We try to do more of a whole person, mind/body/spirit approach in terms of getting a deeper history.
Shad Marvasti, MD, MPH
Arizona Physician sat down for a more in depth discussion on integrative medicine with Shad Marvasti, MD, MPH, Medical Director at HonorHealth Integrative Medicine Clinic and Associate Professor, University of Arizona College of Medicine Phoenix. Dr. Marvasti is also Founding Director of the Wellness, Integrative Medicine, and Nutrition Certificate of Distinction and the Culinary Medicine program at UACOMP. Dr. Marvasti brings a unique perspective to understanding the integrative approach to medicine. He draws on both his experiences in private practice and at the hospital setting.
ARIZONA PHYSICIAN: How would you describe integrative medicine?
DR. MARVASTI: It's a whole person approach to health that includes all aspects of lifestyle and emphasizes the therapeutic relationship between the doctor and the patient. It’s evidence-based and uses all appropriate therapies that are safe and effective both on the conventional side as well as the complementary side. So really, it's kind of the best of both worlds. Let's say you present with diabetes. I'm not only going to look at potential medications or medical tests. I'm also going to look at food prescriptions, exercise prescriptions, other lifestyle changes that you can do. We’ll examine your whole life as part of the care, which includes the social, behavioral, and lifestyle determinants of health. Integrative medicine is the place where you can really achieve wellness and get the tools that you need.
ARIZONA PHYSICIAN: Are patients or other physicians demanding this approach?
DR. MARVASTI: Many hospital health systems are now recognizing the role of employee wellness to prevent burnout and to improve healthcare worker well-being. Integrative medicine really connected well with that. They also did focus groups in the community where they found that there's a number of people asking for these types of services but not able to get it at their doctor's office. Patients are also not able to use some of their insurance for this care. Having that accessibility, having that integrated into the healthcare system, came from a lot of different angles that aligned with HonorHealth and requests from patients and doctors.
ARIZONA PHYSICIAN: There is a lot that may go into visits with the patient to get to root causes of illness. What are the range of services that your team offers?
DR. MARVASTI: An integrative medicine doctor will spend about one hour with you for that initial intake, and we have patients fill out a longer, more involved history. We ask about what's most meaningful and purposeful in your life. We ask details about your diet, sources of stress, how well and how much do you sleep, what your goals are in terms of your health. We try to do more of a whole person, mind body spirit approach in terms of getting a deeper history and then we review that with you and come up with a plan in terms of next steps. Then, we have 30-minute consultations as follow up with the physician. We also have a registered dietitian, a health coach, a massage therapist, an acupuncturist that also includes traditional Chinese medicine recommendations. These modalities blend to empower the patient with tools to make behavioral changes that are impactful. A primary care physician or a specialty physician may want you to do some lifestyle changes, but they don't have the time to go deeper. We have the bandwidth. We have the interdisciplinary team to help patients with very practical next steps in terms of eating, exercise, mindset, improving sleep, and managing stress.
ARIZONA PHYSICIAN: Do patients want the longer sessions with physicians and an interdisciplinary approach or do they want to rush through appointments?
Dr. MARVASTI: The average visit with a doctor is around 7 or 8 minutes. It's like opening the floodgates and suddenly feeling relief to be able to share your story and to be heard. A big piece of feedback I get is the initial visit is therapeutic. Because you have a doctor who is willing to listen and talk to you about all these other aspects of your health that you know may not have been able to ever be examined because there was no time.
ARIZONA PHYSICIAN: At what point do patients turn to integrative medicine?
DR. MARVASTI: We see a wide range from young adults and late teens to elderly in their 70s and 80s. It could be a variety of things. It could be some with a chronic condition like diabetes or heart disease. Someone with chronic pain, someone with digestive issues or allergies, or questions about optimizing their health. Maybe they are an athletic type, but they want to take things to the next level.
ARIZONA PHYSICIAN: What are some of the strengths of integrative medicine versus the more traditional approaches to medicine?
DR. MARVASTI: When you look at the diseases of our time, they account for seven out of every 10 deaths and 77% or more of all healthcare expenditures. These are conditions that don't happen quickly. A heart attack is the result of decades of chronic inflammation and narrowing of the arteries. There are many points where you can intervene through diet and lifestyle to prevent that from happening. A lot of what we do in conventional medicine, unfortunately, is very limited to either medication or some kind of procedure or surgery. And that's often when the disease has progressed to the point where you need more aggressive measures, and they don't come without side effects. When you can avoid those things or minimize those things or you can begin making effective lifestyle changes by using the science of behavior change, then we do a fair amount of deprescribing of medications. I think you reduce the burden of those approaches, and it can be much more cost effective when people start taking a proactive role in their health as opposed to waiting until disease sets in.
