Medicine’s Wellness Conundrum
The New Yorker – November 2021
Author: Jessica Wapner
Michelle didn’t yank Toby’s socks off from the toes. She rolled them down from the calf, using both hands, pausing to cradle each newly bare foot. She gently ran her hands up and down Toby’s exposed shins. She touched one of Toby’s wrists to feel her pulse, and pressed the tips of her thumbs between Toby’s eyes and at her ankles for a few seconds at a time. Sometimes, she held a hand an inch or so above Toby’s skin, then moved it through the air, as though dusting an invisible shelf.
A soft cap warmed Toby’s nearly hairless head; the waxen pallor of chemotherapy hung on her face. She was in the middle of a yearlong course of treatment for early-stage breast cancer, at New York-Presbyterian/Columbia Hospital, in Manhattan. A few months earlier, Toby, who lives in New Jersey, had undergone a double mastectomy and begun chemotherapy.
When the chemo made her nauseated, and the nausea medication only made her feel worse, she began meeting weekly with Michelle Bombacie, who manages the Integrative Therapies Program at Columbia University Irving Medical Center, for a mixture of acupuncture, acupressure, light-touch massage, and Reiki.
“Wellness” is an umbrella term. It can be used to cover forms of traditional Chinese medicine, such as acupressure and acupuncture; aspects of the Indian tradition Ayurveda; and more recent inventions like Reiki, which involves pressure-free caressing and non-touch hand movements. It can also encompass nutritional counselling, herbal supplements, exercise, homeopathy, massage, reflexology, yoga, touch therapy, art therapy, music therapy, aromatherapy, light therapy, and more.
“The wellness movement is one of the defining characteristics of health care in this era,” Timothy Caulfield, a University of Alberta professor focussed on health and science policy, told me. By some estimates, the wellness industry, loosely defined, is worth over four trillion dollars.
Wellness is often presented as an alternative to the modern medical system, and is pursued in spas or other dedicated spaces. But, in recent years, hospitals have begun embracing it, too. By one estimate, around four hundred American hospitals and cancer centers now host a wellness facility of some kind; most offer services aimed at stress reduction and relaxation, but many also promise to help patients improve their energy levels, strengthen their immune systems, and reduce chemotherapy-induced fatigue and nausea.
A few provide fringe services, such as apitherapy (which uses bee products, such as honey or venom), or promise to adjust patients’ life force. Cancer patients are particularly drawn to what’s known as complementary care: up to ninety per cent use some service that falls under the aegis of wellness. At some of the country’s top health-care institutions, patients can receive chemotherapy in one wing of the hospital and, in another, avail themselves of aromatherapy, light-touch massage, and Reiki—interventions that are not supported by large, modern studies and that are rarely covered by insurance.
The commingling of medicine and wellness has been alarming for some physicians. “We’ve become witch doctors,” Steven Novella, a neurologist at the Yale School of Medicine, told the medical Web site STAT, in 2017. Patients at such centers are “being snookered,” Novella argued, and hospitals commit an ethical error in offering services in wellness centers that they would eschew on their medical floors. (Novella is the founder of Science-Based Medicine, a Web site dedicated to debunking alternative therapies.)
Many physicians find Reiki particularly unnerving: practitioners of the technique, which was invented in Japan in the early twentieth century, move their hands on or over the body, ostensibly to shift the flow of energy within it. In 2014, in an article in Slate, the science journalist Brian Palmer reviewed the literature on Reiki and found no evidence that it worked—it was, he wrote, “beneath the dignity of a great cancer center” to offer it.
On the other hand, some doctors support the provision of wellness interventions—even those not backed up by rigorous studies—as long as they do no harm and don’t replace medical care. And many patients feel that such interventions help them. After Toby started seeing Michelle Bombacie, her nausea disappeared, and she became energetic enough to care for two puppies. “I know something changed within me,” she told me.
Although Toby didn’t have strong views about how Reiki works, she described the experience with Bombacie as critical to the success of her treatment. “It gave me the tools to work on my mental health and spiritual health, and to shift my focus from being out of control and kind of helpless to having more trust in myself and my doctors,” she said. Kim Turk, the lead massage therapist at Duke Integrative Medicine, told me that she considers Reiki practitioners to be facilitators who “support people’s own healing.”
Patient satisfaction matters to hospitals—Medicare penalizes them for low satisfaction ratings. Massages and yoga may make patients happier and keep them coming back. “Hospitals are banking on the fact that treating you in a more humane way will make you want to stay as a customer,” Thomas D’Aunno, a New York University professor whose focus includes health-care management, said. And yet medicine, if it is to function, depends on trust.
