Whole Person, Whole Family, Whole Systems, Whole Community: Two Asheville Doctors Re-Craft Healthcare For The 21st Century
By Julie Savage Parker
“The good physician treats the disease; the great physician treats the patient who has the disease.” ~ William Osler
The docs at Integrative Family Medicine of Asheville have found the sweet spot. They view their patients not merely as a collection of living, breathing Lego™ blocks, but as multi-dimensional humans at the intersection of body, mind, spirit… and community. Drs. Brian Lewis and Chad Krisel have structured a clinic that weaves together immensely satisfying ideals, tools and practices to serve their clients, particularly those, like me, who are uninsured or under-insured. But while their pricing is accessible, even people for whom money is no object are flocking to this practice. Why? Read on …
Drs. Krisel and Lewis explain their philosophy this way:
“We see our clients as equals and partners in creating an optimal life for themselves and their communities. To us, integrative medicine is the collaborative integration of best practices from diverse fields to support the health of individuals and communities.
“The art of medicine is meeting each individual in the context of their life, beliefs, and environment to develop sustainable, personal solutions. Medicine must address the community and the environment to enable and facilitate healthy options and behaviors. We have designed our clinic to allow for the time, connection, and understanding to partner with our clients. Together, we develop sustainable approaches in meeting their needs.
“To support this mission, we have founded our clinic on four principles:
Accessibility: Our care will be financially and culturally accessible to a broad population
Sustainability: We will choose options that have greatest impact with the lowest toxicity, and will endeavor to create benefit for future generations
Quality: We will provide high-quality service in a professional, comfortable environment
Integrative Holism: We believe that for health solutions to be sustainable we must address the whole person in the context of their entire life and community. There are many approaches and methods to meet the needs of different individuals, and we encourage cooperation between practitioners to benefit clients and communities.”
“We provide a simple, effective, and transparent health care system that facilitates collaboration with clients, practitioners, and the community. We believe that through empowering individuals and communities we can demonstrate an innovative, scalable model for grass-roots health care change.”
A Short History of Medicine
2000 B.C. – I have an earache. “Here, eat this root.”
A.D. 1000- “That root is heathen. Here, say this prayer.”
A.D. 1850 – “That prayer is superstition. Here, Drink this potion.”
A.D. 1940 – “That potion is snake oil. Here, swallow this pill.”
A.D. 1985 – “That pill is ineffective. Here, take this antibiotic.”
A.D 2000 – “That antibiotic doesn’t work. Here, eat this root.”
We tend to think of medicine in terms of well, medicine – root vs. prayer vs. potion. I daresay that in Asheville in 2014, we are as likely to take a root or prayer or potion or pill or even sometimes an antibiotic (with a probiotic chaser of course). We might even try the occasional dose of snake oil, just to cover all bases. But these choices are only part of the challenge to providing the best in health care. Dr. Lewis and Dr. Krisel are meeting this challenge with a system beautifully designed to look at all pieces of the puzzle.
Almost all discussion of healthcare in 2014 focuses on who pays for treatment, be it pill or potion. But when I sat down with Brian and Chad (patients often call them by their first names), it was clear that neither the type of treatment nor the issue of who is going to be the payer is the sole answer to the question of good healthcare.
A NEW DIRECTION
Several years ago, I asked my friend Debra Roberts about good holistic doctors who were taking new patients. She told me “Brian Lewis!” [Debra, bless you for sending me down this path!] At the time, I really meant ‘integrative’ more than ‘holistic’ and asked Chad and Brian to clarify the terms.
Chad explains: “The term ‘integrative’ is the idea of working across disciplines and integrating the best of what all systems offer, while at the same time acknowledging the baggage that each offers. Historically, and all too often still, each healing discipline seems to stick to their guns and their dogma that it is ‘my way or the highway.’
“In Integrative Medicine, we acknowledge that our primary discipline might do really well with some concerns, but not so well with others. A good example would be when someone comes in with low back pain; from a Western perspective, I could try physical therapy and maybe chiropractic. One option that many Western practitioners offer is narcotic painkillers. We know they give the risk of addiction (not to mention constipation), and we have really good, evidence-based studies that acupuncture treats lower back pain really well. So from an integrative perspective, for low back pain we want to use a treatment with the least potential for side effects and the best chance of efficacious results.”
