Abstract
Mary Hardy, MD, board certified in internal medicine and a specialist in botanical and integrative medicine, has actively combined complementary and alternative therapies with traditional Western medicine for over 30 years in both her clinical practice and research projects. In 1998, Dr. Hardy founded the Integrative Medicine Clinic at Cedars-Sinai and participated in an NCCAM-funded research project that evaluated the barriers and facilitators of integrative medicine practice based on her clinic. Dr. Hardy is currently teaching in the Integrative Medicine Fellowship Program of the Academy of Integrative and Holistic Medicine focusing on efficacy and safety of herbal and dietary supplements as well as clinical management of complex patients. She has previously served as faculty for the Georgetown University Masters Program in Integrative Medicine, the Associate Director of the UCLA Botanical Research Center, the Medical Director of the Simms/Mann-UCLA Center for Integrative Oncology, board member of the Society for Integrative Oncology, co-leader of the Oncology Interest Group in the Consortium of Academic Health Centers of Integrative Medicine, a member of the Stiles Integrative Oncology Center at
I really saw what it was like to be a doctor from that perspective. So I have always had sort of an old-fashioned view about the covenant between doctor and patient. It really is a promise, and it is a sacred piece of work. It is not a punch-a-clock 9-to-5. It is really, truly sacred work. It was seeing that covenant in action, and the love and joy of that from both sides that really convinced me how to practice medicine.
And we have lost sight of that, of the sacred part of our function as physicians. Certainly the trust that someone places in you, that you then accept responsibility for their care, is a very deep and meaningful transaction. It is ignored at our peril. It is a big part of how I have always practiced. Who is the patient? Who is this person in front of me? How does that manifest in the concern they have brought to me? And then how does that affect what kind of therapies they will empower? For me, the best definition of good medicine is the most effective least toxic therapy that the patient will empower.
The kind of connection between my grandfather and his patients was what I observed, and what I saw was really the right way to do things, and how much joy that engendered on both sides. That was where I saw what the covenant of medicine looks like, from watching him practice. So I kind of came into medicine with an old-fashioned notion of what medicine was, and I think that has stood me in good stead, to have that kind of an example so that I could always know that the person was at the center of care. It was not a big revelation to me. When patient-centered care has recently been seen as a “discovery,” for me, it was like, “No, this was the way it has been done.”
I taught in an introduction to clinical medicine class at USC for 14 or 15 years, and so I saw hundreds of new medical students come to their first clinical class, basically. One of the first questions I asked them was, “Well, why are you here? What brought you to this?” And most of them said, “Look, I am really good in science, but I want to help people.” Their basic communication skills of general politeness were pretty good. It is an indictment of our medical system that by the time they have left medical school most medical students were worse communicators than they were before they started. Because that gets worked out of them, right? You are supposed to always just get your job done, et cetera, and that is true. You have a technical responsibility, but you still have to be compassionate even if you are a bit stepped back. You really have to be. And people who enter this career absolutely come in with that as their intention.
Being available for the mystery and the wonder of things is just a delight. How do you have congestive heart failure? What is your family social structure like? How does that impede you or support you, and how can we facilitate that? You know? There are just a zillion interesting questions and it enlivens the technical aspects for me.
So, okay, I can accept that, and I can talk with you, and I can work around it, and I can keep presenting data to you and hope that eventually you will come around. I have found that after about six months at the academic center I was working at, one of the best oncologists called me up and said, “Look, I do not know what you do. The patients love it. I do not know what you do, and I do not want to learn what you do. I do not want to do it. I want you to do it.”
I am seeing everybody, because patients do better. They do not have to stop therapy. They are in much better spirits. They just go through things really much more straightforwardly. That was when that little Rubicon was crossed, when people's own experience convinced them that it was not harmful, it was helpful, and the patients were proselytizing for me. I did not have to do it. They did it for me. That is kind of how that went in academics.
Then after a while, even the most resistant would say “Well, I am not 100% in favor of what you do, but I have to say at least you are inside the tent.” They would often send me the patients who had refused conventional therapy when it could have been very beneficial, because, “Let the witch doctor talk to them.” If I tell them to do it, I am telling them out of a context of, “Look, I understand the full spectrum of what is available, and I still think this would be a good choice for you, but I can make it less toxic for you.”
I think that is going to change. Already medical schools are now 50/50 men and women, and that is a big change from when I was a student. So I think it is just painful about how long it takes. I guess if you spend enough time there and you get enough perspective, you can step back and say, “Yes, things are changing more and better and more frequently.”
