Medicine’s Wellness Conundrum | The New Yorker

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 di lei. She gently ran her hands up and down Toby’s exposed shins of him. She touched one of Toby’s wrists to feel her pulse di lei, and pressed the tips of her thumbs between Toby’s eyes di lui and at her ankles for a few seconds at a time. Sometimes, she held a hand an inch or so above Toby’s skin di lui, 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 di lei. 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 counseling, 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 Slatethe 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 di lei 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 di lei with Bombacie as critical to the success of her treatment di lei. “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 US 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 di lui, 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 Verghesean 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 of lei, 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 di lei 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 di lei energy healer di lei at his home di lei, 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 di lei was stable for several years; last fall, she learned that it had begun spreading again. She continues to feel that her sessions di lei 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 fibers 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 fibers existed in people. The nerves, known as C-tactile afferents, or CT fibers, prompt not only a physical sensation but also pleasant emotions. Gentle stroking — at one to ten centimeters 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.

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