Brian chimes in with: “If you are trying to simmer it down, you could say Integrative Medicine is ‘an evidence-based collaboration for the patient’s maximal benefit with minimal harm.’ The term actually grew from when anything other than Western Medicine was considered ‘alternative’. Later, the phrase ‘alternative and complementary’ developed, then Andrew Weil coined the term ‘Integrative Medicine’ to emphasize collaboration and remove the sense of hierarchy.
“Across the country, people interpret Integrative Medicine and ‘evidence-based’ to mean different things, in how diverse the therapies might be, and how substantial the evidence might be in order to incorporate a therapy. Things that some practitioners might consider ‘fringy’ or having limited evidence, others might consider the very foundation of integrative medicine. There are efforts to develop consensus between various advocate groups, and even to develop new means of studying the therapies, since some modalities are difficult to evaluate with standard, randomized controlled trials.
“The ‘holistic’ aspect is what modern science is starting to refer to as systems biology, realizing that everything is interconnected, everything is a living system. Most ancient healing traditions such as Ayurveda, Native American, African, Tibetan, or Chinese medicine, have this worldview of interconnected living systems. Even the roots of Western Medicine in ancient Greece began with this premise.”
“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.” – Plato
“The holistic perspective is looking at the whole person in the context of their life – I’m not going to just treat blood pressure, but keep in mind family dynamic, living situation, access to food, a safe place to exercise, work stress, and how all this feeds into the whole picture. Instead of just going after high blood pressure with medication, if we address all this, maybe the problem will dissolve on its own because we address the roots of it. It leads to more personalized approaches, incorporating little tweaks around their entire life to produce good results, with fewer side effects and often without medication. We can partner with individuals to thrive. This is more sustainable because we empower them to become more aware of the impact of their choices, and to create a healthy lifestyle that achieves personal goals.”
I told them of a very happy IFMA patient who had been paying $10,000 for medication, now made unnecessary when an IFMA doc helped him greatly improve his health without the use of pharmaceuticals.
Chad: “When talking about causes of death in America, number one is heart disease, number two is cancer, number three is what we call iatrogenic, either physician or pharmacy caused. This is such a mind-blowing statistic. It gets into the model we have created here, the temporal element, having the time to take an integrative, holistic perspective. When you don’t have that time (the national average is 8 – 10.5 minutes that doctors have face-to-face with patients), there are good studies showing the shorter the amount of time with the patient, the higher the rate of prescription.”
“The worst thing about medicine is that one kind makes another necessary.” – Elbert Hubbard
“So much of what we deal with is entirely reversible or preventable, given the right access to resources and knowledge. It begins with the information necessary to know how to eat and to include different things in your lifestyle. If you only have 8 to 10 minutes, it is much easier to write a prescription to try and improve outcomes. These might have side effects, and they see the physician or another provider for another prescription to counteract the first side effect. Then all of a sudden you are paying $10,000 for medications and you are sick. And the underlying root cause of what was initially going on may not have ever been addressed. That is one big symptom of the medical system being very broken.“
Brian: “There is a statistic from the Centers for Disease Control – not a fluffy group or a Left Wing group – that 75% of healthcare expenses in the United States is for conditions that are completely preventable. That translates to 2.8 trillion dollars! That would pay for a lot of schools, healthy school lunches, and community development programs. We could pay our teachers better, increase access to nutrition, and support young adults through college. We could do a lot of things that would invest in cultivating sustainable health for our country.”
Brian: “We know that various things contribute to high blood pressure, but people aren’t protocols. Sometimes in medicine, we are taught to follow treatment protocols to address symptoms instead of resolving an individual’s root causes of suffering. That may work well for acute situations such as a broken arm, but when you are trying to prevent and reverse chronic conditions, you really need to treat the whole person, and this means sitting down with them to grow the solutions that fit their life.
“One of the realizations in public health, kind of earth-shattering news for them, was that after deploying all these altruistic projects in third world countries, the campaigns would fall apart in about five years after the outside team left. Then they learned to resource the natural leaders in the community. They would show up with a project in a box, not fully formed, and present it to the community: ‘These are the parts we know that work. Let’s find your solutions. Let’s grow this together to fit your needs, your community.’