Hospitals are supposed to be bastions of evidence-based care; wellness treatments don’t meet that standard. Can the best of wellness be brought into the hospital without compromising the integrity on which health care depends?
The term “wellness,” as we use it today, dates roughly to 1961, when Halbert L. Dunn, an eminent biostatistician and former head of the National Office of Vital Statistics, published the book “High-Level Wellness.” Dunn took his cue from the constitution of the World Health Organization, ratified in 1948, which redefined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
Wellness, he wrote, was about functioning better over time—having an “ever-expanding tomorrow.” This inspirational idea found a broad audience. In the nineteen-seventies, so-called wellness centers began offering fee-for-service therapies; in the following decades, corporate wellness programs subsidized gym memberships and meditation classes.
The new concept dovetailed with an ongoing medical story. American doctoring in the nineteenth century, as the medical historian Norman Gevitz has written, was “characterized by poorly trained practitioners employing harsh therapies to combat disease entities they understood insufficiently.” As a result, osteopathy, homeopathy, and chiropractic techniques attracted educated, conventionally trained physicians who were frustrated with treatments that didn’t seem to work.
Mainstream doctors readily embraced what we’d now call “alternative” therapies until 1910, when the Carnegie Foundation asked Abraham Flexner, an education reformer from Louisville, Kentucky, to report on the state of medical schools in the U.S. and Canada. Flexner evaluated a hundred and fifty-five medical schools according to the standards of the German medical system, which emphasized rigorous research; in his report, he warned of rampant “charlatanism” and “quackery,” and called for an end to treatments that weren’t evidence-based. Many medical schools closed soon after the report was published.
The Flexner Report ushered in the modern era of American medicine, in which interventions are based on reliable evidence. But Flexner’s disregard for bedside manner and other intangibles had an unexpected consequence. “The profession’s infatuation with the hyper-rational world of German medicine created an excellence in science that was not balanced by a comparable excellence in clinical caring,” Thomas Duffy, a professor at the Yale School of Medicine, wrote, in a centennial history of the report. Physicians, Duffy argued, began to distance themselves from patients. It fell to nurses to provide the empathy that doctoring no longer facilitated, by comforting, massaging, listening, and expressing compassion.
Advances in technology further chilled the clinic. Medicine had long been synonymous with the laying on of hands—with diagnosis by feel and the use of healing touch. Patients, the medical historian Jacalyn Duffin told me, were essentially the authorities on whether they were sick; it was up to physicians to isolate the cause. The invention of the stethoscope, in 1816, shifted the balance. “You weren’t sick unless the doctor found something,” Duffin said.
By the end of the twentieth century, diagnostic devices—X-ray machines, MRI scanners, and ultrasounds—had made diagnosis increasingly objective while allowing doctors to conduct mostly touch-free exams. Abraham Verghese, an infectious-disease physician at the Stanford University School of Medicine, has written that, for doctors today, “the patient in the bed can seem almost as an icon for the ‘real’ patient who’s in the computer.”
These days, moreover, medical practice is focussed on efficiency. In surveys, most doctors say that they spend between nine and twenty-four minutes with each patient per visit. (This may be an overestimate.) One study has found that physicians listen to their patients for an average of eleven seconds before interrupting. There is a gap between what we want from health care and what we get. Wellness stands ready to fill it.
Lila Margulies, a high-school friend of mine, was diagnosed with lung cancer, in March, 2017. Forty-three years old and a nonsmoker, she underwent surgery, chemotherapy, and radiation before the cancer spread to her bones. She had already been interested in wellness—taking herbal supplements, visiting an acupuncturist—and the cancer deepened her interest in alternative approaches. Alongside her treatment, Lila adopted a diet that she believed would stop her cancer from growing, increased her supplement intake, and began working with an energy healer. Her friends contributed to a GoFundMe campaign so that she could afford the expensive healing sessions.
Lila was open with her oncologist about her extra-medical pursuits. She met regularly with her energy healer at his home, in Mahopac, New York, for sessions that combined conversation—he spoke with her about her fear of leaving her young children behind—with a cross-cultural mix of touch therapies. “All of it came back to energy and how energy moves in the body and between people,” Lila told me. Her cancer was stable for several years; last fall, she learned that it had begun spreading again. She continues to feel that her sessions with her healer were beneficial. “It was so tangible,” she said. “It made a huge difference.”
