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The complex web of health and disease

There are multiple factors that can influence our patients' health and GPs should not just rely solely on evidence from randomised clinical trials, explains our new blogger Dr Karine Nohr.

It's 4pm for me, midnight for you, and I'm on my way back from Arizona where I have the tremendous good luck of undertaking a two year Fellowship in Integrative Medicine.

My day job is as a GP in North Sheffield and it is there that I try to sandwich integrative medicine into normal (aka stressful) GP life.

For those of you not familiar with the term, integrative medicine can be described as incorporating a comprehensive person-centred approach that includes physical, psychological, spiritual, therapeutic, preventative and social aspects of what makes a person healthy, embracing a wide range of interventions that encompasses usual care as well as unconventional care and that manages, maintains and restores health.

There is a growing groundswell of support for integrative medicine in the States, not least because their healthcare system is becoming increasingly unsustainable. Despite per capita expenditure at least as twice as high as the average for other Western nations, the USA ranks far down the global list in its population's health, and it is lifestyle diseases; hypertension, CVD, Diabetes, asthma and depression that accounts for half of its expenditure.

On the one hand, there are 45 million Americans who have no health insurance at all. At the other end of the economic spectrum, the level of intervention is so high that stents are being fitted into patients who have no symptoms of angina and women in their early 30's are freezing eggs, ‘just in case'. US Congress experts estimate that one third to one half of expenditure in health has little to do with improvements in health.

In the UK, spiralling health costs and economic difficulties demand continuous critical review. Moreover, the find-it-and-fix-it approach to healthcare has too many shortcomings that frustrate both patients and healthcare practitioners.

Additionally, there are other contributors to ill-health (e.g. within the environment, employment issues, education and food policy) that are beyond the remit of the healthcare services but need to be considered in any joined-up national approach to well-being.

Clearly there are many more dimensions to health and disease than can be measured in an RCT, the importance of psychosocial factors, such as loneliness and unemployment, that can impact on a persons susceptibility to disease.

The huge complexity of the multifactorial nature of ill-health demands a different kind of examination than the limited reductionist approach of the RCT, designed to examine the effect of one factor, such as a drug, where all other factors are constant.

Other research methodologies are required in order for us to evaluate, for example, lifestyle interventions. The whole is greater than the sum of the parts, there are multiple interconnections and there is a danger of overfocussing, that loses sight of the wood for the trees.

We all want evidence, and that is no bad thing. We want to know the usefulness of an intervention, be it conventional or not. Often we may know intuitively that something is right, but not necessarily know why. Sewage and drinking water were separated before the discovery of the ‘germ'. Though discovery of the germ did give credibility to the sanitationists.

Integrative medicine accumulates evidence by studying multiple factors. It takes a holistic approach, looking at synergistic and systemic effects. Additionally, as doctors, we increasingly recognise the potential of mobilising the patients themselves in their own self-care, both at preventative and interventionist levels.

My Integrative Medicine Fellowship takes a holistic approach to health-related issues and also examines what other modalities may have to offer. I hope to share some of my learning with you in this new blog. I'll be balancing this along side my day to day work as a GP and hope that I can transmit some of my enthusiasm for this approach as I go along.

Dr Karine Nohr is a GP in Sheffield

GPs should not just rely solely on evidence from randomised clinical trials, explains our new blogger Dr Karine Nohr