“Then the community would grow a solution that the public health workers couldn’t even dream of, and not only did it work better, but it stuck. When outside workers left, it was still going 10 and 20 years later. You meet people where they’re at, find their natural strengths and resources, and together grow a solution that fits their life. It is much more likely to stick than a list of ‘shoulds’ or ‘shouldn’ts.’”
Chad: “There is a local organization (considerhaiti.org) that has been going to Haiti twice a year for several years to provide pediatric care. Many physicians in town participate and I went a few years ago. Their main focus is providing sustainable nutrition to pediatric populations, then twice a year they see the children in five specific villages. Then they started training community leaders in these local regions and suddenly realized there are about half as many sick children coming to the clinic. Now the team of doctors is half the size, maybe even less. It is in large part what Brian just described.”
Brian: “Each person is like a small community. We find the natural strengths, the perceived obstacles and the real obstacles, and work with them.”
When asked, Chad said only 2 out of 50 or 60 medical students in his graduating class chose an integrative holistic path. Brian said the percentage in his class was about the same.
How could they not? How could they see such a superb approach to patient care and not choose that path? Perhaps they could only see the impossibility of functioning in a system that allows so little time with a patient. Drs. Krisel and Lewis saw this ‘impossibility’ but it didn’t stop them; it inspired them to design a practice where doctor/patient face time is a high priority. And they made it work.
Chad: “Physician satisfaction with the current ‘high tech, low touch’ model is abysmal right now. Each year, 300 physicians commit suicide. More than 50% of physicians don’t recommend going into the profession. Things have to change. When doctors see the possibility of being able to see one to two patients per hour rather than four to five …
“So much of the holistic approach is coming from the philosophical perspective that this patient is more than a conglomeration of systems and is a spiritual being, an emotional being, a physical being – and how does that play out in the context of a life? All you really need for that is to be human. I had a patient the other day who was telling me, ‘When I went to this other doctor, the nurse warned me before I went into the room to not talk about anything except my chief complaint when I made the appointment, because they won’t have time to talk to you about it.’
“This is a privileged position we occupy – being a small part of people’s family and helping out in whatever way we can, and we have a vast knowledge to be able to do so.”
Brian: “It is not uncommon for people behind these closed doors to share things they say they have never told anyone. That is a very vulnerable place. To hold a safe place for them to be heard without being judged, and to help, that is a precious moment.”
Brian: “Many primary care doctors feel overwhelmed with patient volume and paperwork. Most are not happy with what their profession has become. The majority are good people who want to spend time with their patients and help them. The current structure of the U.S. medical system has created a setting in which this is very hard to do well. The average family doctor (primary care doctor) breaks even at 20 patients a day. Only above that do they start bringing money home to pay bills and feed their family. That is primarily why they see so many patients and keep visits short.
“Sometimes out of catastrophe comes creativity. There are people creating new payment models. Across the country there are folks like us trying different ways.”
Chad: “There is a journal called Health Affairs; in 2012, they calculated what it costs for 3rd party payers [insurance]. You have to hire one, two, maybe even four people if you are dealing with insurance companies. The average cost is about $83,000 per physician per year. We have three physicians so that would be $240,000 a year just to deal with insurance.”
Brian: “We have our own hybrid here. Ours is an Integrative and Holistic perspective, a Direct Primary Care payment model, a low overhead clinic, and a community outreach public health component. That is our recipe for this clinic and it is working great.“
THE GREAT INSURANCE MACHINE
Chad: “Who pays the bills, that is who you are working for. We can very honestly say we work for our patients. Our service is to them. If an idea comes up between the two of us, it is just a matter of implementing it. There is no third party, for-profit, billion dollar middle-man dictating whether we can do that or not. So if we want to host monthly classes, it is just a matter of having space to do it. If we want to donate money from selling supplements to non-profits, we can do it. If we want to provide affordable healthcare to small businesses, we can do it. That has been very freeing for both of us.