I studied ethics at one point for a semester at the Harvard Divinity School and I went to a special program and got an ethics certificate because I was firmly convinced that there is a way to figure out what is the right thing to do, and it is not just your own personal opinion—there are guidelines for this. Ethics helped me analyze if there is a conflict here, what values are in conflict? Which means that you can always take a look and say, “If everyone is trying to work toward the good, how can I clarify this so that we can find a compromise that we can all live with, that we still honor the most important value, which is the patient's values.”
Even evidence-based medicine, if you look back at what David Sackett and Archie Cochrane were doing, they said it is a combination of three things, the best clinical evidence available, your best clinical judgment and then what the patient wants—their values. 1 That was included in the original concept of evidence-based medicine.
The first one I did while I was the lead was Ayurveda for diabetes. That turned out to be incredibly fascinating because Ayurveda is obviously a really ancient practice. It is still a part of the world where herbal-based medicine is still used for millions of people and a lot of what they did was written down. Now, on top of that, a lot of the herbs that can be useful for controlling blood sugar have been written about in the regular medical literature, as well for a long time. So we had a lot of data to look at.
And we did something novel. We sent one of the researchers to India and we collected data from Indian studies. These studies are not on PubMed. Half of our data came from that foray into India and really enriched this experience. I also went back and did some research about what Ayurveda said about diabetes, and found out that it was relatively sophisticated for traditional healing. They were able to isolate two versions of diabetes, one that they called karmic diabetes, which happened to younger patients and that you were just born in with, and then a second diabetes that they said came because you overindulged in eating, and something like that. It was very closely aligned with our type 1 and type 2 diabetes, which is just great, you know? Just seeing how tradition can bridge across the ages. It was a really fascinating project.
You had asked what empowered me. My residency was in a hospital in Boston on the edge of Chinatown. So we treated an unassimilated Chinese population, which was very cool. I went with my college roommate, who was Chinese-American, together to China, 35 years ago, when it was still really early. China was still not a westernized country in a lot of ways. So we saw surgeries done under acupuncture anesthesia only. We saw a person having a cerebellopontine angle tumor taken out with just acupuncture in the ear, and they were awake and talking and in no pain.
My roommate spoke Chinese, so we talked to the woman ourselves, and she was awake and blinking her eyes. “Are you okay?” “Yeah, it is fine.” You know, it was not like a Western theater for operating—there were not 62 different machines, and it was not all crammed up with stuff. They were just doing their work with a patient who was awake and very calm. She was not sedated to the point of catatonia. She was just basically chatting away. She was not even intubated or anything.
Then we saw two thyroid surgeries. You are standing at the head of the patient, and the field is up, the curtain is up. As you look over, you are sort of looking over the curtain, looking to the field for the thyroid, and the patient opens their eyes and looks at you, and you are like, “Oh, wow. The person is looking at me.” It was a real revelation.
You have experiences like that, and you say, “You know what? I do not know everything.” And there is a real value in that. There is tremendous value in that. Just to proceed with an open curious mind, you will observe things that you cannot explain, and you always, of course value first safety, primum non nocere.
But if you leave it open for possibilities, you sometimes will get extraordinary results. And if anything, you usually reduce suffering. I would often say to cancer patients, “Look, I cannot guarantee your outcome. We know it is a tough fight. You are geared up for it. You are doing everything you are supposed to do. But let us just say that we do not know the answer yet, and you are going to show me how well you are going to do.” And frequently they would.
I wanted to be able to be free to go back and forth to see him, so I worked in a walk-in medical center in Cambridge, Massachusetts. This was one of the most liberal parts of Boston and my patients were coming in talking about all these things they were doing. They really educated me and got me thinking about ways that there were things that could be done, and challenged me. For instance, “I have bad PMS. Why do I have to only take a birth control pill? Is there not something else you could do for me?” So they really challenged me to learn a different kind of medicine. That was the first change that happened, largely through them.
Then reflecting back on these visits to China, and the unassimilated Chinese population, et cetera, I kept running up against all these opportunities, and decided, “I have to understand this better.” Then programs and teaching started to become available. And then when I was in practice at Cedars-Sinai in that first integrative clinic, we had a lot of musculoskeletal pain, which I expected from an integrative practice. Looking at the data, that was what you would expect.
