Finally, there are intangible elements to integrative medicine, such as those that are a part of noetic therapies. Noetic therapies, what the National Institutes of Health call "frontier medicine," are widely practiced medical therapeutics for which there are no plausible explanations, including spiritual- or prayer-based practices, says cardiologist Mitch Krucoff. "Every physician has had a patient who physiologically should have died, but didn't. These patients frequently appear to have a vital link that wouldn't 'let' them die--and you usually don't have to look far to find a friend or family member, religious verse, or photo of a new grandchild."

Hand-to-hand harmony: stretching is essential in yoga photo by Chris Hildreth

The opposite is true, as well, he notes: Patients without those vital links often don't seem to do as well physically or emotionally. "This phenomenon has led us to look at the human spirit as it relates to cardiology," he says. "In addition to applying Duke's world-class, high-tech cardiology theater, we're now examining the role of internal resources patients may have to help themselves when they have cardiac problems, undergo procedures, heal, and recover."

"Because the human spirit is a potentially critical contributor to their outcomes, we're very interested in the spiritual aspects of intervention so that we can best care for our patients," Krucoff says.

That's the rationale behind Duke's MANTRA (Monitoring and Actualization of Noetic Training) studies. Launched with a 1995 pilot program at the Durham Veterans Administration Hospital by Krucoff and nurse practitioner Suzanne Crater, MANTRA includes patients who have or had blocked coronary arteries and who, like many cardiac patients, are facing their own mortality. The results of the 150-patient pilot study, which integrated noetic (spirit-related) therapies like guided imagery, breath control, touch therapy, and off-site prayer with traditional ones, were promising. Patients receiving noetic therapies including off-site prayer in addition to their standard treatment had 30 percent fewer complications overall; those who were treated with the double-blinded, off-site prayers from eight prayer groups around the world had 50 percent fewer minor complications and 100 percent fewer major complications.

Krucoff stresses, however, that while data consistently suggested that noetic therapies are beneficial, the pilot study was too small to be statistically definitive, and may not be generalizable to other health-care settings. That's the reason for Phase 2 of the study, launched in 1999 to examine the roles of music, imagery, and touch therapy in cardiac care. Krucoff says Phase 2 already has more than 500 participants and can include up to 1,000 more.

"We can see the world of the tangible and the procedural, but when it comes to the intangible--things whose mechanisms we may not fully understand--the only thing we can do is measure clinical outcomes," he says. "An incomplete understanding of how or why the human spirit works isn't a place to stop thinking or conducting research about it."

This philosophy is widely shared throughout the medical center, he adds. "At the highest levels, Duke's vision as an institution is to re-define the optimal healing space for human beings by combining the best in cutting-edge technology with awareness, cultivation, and activation of the rest of the human being. We consider this the most fertile ground for the next real advance in health care."

As with anything outside the borders of traditional medicine, research, education, and mainstream support are crucial to the continued growth of integrative medicine. A $1-million Centers for Medicare and Medicaid Services grant awarded to Duke last year will launch a two-year pilot study to better define whole-person health care and examine ways people can strategically implement integrative health planning into their lives for improved health.

Duke also offers students integrative-medicine curriculum options. The School of Nursing offers a health and nursing ministries master's degree designed to prepare nurses to serve as medical professionals as well as promoters of whole-person care in specific faith-based communities. And the medical school's integrative medicine program includes monthly body-mind case correlation dinners, CAM lectures, and courses that teach students to take an integrative approach not only in caring for their patients, but in caring for themselves.

"Education is critical if we're going to train the next generation of health-care providers to think in this integrative model," says DCIM education consultant Pali Delevitt. "It's not about replacing one set of modalities for another; it's about exposing Duke medical students to integrative-medicine practitioners who are successful and teaching them to think holistically, to view illness and healing from other paradigms.

"Traditional belief systems are not the final word. The history of medicine shows that how we answer the question 'What is science?' continuously evolves due to new knowledge. Integrative thinking is a philosophy that's about looking inward and outward, and practicing healing, not just practicing medicine--and this is what students are clamoring for. They see integrative medicine as an opportunity to grow, create community and personal wellness, and stay balanced as they study and practice medicine."

Besides Duke's support of integrative medicine, interest from the larger arena is growing. One example is the November 2001 launch of a joint frontier medicine program by the National Institutes of Health and the National Center for Complementary and Alternative Medicine. "Public interest in integrative medicine is so intense, and health-care issues so important, that the federal government, in the absence of industry support, is now supporting integrative medicine," says Krucoff. "That's a huge step forward."

But there are still many challenges to bringing integrative medicine to the fore. Standardization in the practice and licensing of CAM has yet to happen. And although some major insurers are beginning to subsidize CAM services, most Americans must pay out of pocket for them.

What can the average person--the average patient--do? "People must vote with their feet about their health-care choices, by speaking to their employers about the plans that are offered and by making sure they relate to their physicians as partners in their health care," says Snyderman. "Involvement of the patient in their care is absolutely key, and this is the type of health-care delivery we are trying to make available at Duke.

"Seventy-five percent of health-care costs are spent treating chronic diseases, often at a late stage. We have the ability to make a big impact in the prevention and treatment of chronic diseases--and therefore to improve the overall quality and cost of health care--because so many of these diseases are impacted when people modify their behaviors. We need to jump-start the solution to the problem of effectively treating chronic disease. And that's why Duke is involved in creating a national platform to find out what really works in this field."

Will alternative therapies become a standard, accepted piece of America's medical landscape? "My hope is that through Duke's widespread support of and involvement in integrative medicine, we can foster a mindset of wellness and involve patients in their own health care," says Snyderman. "We must give patients the full range of what they need to improve their health. We must do so by recognizing each one as an individual in his or her own life setting and by engaging them in their own health care. If we don't do this, we're providing only a small segment of what patients expect and deserve from a system that is supposed to be working with them to improve their health."

--Lyttle is a Triangle-based freelance writer.