Sorry, I'm Brian Berman. I've trained as a family physician. I'm professor of family and community medicine at the University of Maryland School of Medicine, and I started a center for integrative medicine in 1991, that's 26 years ago. To see how we could bring in more scientific rigor and to explore the intersection of conventional medical care and back then complementary to alternative medicine. I'm also the president of the Institute for Integrative Health, which is a not for profit organization. It's more of a think tank, and it's exploring how do we move from solely disease management to health and well-being, particularly in the communities. How did you personally train them and moved from the rank of family medicine to complementary medicine? Yeah. Well, I trained back in the late 1970s in family medicine, and what I found was we had a good model, subtly the biopsychosocial model for family medicine, it was a good model all round, but it was hard to operationalize. So, I found I had great training for acute care. So, somebody came into our casualty emergency room with heart attack status, it doesn't matter because I had excellent training for that, but when people came in on a day-to-day basis to my primary care with chronic diseases, I didn't have all the answers that I was looking for. So, back in the late '70s or '80s, I started to look for other ways I could complement the work, that I was doing which led me to go to the UK, where I got my grounding in complementary alternative medicine. Incorporated different practices into my primary care, and was able to expand the toolbox in a way, and eventually realize that we are the toolbox. Our interactions with our patients is what's the key ingredients, sometimes a key missing ingredient. But, that's where it all stems from, and so I started to gradually and cooperatively a new way of practicing. Came back to the United States in 1981 to see how we could really bringing this into the mainstream. So, it was the first center, that academic health center in the United States back then, and really we were looking at what was the scientific foundation, the efficacy of some of these therapies, and particularly explore the integration with conventional medical care. So, how would you envision integrative care. Specifically, we're interested in support of cancer care, maybe palliative cancer care. All kinds of agendas of family medicine and palliative care and integrative care. Yeah. Shared by these patient-centered approach. Yeah. Holistic approach of biopsychosocial and today WHO talks also about spiritual aspect, of course. How would you envision the way integrative model should be implemented within a conventional cancer care facility. Maybe, one way to illustrate this because it starts with putting the patient in the center. Not to say this is what I know, this is what my tool is and so that's what I'm going to do, but if you put the patient in the center and you have some shared decision making approaches, then things really open up. So, if I give you an example maybe of a patient from my practice might be a way to illustrate what I'm talking about, and this was a real patient. Somebody in their mid-50s who was just coming in, I kept saying, you need to have a colonoscopy, and they kept on putting it off. There was a history of some colon polyps with nothing in colon cancer, anything like that. So, they went and had a colonoscopy, and lo and behold, there was a big mass in the colon and it was an adenocarcinoma, and they have laterally also had metabolic syndrome. So, this person went in for colonoscopy, didn't know anything about it. They said we found the mass, now it's to repair tissue biopsy a couple of days later, and the whole world had just turned upside down. So, we'd looked at okay, how we could approach this together, since a joint process. What can I do to help you, and what can we teach you ways that you can help yourself and the person was naturally really scared. So, first thing we said okay, we need to find a really good surgeon and first thing to do was to remove the tumor, and also to get a staging and to see what was really going on. So, we did that and unfortunately it had invaded the muscle, but it hadn't gone through the perineural wall, but how it spread through any lymph nodes as it turned out, and there was no metastasis. So, that was the good news. So, now we had somebody who was really scared. So, we had things that we could do to reduce all the stress, all the fear, all the anxiety that was going on in that person's life, for that point in time. So, there were things like just touch, massage therapy. We made sure that they got glutamine. So, that helps with the recovery from colon surgery. All that was done. The person knew how to meditate. So, we made sure that they are using meditation. We brought in some music therapy, as part of during the surgery, and then afterwards we had some very funny stories about that some of the doctors walking in, and the family having massage, the patient having massage, so even laughter coming. So, you attribute to the patient and the caregiver as well. Yeah, and for sure. Then, we said okay, see your oncologist. Oncologist said this is good. It's going to be with this staging of to a wait-and-see because nothing more that we really have to offer at the state. The oncogenetic testing was done and all that said. There's like less than a 15 percent chance of recurrence, but still a chance of recurrence. Even a bit of tissue was taken, so that they could have sent through a lab to see. It's a little bit controversial, but to see, which if you needed