ARIZONA PHYSICIAN: Are there one or two areas in which you believe that integrative medicine needs to improve?
DR. MARVASTI: We need to improve the availability of integrative medicine within hospital health systems. I really feel like they have a central place to be able to address chronic diseases, as well as some of the medical mysteries and more complex conditions like chronic fatigue syndrome or irritable bowel syndrome. We want to be about health promotion and prevention and then really look at maximizing our lifestyle approaches as opposed to that being the last thing that we do. The other challenge is being able to get reimbursement by health insurance.
ARIZONA PHYSICIAN: Describe billing and how insurance carriers respond.
DR. MARVASTI: You can either bill for time or you can bill for the complexity of a visit. I think we go back and forth in some instances. Billing for time makes a lot of sense, but then there's other cases where the medical complexity of the case fits better. We can get reimbursed for that extra time spent counseling and reviewing medications or charts. I think ours is really a hybrid model. Some services like acupuncture and dietitian and massage may not be covered. We are working to use reduced rates compared to what's out there in the community or package services to make them more accessible.
ARIZONA PHYSICIAN: Are there innovative approaches you’re trying?
DR. MARVASTI: The cool thing about our approach is that we're trying to cater to all backgrounds, whether you're someone who's highly affluent and wants to optimize health or you’re someone who is food insecure. The other innovation is we do shared group visits. Food is Medicine is one group visit that we do mostly with AHCCCS patients who are food insecure. We partner with Desert Mission Food Bank to bring in fresh produce. We're also looking at innovations in resident education, as well as medical students. We’re going to pioneer group visits for diabetes with clinical pharmacy and our registered dietitian.
ARIZONA PHYSICIAN: There was a recent New York Times article that focused on moral injury for physicians. Physicians want to see better outcomes for patients and have a more active role in shaping care. Do you see that integrative medicine is helping to close that gap?
DR. MARVASTI: Absolutely. We focus more on helping to empower the patient and teaming up with them to make these lifestyle changes and not just churning and burning through giving a medication and then moving on to the next. You feel more satisfied because you're making a meaningful connection with the patient. You're seeing them make strides in their life. You get away from the pessimism of seeing a patient and predicting the repeat visitors because nothing's changing. It's better to do a deeper dive with motivational interviewing and see why they wanted to do this, like they wanted to be around for their grandchildren's graduation, and they found whatever was purposeful and meaningful in life and motivated them to change. And then they come back with gratitude. That's a positive experience as a physician.
ARIZONA PHYSICIAN: Are you seeing the patients listening, adopting, and making the changes?
DR. MARVASTI: For the most part, we do see that. Obviously, trying to make changes is not easy. You gotta do the work when it comes to diet and lifestyle. Because people are coming to us for a consultation, they're motivated to listen and try to make those changes as opposed to when I was doing primary care, it would be a little bit of a mixed bag.
ARIZONA PHYSICIAN: What do you hear from other docs around the valley about integrative medicine?
DR. MARVASTI: There's a range. Some are excited and want to know more. Others question what it is and believe medicine should just be medication or surgery. We should work as part of an interprofessional team and there’s no question the physician is the quarterback. Patients respond to physicians. I use this analogy for my medical students. Regardless of the smoking cessation intervention, adding just one physician who says to the patient, “The best thing you can do for your health is to quit smoking and I highly recommend you quit smoking,” makes the intervention much more effective. To me, it shows the power of the physician to make an impact. I tell patients, “What you eat matters. How you sleep matters. The relationships in your life matter. How you manage stress matters and let me tell you how to manage it.”
Meet Dr. Shad
Farshad (Shad) Fani Marvasti, MD, graduated from the University of Arizona College of Medicine, Tucson, and completed the Stanford-O'Connor Family Medicine Residency at O'Connor Hospital in San Jose, CA. He has been practicing since 2010, first in private practice and now with HonorHealth, and teaching students at the University of Arizona College of Medicine —Phoenix. You can reach him at doctorshad.com.