Research has explained some of the physical mechanisms that underlie our enjoyment of light touch. In the late nineteen-thirties, a Swedish neurophysiologist named Yngve Zotterman discovered nerve fibres in cats that respond to slow, gentle touch. In the nineteen-nineties, another neurophysiologist from Sweden, Åke Vallbo, working with other researchers, found that the same fibres existed in people.
The nerves, known as C-tactile afferents, or CT fibres, prompt not only a physical sensation but also pleasant emotions. Gentle stroking—at one to ten centimetres per second, with a hand or a body-temperature object—releases opiates, along with other chemicals that make us feel good. These relaxing effects originate in the manipulation of the skin. “There’s a specific receptor and a specific pathway,” Frauke Musial, a professor at the government-funded National Research Center in Complementary and Alternative Medicine, at the Arctic University of Norway, told me. Without touch, we never experience the feelings that touch causes.
Francis McGlone, a neuroscientist at Liverpool John Moores University, in the U.K., has argued that CT fibres help explain the psychologist Harry Harlow’s famous studies of infant monkeys, conducted in the late nineteen-fifties and early nineteen-sixties. Harlow’s team separated the infants from their mothers, then offered substitute mothers made of wire; one held food, while the other was covered in cloth. Most of the infants gravitated toward the cloth-covered substitutes, even when that meant going hungry. McGlone believes that the cloth “mothers” provided more CT-fibre stimulation. “This isn’t some hippie nonsense,” he told me. “This is an absolutely clear, instinctive need for physical contact.”
Feeling better, of course, doesn’t necessarily make you better. Researchers have struggled to design a randomized trial that can test the medical effectiveness of touch. “You cannot give someone a massage without them knowing it, or without the provider knowing it,” Irina Todorov, the medical director of the Cleveland Clinic’s Center for Integrative and Lifestyle Medicine, said.
A handful of robust studies have succeeded in linking touch to clinical outcomes: in a single study of four hundred and seven people with breast cancer conducted in North Carolina, for instance, those receiving therapeutic massage or healing-touch therapy reported relief of cancer-related pain; in 2014, researchers at the University of Pennsylvania found that, for two hundred and thirteen people who’d received Reiki sessions, the intervention reduced stress, anxiety, depression, and fatigue by more than half. Tiffany Field, the director of the Touch Research Institute, at the University of Miami’s Miller School of Medicine, has reviewed four decades of clinical research on moderate-pressure massage and is convinced that it is medically useful. “We know its profound effect,” she told me.
Ultimately, however, evidence for the medical benefit of touch is inconsistent, and medical authorities have embraced its clinical use only cautiously. In its guidelines, the American Society of Clinical Oncology, the leading professional cancer organization, describes “healing touch” as having “small” benefits, and massage as having “small” and sometimes “moderate” benefits.
In 2018, the Joint Commission, an organization that accredits hospitals, began requiring them to offer pain treatments that do not include opioids; among the approaches that the Commission recommended were meditation, music therapy, acupuncture, chiropractic, osteopathy, and massage.
If Flexner were alive today, he might refrain from applying labels like “charlatanism” and “quackery” to certain forms of touch therapy. At the same time, he would almost certainly object to many of the “alternative” narratives within which those therapies are framed. Meanwhile, Lila, for her part, was glad that her energy-healing sessions happened in a nonscientific environment with spirituality at its center. “I didn’t want to spend my life identifying as a patient,” she told me. The fact that wellness isn’t strictly medical can be part of its appeal.
Early in Lila’s treatment, her oncologist himself developed cancer. She tried to tell him more about her alternative regimen. He was supportive of her pursuits, but not inclined to try them himself. She recalled him saying to her, affectionately but decisively, “You do your witchy stuff—that’s not for me.” A sharp line existed between Lila’s medical treatments and her wellness experiences.
Toby, by contrast, received her wellness treatments from Bombacie on the hospital grounds; she lay on an examination table in a doctor’s office off a typical hospital corridor. Bombacie had put the blinds down, turned off the fluorescent lights, and switched on a dim, built-in desk lamp—an attempt to square the soothing vibes of wellness with the regimentation of medicine.
About fifteen years ago, Elizabeth Teisberg and Michael Porter—professors at the University of Texas at Austin’s Dell Medical School and at Harvard Business School, respectively—decided to see if they could achieve this on a larger scale, by devising a medical model into which wellness considerations would fit more seamlessly. “Hospitals traditionally provide acute care that is organized around how physicians specialize, rather than around the needs of the individual and family through the full cycle of care,” Teisberg told me.