chemotherapy later on, which ones are combinations we are going to be the best, and even that found some interesting things that it wasn't your typical ones that you will do, but it was some ones that could do further down the line, which would be the most helpful. Fortunately, this person didn't need chemotherapy. But, we said well there's other things that we can do and to help you. So, one person's in the hospital there in a hyper inflammatory state. Getting drugs to lower this hyper inflammatory state. While they're getting food, that was creating a hyper inflammatory state. So, coffee, cakes, it was incredible. I talked to the head of the hospital later on because he said no, what we do to improve, I said start with the food because that's a tough one to change. So, and the person was going to leave because of all the things that we've done. She was ready to leave, with also a low dose anesthetic. So, you see the combination. This is not one or the other, but the combination she was able to leave in a couple of days, rather than a typical more course of three or four days within a couple of days time that she was able to leave the hospital, had no education about what to do with food wines, just had a part of her colon taken out. Couldn't just go in and eat healthy, green foods, and also there was a process of teaching about diet. Diet was really fundamental, diet was so she and her family could have some control over, and gave her some ways that you could really do some things for herself. So, diet was one big part of this, and the advice that she was getting was just shocking. It was like, you can have pretty much anything you want, just take out the medicine and tomatoes. She's saying, "Well, I can go have a Big Mac and just take the lettuce and tomato off, and that's a very little tight. So, we made sure that she started to really be educated about food and nutrition, and then we've looked at other things, the metabolic syndrome, how to beat that. So, the metabolic syndrome was a part because that can really increase the inflammation, that can really, with that you'll have a lot more side effects from either recurrence of the cancer or from the treatment itself. So, we really wanted to look at how could we have reduced the metabolic syndrome in itself. That's a classic family medicine perspective to see how the patient is with oncological problem, with the anxiety, with the other ailments like the metabolic syndrome. Now, we're just expanding the toolbox that we were using with the classic family medicine approach. So, we gave much more advice about types of foods, and about types of diets, things like Curcumin tumor, importance of that. Vitamin D, importance of that. Each one had research to back all these up. Same thing with mindfulness-based stress reduction. Same thing with music therapies, all things that you could do for yourself. Being out in nature walking. Social connections, good sleep, all this to me is when we're talking about an expanded view of care. It's good family medicine, but it goes beyond that. It goes beyond that spiritual side, goes beyond the tools that are being offered. So, when you say beyond? What's the connection from your point of view between family medicine, integrative care. I think in a way they're very parallel. But family medicine, we're not talking about things like acupuncture. We're not talking about really a deep knowledge of nutrition or herbal medicines or mind-body approaches. That we are taught about whether or not we do it or not, but same thing with even integrated medicine. We are taught about the importance of the relationship between the doctor and the patient. So, I think that one in a way, I look at it that integrative medicine is a way of operationalizing the biopsychosocial approach. We know it's a good thing to do, but it's not so easy to do. We have some in health psychology, in social work, they do it. But in medical doctors, we don't do such a good job of that. But they heard another aspect in the way you describe the treatment for this patient, and that's the multi-disciplinary approach. For sure. I understood that you worked with some other professionals. Yeah. So, one person is not going to have all the answers. But if you work as a team, a respectful team, together and central on the team, on this bus is the patient. So, there's a lot to do with shared decision-making, then you can really enhance the offerings that you have. Some of it is ways that the patient can heal themselves and some of the things that we can do for the patient. So, we can get it into all the pathways, the HDAC, C-reactive protein, the NF-kB. We have different tools that we can really help optimize the person's well being. I think in a way, that's what we're really after. We can't do it just with our drugs and radiotherapy and all important things that we have. But ways that we can really optimize the human potential to heal. I think that's where that truly integrative approach comes in. So, if you envision an integrated supportive care team inside an oncology center, who might be the players, I mean, with who would you work, I mean. It should be an evolve for integrity of physician, integrity of practitioners, maybe working with nurses and oncologists who already are on board. I mean, who are the players there? How would you envision the integration process and team. Yeah. Well, that's a great question. We're actually looking at that now with our new University of Maryland's proton center. They said we have people coming from all over the world and they only treat them for 30 minutes a day with these proton therapy. What else