I also had a ton of women's issues coming to me then. I have always had a very robustly female practice. But then, after about a year or two into it, they started saying, “Look, you know, you did such a great job with my menopause, but now I have breast cancer, and I want the same treatment you gave me for my menopause. I want you thinking about how to do my cancer better.” They pushed, led, dragged, and challenged.
So that was really how I started doing integrative oncology, because the patients I had been caring for all along started getting sick this way. Then once I started doing it, the patient demand started to really invest me in this. It is very good work and it can make a real difference. So at that time I started doing it. I was in private practice, and I then got recruited to the Cedars-Sinai program, and then from Cedars I got recruited to go to UCLA as the Associate Director of the Botanical Research Center there.
The other half of my time I was working for the Venice Family Clinic—the largest free clinic—helping to initiate, with Myles Spar, a wellness program, which is, again, a very novel application. People did not think that poor people wanted integrative medicine. You know, you had to be the typical white, upper-middle-class, disposable-income person. It turns out everybody wants to be treated this way.
I do think it is a problem, because when integrative medicine first started, you had to have an available population that was willing to implement it and could afford to implement it, because this was not, and probably still is not, completely embraced by the mainstream. So the mainstream did not want to pay for therapies they thought were experimental at best and mumbo-jumbo at worst. And you have seen the waterfront here in our “integrative/alternative” world, and some things are really bizarre and probably not effective, may or may not be harmful, but probably are not effective, and some of them are cuckoo, just really cuckoo. Other things are very rational or empirically effective.
One thing I did that was so useful in integrative oncology was to empower the patient, so say to the patient, “You are not on the worst rollercoaster ride of your life. You are not a passive person being dragged all over the place. You are the captain of your ship. There are things you can do that will help you, and at any stage along this, it is your will and your consent and your engagement that makes this a functional intervention for you. And if you cannot get behind yourself, it does not matter what they do to you, because they are not doing it with you.” I have had interesting discussions with students about how we used to be healer-priests, and we do not do that anymore, but there is still a sacred function to our work. I think that is a fascinating discussion.
In integrative oncology, it was about standing in a very technical powerful place and saying, “Do not forget about nature. Do not forget about the patient's empowerment.” Leave them in positive uncertainty, you know? They know things are bad. But do not tell them, “You have two months to live.” Tell them, “We are going to set you up for the best shot you can take, and then you will show me how well you will do.” Let them show you, let them create something that you could not anticipate.
I teach some of the early classes. I like this because you get to sort of inoculate people against what is going to come, like, “Keep talking to people like this, even though they tell you not to.” And you can also set their expectation. You can help them structure how to think about a patient or a problem, and think in terms of systems, like, “This is the inflammation system. This is the physiology for this. This is the social stress for this.” So it is not just, “I learn that when you see someone with frequent urinary tract infections, you give them cranberry.” It is more like let us expand this out a little bit, and let us just not practice heroic alternative medicine. Let us practice truly integrative medicine, integrating as many parts of the person as you can hold in your hand while you are seeing them.
So I really like being in that position, where I can share with people, “Well, have you thought about it this way, or have you thought about that way?” Or you are talking, and then, “Here is the person who has developed this and done a research paper on this, or here another way to think about this.” I find that to be incredibly rich, incredibly useful and incredibly enlivening for me. You know, you can say, “Oh, it is such an unselfish practice.” No, are you kidding me? I feel great when I practice this way, and when I teach. I am doing it because I think it is the right thing to do, but I am also doing it because it feels good. You know? I really enjoy connecting with the students.
Then when I was at the integrative oncology program at UCLA, there was an elective that the senior students could take to come and spend two weeks with me while I saw patients. And what was astonishing was that most of them did not know how to take a diet history, had never talked to patients this way before. So they thought they were going to come and learn like useless herbs. It is like really, “No, let us get back to basics. What is your stress level like? How are you exercising? Let us look at this, what you have reported to me for your diet. How can I analyze that so I can make specific suggestions for modifying it, not just eat a good diet, but really, you could make this choice differently.” So, again, even when you are teaching integrative medicine, you go back to basics.
I also taught for a while at George Washington with Andy Heyman, MD. That was in a master's program. Then I have been exposed to the program at University of Arizona and am also now teaching in the program at AIHM with Mimi Guarneri, MD.
From all those different perspectives, I think there is a unifying message, which is, go back to basics, make sure you see who the person is in front of you, encompass as much of them as you can, and offer them, again, the most effective, least toxic therapies that you can help them empower.
