient but I tend to get referrals from other specialists when they have run out of options, when they “have tried everything” or there is no identifiable problem so to speak but the child is not functionally well.
How successful do you end up being with your IM patients?
It depends on the underlying issues. It’s often difficult to study because it’s a multi-pronged approach because you are treating the whole patient but we have been quite successful for patients with dyspepsia and nausea. In terms of more generalized, functional abdominal pain, the picture is a bit muddier and it can sometimes be not as successful.
How long do you typically see a patient for?
Initially, especially if we are using acupuncture, I will see the patient pretty frequently, about every week or every other week. As they improve, the treatments are spread out to every 2 to 3 months for more of a maintenance visit. Most of the time I am co-managing patients with the referring physician.
What side effects to you see with some of these alternative modalities?
In terms of the botanicals, they are fairly safe but I do advise on certain side effects. For instance, I often use ginger to treat nausea but it does act as a blood thinner. So it’s important to let patients know, especially if they are going in for any sort of surgical procedure. I remind them that it is a medicine, and they should treat it as such. The most common side effect seen with acupuncture is a little bit of site irritation from the needle, which is actually quite small. What we are aiming for is a dull achy pressure and sometimes that pressure can linger for a bit. The complications (bleeding, hematoma) are extremely rare but I do review them.
Do you find that acupuncture is one of the more commonly used tools from your “IM toolbox”?
It depends on what the patient needs, but it’s a modality where I can see the problem in a completely different light. Even when, from a conventionally medical standpoint, everything “seems normal”, I can evaluate their tongue, their pulse, do a history and see that they have 5 imbalances — there’s always something to treat. From a TCM standpoint, you are a good doctor if you can prevent illness. When you have organic manifestations, you’ve already failed in a sense. The other thing that’s been huge in my practice is relaxation response and I will often refer patients for hypnosis or to see a psychologist.
Have your colleagues been at all skeptical of your approach?
There’s a spectrum for sure. I’m fortunate that my division chief is supportive. It requires a bit of a cultural shift as well. 15 years ago at Stanford, people hadn’t really heard about acupuncture. Now, 5 or 6 of the anesthesiologists at Stanford are trained in acupuncture. In fact, the culture has shifted so much that you can actually get a pain consult in the PICU and the patient can get bedside acupuncture. So things have really changed in the last 10 to 15 years. People have a reason to be skeptical because there is a lot of misinformation on “Dr. Internet” out there but IM is an evidence based approach.
I’m assuming that not many physicians offer or are trained in acupuncture. What is the difference between a physician vs. a non-physician offering these services?
There is a huge spectrum of training. A licensed acupuncturist may not know some of the medical issues associated with certain conditions. On the flip side, I’m very focused on the medical conditions I treat and so I don’t really treat conditions like headaches and back pain. So the benefit of going to an acupuncturist is that that’s all that they are doing and they are very well equipped to treat a variety conditions with needles.
What would you recommend for patients who are unable to find physician practices that offer these types of services and are interested in learning if acupuncture can help their child?
The most important thing is that it has to be done in a safe way. Parents should look for the initials “LAC” after an acupuncturist’s name which indicates that they are a licensed acupuncturist. I would be wary of any provider that recommends stopping medical care or encourages a patient to stop seeing their physician. If there is a physician practicing acupuncture, there is board, the American Board of Medical Acupuncture, which offers a diploma in medical acupuncture (DABMA) and ensures that that the person has been adequately trained. In terms of whether or not acupuncture can be helpful for their child, it depends on the specific problem. In general, though, acupuncture is very safe.
What do you think is the biggest misconception about acupuncture?
In the medical community there is a bit of skepticism around the efficacy of acupuncture. It’s understandable in the sense that “sham” acupuncture has been shown to provide relief from pain, presumably via the “placebo effect”. But, truthfully, I’m a believer in the placebo effect if it can benefit the patient. Ultimately, though, I think that acupuncture should be viewed as just a part of medical care, with communication back and forth, just as with any other specialty.
Is there a movement to bring medical acupuncture to medical training?
There is a movement to bring IM to medical training and residency training. Just the basics, so that at a minimum, even if as a physician you are not practicing it, you are able to talk about it with your patients, know what’s safe and what’s not safe, how to read a supplement bottle and knowing about available resources to check for drug interactions, etc.
What resources can you recommend for physicians and for families to not only learn more, but to determine the safety of these modalities?
If it’s a supplement, Consumer Lab, is a great resource that tests for the quality of various products. In terms of safety, Natural Medicines Database, is fantastic and I use it all of the time. It has an interactions checker and provides a monograph as well as references. It requires subscription for access but the NIH also has information on their site.
So, to conclude, do you have any final recommendations for parents in terms of maintaining good overall GI health?
Oh gosh! There’s a lot to cover there. Whole, non-processed foods – more of a plant-based diet. There are so many interesting studies about inflammatory bowel disease (IBD) and the effects of more Westernized diets in terms of going from traditional diets, as with for example, in Japan of rice, vegetables and some fish to more McDonald’s and other fast foods. The rates of IBD go dramatically up. Of course it’s multi-factorial but I’m a huge proponent of organic, whole foods, trying to “eat the rainbow”. In terms of probiotics, I don’t generally recommend a daily probiotic for good health. But, there are certain strains of bacteria that can be helpful for colic or irritable bowel syndrome. In terms of the gut microbiome, we are still at the tip of the iceberg with regards to what we know and what we don’t necessarily know if it’s going to be helpful or not so I try to stick with what’s been studied. The American Gut Project is working to answer how diet and lifestyle shape our gut microbiome. If you want to participate, they will send you a kit to swab your cheek, skin and stool and they will tell you how diverse your own microbiome (and even that of your pet!) is. They are finding that the more diverse your gut microbiome is, the better. So eating fermented foods, working in the garden, having pets, all of these things can potentially improve your health. On the other hand, antibiotics narrow it and other factors such as processed foods can sway your microbiome in a different direction.
Ok, so really last question. What are your go to references and resources for IM?
In terms of herbs, I really like Tieraona Low Dog’s Healthy at Home. It offers a very balanced approach in terms of when you might need to see a doctor vs. using eucalyptus steam bath to treat upper respiratory infections. Integrative Medicine is such a broad topic but Andrew Weil’s books offer a great overview.
Truly, I learned so much from our conversation. Integrative approaches make sense, not only in terms of GI health, but for overall health and well-being. There is so much information out there that it’s sometimes difficult to separate science from quackery. Whether it be the use of botanical and herbal remedies, acupuncture, the significance of our microbiome or the mind body connection — I think the key is to be open-minded while at the same time remain inquisitive enough to explore new data and research. I’d love for patients and physicians to be able to discuss whatever alternative therapies they may be exploring in a collaborative way. As a physician, I know that I don’t have all of the answers and I hope that I remain curious enough to explore.
In addition to resources mentioned throughout, I am providing a couple of links to some talks that I found to be useful and are worth a listen. I know that I covered a lot and as Dr. Yeh mentioned, it’s just the tip of the iceberg.
TED talk by Rob Knight: How are Microbes Make Us Who We Are
Live Dirty, Eat Clean: Why the Microbiome is the Future of Medicine
60 Minutes: Mindfulness Featuring Jon Kabat-Zinn
Consumer Lab: information on the quality of supplements and nutrition products
Natural Medicines Database: clinical information on complementary, alternative and integrative therapies