“Under the Affordable Care Act, this model fits perfectly. The idea is to get the highest deductible insurance plan appropriate, then combine it with a direct, primary care practice such as ours. Your family doctor handles 80% of your healthcare needs. You then have insurance for every now and again when you might need a specialist. Over the next 30 or 40 years, you will save thousands of dollars through this approach. If you are diagnosed with a rare illness that requires ongoing, expensive, sub-specialist care, then you just switch the very next year to a higher coverage insurance plan.” [See integrativeasheville.org for more information.]
Chad: “The highlight of my day is seeing patients. Some of the administrative things, i.e. running the business, is not always the most fun. Seeing patients is one of the most sacred acts I can ever imagine myself participating in. And the aspects of people’s lives that they are willing to share with me, I am just profoundly humbled. I think we all are. We have been given this privilege to do this work and are in a setting where we can actually do it. Where Brian and I used to work, we were seeing upwards of 50 patients a day sometimes. You can’t imagine how unsettling it was. Here we see between 11 and 15 a day. Standard family medicine is between 11 and 15+ per half day.”
Brian: “I got tired of cutting off little old ladies who were just starting to share what was important. It was ‘Sorry, gotta go!’ It broke my heart every time.”
Chad: “Doctors often report it is not until the last few minutes that the real problem comes out. So if you have a visit that is 20 or 30 minutes long, it may come out at 10 minutes and then you have 10 or 20 minutes to deal with it.”
Brian: “What makes me so happy is seeing it work. Not just financially, but seeing people get better, feeling empowered, and having an impact in the community. What touches my heart the most is when people feel ‘Wow, there is a different way! These guys are doing it, other people are doing it, this is an example of doing something good.’ Sometimes it is a simple and profound opening, a shift in perspective. When I see that touch someone’s heart and I know they are more likely to walk away and do something inspiring, I can get a bit teary. All the work is worth it.”
Chad: “If I can share from patient feedback that we received: ‘In spite of my insurance enrollment, I am keeping Integrative Family Medicine as my primary because I like the way they approach medicine; I trust their methods more than I do the standard medical practices in America today.’ I think that says it all. In terms of the demand, this is a person who has insurance and can likely see another doctor for some reimbursed rate, and they are coming here. We take time with them, we have a philosophical approach they resonate with, in a way that is accessible and affordable.”
Brian: “You asked, when we first sat down and put our heads together, how did we dream this up? Chad and I have similar ideals on how we want to live life. Neither one of us is looking to build big mansions. We are pretty content with living a simple life. I am probably happier out in nature than in buildings. So we reverse-engineered it. What do we have to charge to live lives the way we want to and save for the future in a responsible way? What systems do we need to build to do an integrative holistic business? And that is when we started looking at different models. We were very clear in the beginning, everything will organize around our incentives. Let’s choose them carefully. Anytime we have a choice, let’s incentivize ourselves to take better care of the patient, not do more procedures. We actually do better as a business when people come in less. So we have incentives to help them get well! Thus there is a really good reason to do classes on diabetes, hypertension, etc. We can get creative, use group dynamics, and partner with others in the community to help people take better care of themselves and each other. Part of the reason we donate our profits from the sale of supplements to non-profits is to build this collaboration and because we didn’t want to be incentivized to sell more supplements – we wanted to keep it clean.”
Chad: “It is standard across the medical system that doctors get paid more based on making patient visits more expensive – the more x-rays and procedures they do, the more money the doctor brings home – at a time when the amount we spend on health care as a nation has the potential to bring the entire economy down. I think most doctors are good people practicing in a broken system.”
ASHEVILLE AS FERTILE GROUND
Brian: “I am excited about doing this in Asheville – it is a great place to pilot this project. We have one of the highest concentrations of integrative providers in the country, and there is a culture of supporting creative ideas. I have heard of many people wanting to build the retreat center. Sometimes I hear of it being a high-end spa facility, back to nature seclusion, or even the premier Southeast destination. The longer I am here, I am beginning to see Asheville as the retreat center itself, a collaborative network of practitioners and facilities embedded in an overall culture of health and natural beauty.
“We are fortunate to have access to local foods, pioneering sustainability experts, national leaders in various disciplines, and a remarkable natural environment. We live in a community where there are healthy relationships, a slower and fulfilling pace of life, and an ethos of ‘more isn’t necessarily better.’ We have been able to reach out to these incredibly skilled people to teach our classes and help weave the tapestry of a healthy community.
