Enhancing the Care of Patients Undergoing Complex Medical Evaluation: A Program to Preschedule Integrative Medicine Services View PDF

Many patients travel to Mayo Clinic for complex medical care, which often requires multiple specialty evaluations and evaluation of complex undifferentiated symptoms. Many patients also come who have received medical diagnoses elsewhere and have been given treatment recommendations they do not find acceptable or want another opinion.
When patients request an appointment in General Internal Medicine, they first complete an appointment request form. The form has 2 purposes:

• To identify the patient’s main priorities/concerns for seeking an appointment and
• To determine if Mayo Clinic has appropriate diagnostic and therapeutic offerings to satisfy the patient’s concerns.

The Consultative Medicine Clinic becomes the starting point for many patients in General Internal Medicine and therefore at Mayo Clinic. Many of these individuals have exhausted their local medical resources looking for a diagnosis and cure for their conditions. Many of these patients are emotionally, psychologically, and physically stressed and have markedly impaired lifestyles.

The Consultative Medicine Clinic appointment process begins with having patients complete an appointment request form as mentioned above, either online or facilitated by a phone interview. The appointment request form was created because many more patients were requesting appointments than were available. The form is intended to help identify which patients have the highest probability of having their needs met via an in-person evaluation. The information the patient provides includes concerns for which they would like to be evaluated, any current diagnoses for these issues, and questions about pain, and number of current medications. The Patient Health Questionnaire-2 and the Generalized Anxiety Disorder-2 are also completed as part of the intake process. The appointment request form is administered through our Survey Research Centre and is very adaptable. For instance, questions can be added and/or removed within minutes. This allows the form to be tailored to current practice needs and opportunities.

Dedicated triage physicians review each appointment request form to determine whether a patient is likely to benefit from an evaluation at Mayo Clinic, starting in the Consultative Medicine Clinic. If a patient is determined to be a good candidate, the form is used to pre-order consultations and tests that may be useful for the planned evaluation and to help streamline the patient’s visit.

Once patients arrive on our campus, they begin their itinerary with an overall medical evaluation with a general internist. This includes a 90 min visit for a thorough history and physical examination. Often, the initial visit requires substantial review of outside records that the patient brings to the visit or has made available electronically via an electronic health record. At this point, additional consultations and tests may be added to the itinerary generated by the appointment request form or cancelled if they are deemed unnecessary. The patient then completes the recommended evaluations and meets again with the internist for a summary visit.

Most patients who come to our Consultative Medicine Clinic have either been thoroughly evaluated elsewhere, or they live in areas where medical resources are scarce and have not received a formal diagnosis for their symptoms, which are often chronic. Many of the patients have exhausted their local resources and are frustrated by their experiences with the medical community. Thus, they are willing to use their resources to travel to our institution. Because of the stresses of these chronic and often undiagnosed medical conditions, many of the patients have untreated excess stress. Additionally, they have often tried various nonpharmacologic means to help lessen their symptoms. Some patients report that they take 10 or more herbal supplements.

Mayo Clinic has recognized that many patient needs could not be fully addressed with conventional approaches and in 2000 started an Integrative Medicine Program. The goal of the program was rigorous assessment of novel therapies that, when evidence-based, could be incorporated into clinical practice. This concept of integrating both conventional and evidence-based complementary therapies has been termed integrative medicine. A commonly cited definition states, “Integrative medicine and health reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, health care professionals, and disciplines to achieve optimal health and healing” [1].

Over the past 20 years, members of the Integrative Medicine Program at Mayo Clinic have conducted over 200 clinical trials on a variety of complementary therapies. The goal of this research has been to assess which therapies and modalities have both evidence of efficacy and also fit the Mayo Clinic model of high-quality, compassionate care. The trials have resulted in the incorporation of numerous types of consultations and therapies (e.g., massage, acupuncture, meditation, biofeedback, guided imagery, animal-assisted therapy) into the outpatient and inpatient practices at Mayo Clinic. These services can be requested via electronic orders in the same fashion as conventional services (e.g., cardiology consultation, laboratory tests). Therapists evaluate and treat patients according to the scope of their certification or licensure and then document the findings in the electronic health record. Communication between the referring practitioner and therapist is both encouraged and expected so that patients receive a cohesive message regarding their care. An important part of the program is teaching patients skills they can use at home for self-care (e.g., meditation, tai chi, yoga) [2,3].

Patients who come to the Consultative Medicine Clinic with chronic pain and undifferentiated/unexplained symptoms are often frustrated, stressed, and have no clear path forward for dealing with their symptoms and issues. They often feel as though they have been passed from practitioner to practitioner and from specialty to specialty. Thus, we identified an unmet need of patients with complex issues in our consultative medicine practice for an integrative approach to care that would provide greater opportunities to address the whole personmind, body, and spirit.

Many patients wanted consultations to explore stress management and/or herbal supplementation once they arrived on campus. In fact, practitioners in consultative medicine referred the most patients to the Integrative Medicine Program.