As an alternative, she and Porter proposed the creation of “integrated practice units”—teams that include social workers, mental-health professionals, physical therapists, and nutritionists who work alongside doctors. About five years ago, the Musculoskeletal Institute at Dell Medical School began to adopt Teisberg and Porter’s model. Treatment there is organized around helping patients function in their lives, whatever that might mean—wellness, in Dunn’s sense—and staff members work in multidisciplinary, need-centric teams. The back-pain team, for instance, includes not just spine specialists but chiropractors, physical therapists, and social workers. Karl Koenig, the orthopedic surgeon who directs the Institute, told me that the group doesn’t judge itself by patient volume. “We measure how many patients we made better and how much better they are,” he said.
The Livestrong Cancer Institutes, also at Dell Medical School, have developed an even more expansive approach. S. Gail Eckhardt, L.C.I.’s director, told me that her team hopes to solve a core challenge of modern cancer treatment: although people now live with cancer for many years, hospitals still address it as a short-term illness. “They’re stressed out, they need therapy, they want nutritional advice,” she said, of today’s cancer patients. When those kinds of supportive services aren’t provided, “patients feel as if no one is looking out for anything other than the very strict medical component of their care.”
L.C.I., which opened in 2018, considers a wide range of interventions, including wellness services, as potentially valuable, and provides some while facilitating others. The cancer center has established connections with businesses and nonprofits in Austin that offer alternative therapies outside of the hospital; this approach allows a patient to see a genetic counsellor or psychiatrist on hospital grounds and then attend a yoga class or receive acupuncture at a partner facility.
The medical staff deliberately resists judging patients for their preferences, an attitude that they feel ultimately serves patients best. Elizabeth Kvale, L.C.I.’s founding medical director, recalled one patient, a woman with ovarian cancer who was determined to treat her disease solely through nutrition.
The woman had been scared off chemotherapy by what she’d read online. Some doctors would have declined to work with a patient who didn’t want to receive treatment. But Kvale agreed to provide her with tumor-marker tests, which could track the progress of her cancer, while the woman pursued her alternative route. “By virtue of being open to that—having dialogues about what was important to her—she ultimately decided she wanted to pursue more standard therapies,” Kvale said. Alternative therapies may not happen in the hospital, but the fact that conversations about them do makes a difference to patients.
Clarity and forthrightness are central to the model. The cancer center doesn’t sugarcoat medical opinion about unproven interventions. “We are honest about what we can and can’t recommend,” Eckhardt said. In their recommendations, staffers take into account not just the proven efficacy of proposed alternative treatments but their cost. Still, most of the time, the cancer center will try to find whatever a patient wants somewhere in Austin. “I think patients have to be empowered to make their own decisions,” Eckhardt said. “It’s not a paternalistic society where the physicians know everything.”
Whether these approaches are sustainable depends in part on insurance companies. At the Livestrong Cancer Institutes, insurance works as it normally does because the center itself coördinates wellness services without actually offering most of them. But at the Musculoskeletal Institute, patients or insurers make a single up-front payment each year that covers all the care they’ll receive. This bundled payment costs more than an exam with a single specialist but pays for a range of patient-focussed services.
Central Health, the public health service in Travis County, where Austin is situated, provides coverage for poor and vulnerable people, and has agreed to try the Institute’s bundled-payments approach; it now makes a single, annual payment for non-emergency musculoskeletal issues, such as osteoarthritis, chronic shoulder pain, and carpal-tunnel syndrome. Commercial payers, such as Aetna or United Healthcare, have not yet agreed to bundled, up-front payments; neither has the Centers for Medicare and Medicaid Services.
Medical norms are always shifting. Before Flexner came along, hospitals practiced a hodgepodge of techniques associated with a broad range of philosophies. After Flexner, order was brought to the chaos. Today, as some hospitals become more permissive, there is no obvious approach that will satisfy everyone. “No Wellness Allowed” doesn’t work, but neither does “Anything Goes.” Patients like Lila and Toby want autonomy and human warmth. Cautious physicians want evidence. Wellness practitioners ask for space and a financial infrastructure that supports their work. There may be no place where these circles overlap.
The way forward may not lie in the adoption of any one structure but in the cultivation of an attitude that accepts that people have a range of needs when it comes to their health and well-being. Inevitably, doctors and patients won’t always see eye to eye. Some doctors will harbor a secret disdain for Reiki; Kvale told me that homeopathy alarms her the most. “We all have our triggers,” she said. Still, she went on, patients should be able to “bring their whole selves to an appointment.” From there, a relationship can begin.