I do think that there are more people going into integrative medicine. It is not so much an oddity as it used to be anymore. I think that is really terrific. I see a lot of men as well as women doing this. I see a lot of psychiatrists really interested in this, and that is an interesting application of these therapies. I have seen surgeons. I have seen lots of primary care docs, but all kinds of docs are doing this. And they want to go back even to their highly technical medicine and practice it in a more mindful way, or practice it with more of a wellness attitude.
Mimi's program at the AIHM has developed a scholarship program, and they fund health care workers who are currently working in social safety net clinics to come and be trained. And these folks are committed to putting that back into practice in their social safety net clinics, usually treating a socioecomonically disadvantaged population. I think training a practitioner to then go back into those communities is one thing. Getting funding for some of these things is another thing. And having care networks like HMOs or larger health systems start to think about ways that they could provide for all patients—for instance, paying for a vitamin or herbs that have applications that are validated by research—that would be not only more appropriate, but would probably be less expensive. So focusing on funding research that will validate some of these therapies and reduce resistance and make you realize that these therapies are largely nontoxic. A huge part of my research career has been investigating the safety of these therapies. But these are largely nontoxic. With very important caveats, they are largely nontoxic, that it is worth a try. And you could then try it and see how it goes, and if it goes well, do more of it. You know?
My program at UCLA was a success not because I was a brilliant practitioner, but because my co-practitioners respected me, knew that I would stay out of their way, knew that I knew what the issues were. And they said, “Well, if she thinks it is okay, we trust her. We can leave it to her.”
The more people we have who can go into the conventional system and can do that, I think that is going to be our next-generation transition. Continue to write, continue to research, and educate practitioners and patients. That is why I am spending my time on educating practitioners mostly, because I think that is what is going to absolutely drive this field forward.
But you are right. It is not uncommon that people will look at a bunch of toxic stuff and then say, “Oh, it is this other thing that really has done the whole deal.” For example, I was going to do a research study looking at a soluble fiber for helping diabetics by slowing stomach emptying, and maybe then decreasing their postprandial peaks of glucose. I was waiting in the Institutional Review Board meeting while they were talking about other studies. The person before me was looking at a cancer drug, which just had horrendous side effects. It was a phase 1/2 study. You could ablate your bone marrow, you could do this, you could do that, and death was very high on the list of possibilities. And then they come to mine, and they are saying, “Well, we do not know this stuff is not toxic,” and I am like, “Are you kidding me? Were you awake in the last presentation? This is fiber. This is just fiber. It is food.” They did not know what the toxicity of my fiber was. There is a real confirmation bias, which is better, but still there for sure.
Next there was excellent work that Norm Farnsworth and his team did at his botanical research center at the University of Chicago in Illinois, and they proved that black cohosh was serotoninergic—it bound to the serotoninergic neurons in the hypothalamus and controlled temperature that way. It was not estrogenic. Fredi Kronenberg again proved this by looking at binding and other studies. Black cohosh was non-estrogenic. But it has been incredibly challenging to get that word out. The only time there was an estrogenic effect proven was in the 1950s with a very crude extract in mice, who do not metabolize estrogen like humans, so that is off the table as useful research for effects in human women.
A long carefully assessed safety study conducted by Bionorica from Germany with 400 women given black cohosh for a year looked at uterine lining, the maturation of cells in the vagina, and no estrogenic effect was found anywhere. 4 They also did safety data by collecting labs. They collected white blood cell counts, liver function tests, et cetera. So we have a year's worth of data on 400 people. When I looked at the individual person-level data, there were some LFT elevations, but they were small, and they were not sustained. So if your liver enzymes were elevated on the first draw, by the second draw they were not. So there was no place where any two levels were elevated, and no person had two elevations out of the three times tested. There was a big review done at the National Institutes of Health as well that came to the same conclusion—there was no evidence of an estrogenic effect of black cohosh and, therefore, there was not a particular risk. 5 There was a group of researchers in Spain who gave breast cancer patients the Bionorica black cohosh extract, and they did not show any evidence of increased risk of developing breast cancer. 6 Now, a year may not be a long time for that, but it was still much longer than we usually have.
So the evidence chain does not hold up. Black cohosh does not affect breast cancer cells in vitro via the estrogen receptor. It does not have estrogenic binding capacities. It does not act estrogenically in the body, so it does not affect the maturation of cells in the vagina. It was not hepatotoxic in these studies. And that is really robust data, rather than a few messy case reports where all the variables have not been controlled for. When you look at a case report, you are evaluating that to assess causality, you are supposed to rule out all other potential causality, like is there another explanation? You are supposed to apply Occam's Razor. What is the simplest explanation for this, or what is the most likely explanation for this? Do you have another likely explanation? It does not mean that the thing that you are worried about could not be the cause, but it is not the only potential cause, and it may not even be the most likely cause. I think that is how literature gets distorted, and it is really hard to clean it back up.