With the availability of our Integrative Medicine Program, as described above, and patient need, we began asking 3 additional questions on the consultative medicine appointment request form to gauge patient interest and desire for consultation with an integrative medicine specialist during their time on campus (Box), which are summarized below:

• Would you like to meet with a specialist to learn stress management techniques?
• Are you currently taking any dietary or herbal supplements?
• Would you like to meet with a specialist to discuss any questions about herbal and/or dietary supplements?

We began asking these questions in March 2019, and they remained part of the appointment request form until November 19, 2019 when a revised version was implemented, which did not include these questions. In that time, 14,690 forms were completed. Of the 6,063 potential patients who responded to the question about scheduling a stress management specialist, 2,014 (33%) said “yes”. Of the total group of 14,690 patients, 6,186 (42%) responded that they were taking dietary herbal supplements, and 1,810 of 5,926 (31%) were interested in a consultation with a specialist to discuss herbal and/or dietary supplements.

Of those patients who were offered an appointment at Mayo Clinic and came for an evaluation, 638 indicated that they would be interested in learning about stress management from a specialist. Of these 638 patients, 245 (38%) completed a stress management consultation in our Integrative Medicine Program.

Of the patients offered an appointment, 1,268 said that they took dietary or herbal supplements. Of those 1,268, only 160 (13%) completed an herbal supplements consultation. However, 170 of 491 patients (35%) who indicated they wanted to meet with a specialist to discuss herbs and/or dietary supplements did complete a consultation.

Patient satisfaction data was collected during this same period for all Mayo Clinic patients, including those in this study. Of patients who had an appointment in Integrative Medicine, 89.1% had the highest (top box) opinion of the care they received during the visit. Similarly, 89.1% would recommend the practice.

Our consultative medicine practice, by design, serves a concentrated group of patients with chronic, often unexplained, symptoms. Many of our patients who have been diagnosed elsewhere want to affirm their treatment plans, coordinate complex medical care requiring multiple specialties, or seek answers to their undifferentiated symptoms. We sought to see if we could meet an unmet need by identifying patients who would like integrated services and then helped add those services to the patient’s itinerary.

We recognize that dealing with complex medical conditions and difficult diagnoses through the health care system can be emotionally draining and stressful for patients, often affecting other aspects of their lives including sleep, outlook, mood, dietary habits, physical activity, leisure activity, and sense of well-being. We also recognize that lifestyle interventions and refocusing on factors that promote the healthiest and happiest possible lives are integral to having patients leave with something better than just another round of normal tests without dealing with the physical and emotional pain that brought them to our practice in the first place.

We were able to implement an inexpensive intervention that allowed patients to choose whether they wanted specialty consultations included in their appointment itinerary before they travelled to our institution. In doing so, we positively affected our patients’ lives and medical experiences by providing those who received consultations with tools they could use away from doctors’ offices. About onethird of patients wanting to meet with specialists in dietary or herbal supplements or stress management were able to do so during their visits. This number may have been lower than expected because our patients are often in town for very short stays, and consultations cannot be scheduled in time to fit into a patient’s itinerary. On some occasions, patients and the practitioners overseeing their evaluations mutually decided that a consultation in the Integrative Medicine Program was not needed on a particular trip or that appropriate dietary supplements were already being taken, not warranting an herbal supplements consultation.

The number of patients interested in this service speaks to the need for comprehensive services outside of conventional medicine in tertiary medical centres caring for patients with complex issues and stressful and challenging situations. Asking patients whether they would like these services at intake can help manage the demand for and scheduling of services, especially for patients traveling from a distance. Our study focused on stress management and supplements; however, various other services could also be considered for intake questionnaires, including acupuncture and massage. In the revised version of the appointment request form, we opted not to include these questions initially because the popularity of the services made it even more difficult to meet the demand.

In conclusion, patients navigating health care systems frequently are stressed by the complexity of their situations. Integrative medicine can help patients regain control of their lives. Through these services, patients can learn the importance of diet, exercise, sleep, stress management, leisure activities, a positive outlook, spiritualty, prioritization, and socialization-all of which are key components of living a happy and healthy life despite a chronic or complex medical condition. Integrative medicine can give patients the strategies they need to move forward with the best possible life. Future studies could determine outcomes after discharge from tertiary care to learn if patients who participated in consultations from Integrative Medicine are better equipped to follow through on the recommendations of their practitioners.

We gratefully acknowledge the support of The HEAD Foundation Singapore in supporting Dr. Bauer’s research time, as well as Mandy R Jerde, Lucille R Larson, and Eman L Darby for making this work possible by gathering data.

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All authors participated in the design and data acquisition. All authors contributed to the manuscript, reviewed the final draft, and agree to be accountable for the study.

1. Academic Consortium for Integrative Medicine and Health (2021) A transformed healthcare system promoting integrative medicine and health for all. Virginia, United States.
2. Barnes PM, Powell-Griner E, McFann K, Nahin RL (2004) Complementary and alternative medicine use among adults: United States, 2002. Semin Int Med 343: 1-19. https://doi.org/10.1016/j.sigm.2004.07.003
3. Barnes PM, Bloom B, Nahin RL (2008) Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report 12: 1-23.