That is the wonderful part of being a community-oriented family physician. We never treat a symptom or a person in isolation. They are in a system of their community, family, and personal beliefs/habits. I love that in Asheville, this approach is possible. Partnering with great programs – anything from Brother Wolf to Ashevillage – supports our patients and our community. Inspiration and collaboration are positive contagions. There are a lot of people doing great things here, and we’re just another one paddling the boat forward. This city is becoming an example of a different way to live. That is a large part of why people are drawn here and what we can continue to cultivate together.”
Chad: “What we are part of, both locally and nationally, is showing that a bottom-up, grassroots approach to healthcare change is not only possible, but is potentially the fix for our healthcare system. Asheville has been the perfect place to do this, in terms of opening its arms to us for what was initially a bit of a gamble. We felt confident in what we were doing, but without the community welcoming us, this wouldn’t exist. And the potential for other clinics around the country [increases] with the example we are setting.”
Brian: “We have been contacted frequently by doctors across the country and we can tell them, in all honesty, it’s working great! And we hope that inspires them to give it a try.”
MORE ABOUT THE MEN BEHIND THE STETHOSCOPES
Both Chad and Brian emerged as nationwide leaders, even while still in medical school. I invite you to look at their website – integrativeasheville.org – to read more about their histories and what moves them, and explore the rich resources they provide while you are there.
I admit to being totally biased regarding these two men and their work. Their whole-hearted devotion to the well-being of their patients is evident in everything they say and do. If you are looking for a doctor with a wide-open heart, a doctor with a beautifully balanced male/female energy, and a doctor who is a real mensch – look no further. Both Dr. Brian R. Lewis and Dr. Chad S. Krisel fill the bill.
HOW TO FIND OUT MORE
Visit their website, integrativeasheville.org; give them a call at 828-575-6900; on Facebook, they are Integrative Family Medicine of Asheville; sign up on their website for their free monthly newsletter; attend one of their free monthly classes which feature local experts giving practical courses on cooking, healthy shopping on a budget, growing your own foods, using foods as medicine, herbal medicine, yoga, meditation, qigong and more.
A patient’s eye view of the guys behind the stethoscopes:
“I switched to IFMA as my health providers because I really like their philosophy and approach to healing and being proactive in mind/body/spirit health. I am a true believer in the “everything is connected” perspective to life. I recently experienced some extreme stress which caused difficult physical symptoms. ‘Dr. Chad’ took time to listen and talk to me about my life circumstances and my body’s response to them. “We will come up with a plan” he said. I appreciate his compassionate partnering with me to find balance and health. I trust the integrative approach to health and think this is the way we need to proceed in health care in this country, from true nutrition (“food is medicine”), exercise, life purpose, spiritual connection and community. I think Dr. Chad and his associates are offering and achieving this here in Asheville and we are blessed to have them here.” ~ Becky
“With regard to Brian Lewis – I find him to be attentive, knowledgeable, approachable, happy and full of hope. The office in general is full of cheerful people, and that, in itself, gives way to healing whatever your ailment is.” ~ Anita
“Dr. Krisel really listens deeply and completely to what is going on with me and is very caring.“ ~ Roger
“Dr. Brian Lewis is a very good doctor, very conscientious, very professional. He has a nice bearing; he is easy-going and puts you at ease.” ~ RK
“Chad Krisel and the folks at IFMA are superb. Any doctor worth her/his salt must learn to take an integrative holistic approach – surely this is what medicine in the 21st century must become.” ~ JB
“Brian Lewis and his team are at the cutting edge of integrative medicine and a new model of affordability. Their care for my family has always been holistic yet medically effective. If all doctors followed their model, the economy would save trillions and ‘Obamacare’ would be unnecessary.” Michael
“The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease.” Thomas Edison
Julie Parker has been a patient of Brian Lewis and the good folks at IFMA since day one of their practice. At this point in her life, she is totally focused on reinventing herself from the ground (or the ‘grassroots’) up, and is deeply grateful for the loving support of Dr. Lewis and Dr. Krisel in her journey. She takes this opportunity to quote Seneca: “People pay the doctor for his trouble; for his kindness they still remain in his debt.”