I think black cohosh is a fantastic herb, and it comes to us from a native tradition of our own Native Americans, although it got developed commercially in Europe before it was widely used here as a modern phytomedicine. It is a very beautiful very interesting herb.
Right now—and it is not necessarily a disadvantage—this kind of medicine that you and I believe in with all of our hearts and souls is a specialty, and it is being recognized as this now, which I think is good, because it is a special kind of use. Now, does that mean that we could not teach enough practitioners, pharmacists, physicians, and nurses about phytomedicine so that they could maybe have a handful of things that they can use in their practice, or so that they will be more permissive rather than dismissive if someone is using these therapies, or so that they, the Western practitioner, will be able to evaluate risk? I think that is why we are in a position now where integrative medicine is a specialty. We should make our knowledge as well known as possible. But then the average practitioner is not going to end up knowing what I know about black cohosh. They just will not. I have spent years in this field, and I ran a botanical research center with my chief, David Heber, MD, and I have been in integrative oncology for 15 years, and I was in practice 10 years before all that.
Now, I have a prejudice in this area. I have a confirmation bias of my own. I really started getting a grip on botanical medicine when I learned about phytochemicals. I basically did the pharmacology of herbal medicine to wrap my head around this field, to give myself a structure so I could learn this new information in a way that made sense to me as a Western trained medical doctor. Then I could go back to the more folk tradition or the more traditional type of herbal medicine that will have multiple indications. Like, for example, black cohosh in the 19th century had a very strong indication for pain management, and there are lots of reasons why that might be. But if you are first trying to learn herbal medicine, that makes you kind of crazy. I am a doctor, and I am not going to abandon that and it is a very useful place to start from. I am going to be interested, as a doctor, in phytomedicines, really, really interested in medicines that have been regulated, standardized, are consistent, so that when I put them into this very sophisticated system, I can be pretty clear about the actions and the effects of what I am going to see.
Now, I have some other friends who are traditional herbalists. Amanda McQuade Crawford and Tieraona Low Dog, for example. When Amanda and I sit down together, we are able to really completely share. She is trained to professional standards. That is a very different kind of herbalist than someone who casually picks some things up.
David Hoffman is another really great colleague of mine. He is a wonderful practitioner. He knows more about adaptogens than anybody I have ever met before. I would yield my training to his in a second. If he says, “Oh, this is the right adaptogen,” I would be like, “Aye-aye, sir. Will do.” You know? Because he has had years of training.
So I do not want to throw the baby out with the bathwater. If we integrate herbal medicine into conventional medicine, I think the first step is the step I am talking about, doing phytomedicines especially for medically trained practitioners. Phytomedicine has a practice in Europe. But I do not want to disadvantage and diminish our practitioners in the other realm of herbal medicine who are highly skilled, very well trained, very sophisticated practitioners, and I want us to honor them, learn from them, and maybe eventually we will find a way where a large enough primary care practice will have a visiting herbalist who can practice the way Amanda does or the way David does and be offering people, “Well, if you do not really want to take XYZ, if you are willing to do this and this and this, we can manage you in this part of the clinic,” and that would be great, too.
And I said, “Look, do you want to be helpful if someone says to you, ‘I do not want what you have to offer’? Do you want to not listen to, not validate them, or do you want to say, ‘I respect your concern. These are strong medicines. Let us try another way first. If that does not work, we can come back and revisit this.’”
E-mail: mary@maryhardy.com
Does that not leave you in a flexible therapeutic stance with people? Does that not create trust and accommodation so that if someone really is in trouble you say, “Look, I hate to have to say this, but you need to go in the hospital. This is not safe for you right now.” And over the course of practicing with them and being accommodating and working with them and not ever doing an inappropriate thing with them, but just trying to always find what medicine will they empower, if you say that to them, then they really have a whole history to fall back on of, “S/he has always listened to me. S/he has always taken my perspective into account. I guess I can yield this time, because I know s/he believes that, and would tell me if it was not true.”
I think that is an example of how teaching can be powerful. And if I can do that a hundred more times before I am done with my career, I will have created a future for the patients I will not be there to see.