can we offer? We said, "Let's bring in the integrative physician and endorse into this process." But let's do it not that this is an add-on, the tail that wags the dog, but let's do this for everybody coming in, so we can get an overall assessment of what's going on in the context of their lives, with their family involved, and to really see what's going on. So, you have your integrative care practitioners. You have your nurse for sure. You have a, ideally, a nutritionist on this team. A health coach could be part of this team. The integrative physician who really can look at taking a whole person history and physical with this. Then, you want to look at ways that you can reduce the stress, so you have somebody whether it's a health psychologist or social worker or somebody who can work with the mind-body approaches, and give people some self-care skills. Within that, if you're fortunate enough to have a really good natural path or if you're a nurse or your doctor, knows a lot about the purple side to this, then all the better. Some people would add in functional medicine, so that you could look at about functional medicine. But to really look at a systems approach to this chronic disease. So, I think these are some of the things that would be on the team, and then you would try to individualize it to that particular person, so that you can come up with ways that fits for their life and their circumstances. So, that you can really look at, this is a shocking time for many people or it's a time where it's becoming more and more getting at the sort of palliative care side of it. I mean, some people that we work with say that integrative medicine and palliative care is the same thing. You're working as a team and you're having specific goals that you're trying to achieve. You want to optimize that person's coping at whatever stage they're at. So, it's looking at this traumatic event, but the trauma-inducing growth. To do that, you need to have time to see what's going on with that particular person, and then see with them because they'll certainly have things to say about this particular patient. What's going to really make a difference? What can I really do? Maybe that person says, "I love being in nature, and that's what really gives me peace." Another one says, "I like going to the opera." Or somebody else says, "I like listening to music." So many different ways towards healing and making whole. I wonder from health system perspective and from your perspective as a medical educator. This is really part of your being, your passion. How would you envision, in these integrative model, the role of integrative physicians? Should integrative medicine be separate speciality? Should it be part of palliative care training, family medicine training, of oncologic training or should it be standalone? I'm a big believer that it's not standalone. We turned down a number of times and places to be a Department of Integrative Medicine. I said, "No, this would be just part and parcel of good medical care." That's the goal, it's not to have something separate. Whether or not that actually is completely realized, but I would love to see it, so that when the medical students come along, or the residents come along, they're learning different aspects of this. Someone had just come up to their, you know, they dip their toe in. Others maybe wait up to the waist and others will say, "I'm going to become an integrative physician." That's fine, part of it is a mindset. First of all, it starts with yourself and self caring. Then, you can play your violin the best that you possibly can to really be there, be present for the patients, and to model that for the students as well as for the patients. But then, it's also different tools and different ways that you can have to relate to that person. So, all the things that we know is good family medicine, but really deeply listening. When I was in medical school in Dublin Ireland, our medical tutor said, "This isn't that difficult. You have the knowledge behind you, but if you really listen to your patients, really listen, don't interrupt, they will tell you what's going on, what's really going on with them." But we don't do that and we know that. We have a long ways to go to get back to that listening state. So, these are some of the intentions that we need to bring back into that. I think that could be for what other, whatever profession that you're going into. Whether your ear, nose, and throat surgeon, or a cancer specialist, or any aspect certainly family medicine. The research should follow all that. We lead the Cochrane Collaboration's complementary medicine field. I think we've published 700 peer review articles over the years. Systematic reviews. Systematic reviews, randomized controlled trial, basic science unit. But the research needs to be very relevant and useful, and I think we need to keep that in mind. So, there's a lot of tools that are coming up now about pragmatic trials, about qualitative research, stakeholder engagement, and I used to sort of poo poo that a little bit. I didn't quite fit into the Cochrane or our mold. I start to see now how that all complements and starts to build a house of evidence that could really make a difference. My overall goal now is how do we create an epidemic of health? Not just disease management. I think that when people talk about changing the culture, these are some of the ways that we're talking about that could actually do that. Then, we have a different world culture. Antonovsky suggested the concept of salutogenesis. Absolutely. That's part of your vision I understand. Absolutely, yeah.