AT: You’ve had an interest in research for many years. Let’s begin by talking about that. What fascinates you about research?
David Riley: At first blush, research may appear fairly cut-and-dried. Yet, this has not been my experience. I’ve found research to be a powerful tool for communication of valuable information and at the same time, it has some of the characteristics of a coded message like those used in private societies or tribal rituals. The main point is that research is not only about objective data; it is a much richer intersection of personal and cultural beliefs with what we know and how we establish what we know and believe and why.
Of course, it is the “currency” of information exchange in the scientific community. If you want to communicate with the scientific community about complementary and alternative therapies, you will be much more effective if you use their language. I used to believe that the results of research would give me definitive answers that would be forever memorialized. This has not been my experience; in fact, I usually have more questions when I finish a clinical trial than when I began. The answers you get out of clinical research are largely the result of the questions that you ask and the way you ask them, your hypotheses, and your methods. Those questions and answers pass through our visible and invisible cultural filters. Sometimes answers are accepted as true that may later be shown to be false and likewise answers that cannot be explain or that are incongruent with the cultural and scientific tradition are commonly rejected. So, for example, medicine is attached to finding material explanations for physiological changes and illness that occur in the body. It seems to follow from the reasoning that since we can see the body, and the body is a physical entity, there must be a physical or material explanation for illness. We seem to have difficulty believing that mind-body forces, spirituality, and other non-material energies that we all accept as real in everyday life can cause illnesses or stimulate health. I don’t want to deny the physical and material causes of disease, but they seem to exist on the surface of a much richer reality. The essence of science is curiosity, and these phenomena that cannot be easily explained with our current models need to be accommodated. This touches on the question of what constitutes evidence. There’s a tendency in scientific circles to ignore evidence that challenges the conventional model - the very evidence that should pique one’s curiosity is dismissed! I think we have to look at all of the evidence, not just the evidence we like. All of the anomalous data that are dismissed comprise an extensive body of uncontrolled clinical observations that make up the raw material of science, from which one can develop a testable hypothesis. For me, this is the essence of science and the reason I get excited about science and the scientific method.
We need to recognize that some CAM modalities do not easily fit into the biomedical model. Most of these treatments can be researched and studied scientifically; however, it will be challenging to do so, and we may need to expand our view of the scientific method. We will almost certainly need to look at a broader base of evidence than that which is derived solely from randomized controlled trials. Of course we do that already in surgery. Many commonly accepted conventional medical therapies have limited evidence for their effectiveness. Just today I saw someone who in the 1950s was treated with radium irradiation for birthmarks and is suffering the consequences. It is a myth that most of what we do in conventional medicine is evidence-based from randomized controlled clinical trials. One of the common hallmarks of CAM therapies is that they are individualized to the patient and often used in combination with other therapies and lifestyle recommendations. It will be challenging to study these therapies, and it probably cannot be done using the cookie-cutter approach so common in contemporary medical research. In conventional pharmacology, for example, the general plan for some time has been to isolate biologically active plant components, patent a synthetic analog, and bring a drug to market. These drugs often have one very powerful action that overwhelms the body’s ability to respond. Botanical preparations are different. First of all, most of t hem are not patentable, and therefore cannot economically justify a $200-500 million drug development cost. Second, in most botanical preparations the whole plant is used. It is full of compounds that may have paradoxical effects that stimulate different actions in different patients. When you offer the body a choice of responses, multiple outcomes may occur. How does one test this? Are the group characteristics that are evaluated in a typical randomized controlled trial the best way to go? Perhaps not. A less reductionistic model that can handle multiple variables with a variety of possible outcomes might be necessary. This is one of the reasons I am personally more interested in overall outcomes than specific effects.
There are many ways to conduct an investigation. Imagine a mural on the side of a large building. If we step back far enough from the mural to see it in its entirety, we will miss many of the details, but hopefully we will have an overview. If, however, we stand close and use a telescope to look at the mural, we will get a very precise, in-depth view of a very small portion, but we could not begin to offer a description of the whole mural. I am interested in the overall mural. One of the areas of research I’m most interested in is health services research. I enjoy looking at what happens in a practice -based setting. Even though I may be able to control for variables in the same way I can in a randomized controlled trial, the data sets and information that emerge are very rich. In the process of controlling for all the variables in a randomized controlled trial, you set up another set of artificial circumstances that differ from the real world of medicine. I want to evaluate how a medical therapy works in a practice-based setting and use that information to educate providers and patients and help design better clinical trials.
I think the effectiveness of any medical therapy has a non-specific component. This means that how I relate to my patients and how they re&late to me, the effect of coming into my office, and all sorts of other things have an impact on the outcome of the treatment. This is in addition to the medication I may give or the therapies I use. I don’t believe these nonspecific responses are either linear or trivial. The study of placebos by Ted Kaptchuk and the exploration of the therapeutic encounter by David Riley raise important questions about what it means to treat patients.
AT: Imagine that 100 patients come to see you and 30 get better even though you do nothing. You see another 100 patients with the same problem and give them treatment X. If only 20 get better, you say the treatment isn’t very good, because 30 got better without doing anything, assuming the patients were equal. Another 100 patients come in and you give them treatment Y and 50 get better. The conclusion is that treatment Y is good.
Riley: There are some difficulties with that reasoning, though it does seem to be commonplace. You are assuming a stable placebo response across time and across groups, and I am not aware that the placebo response has been shown to be stable or linear. When calculating result s in conventional clinical research, we generally assume that the total response of the treatment has 2 components: one is the effect of the medication or treatment and the other is a placebo response. If you add those up, you get the total response. But we assume there is linearity across patients, across time, and across treatments that has not been demonstrated. It may be that for those who are highly suggestible, the placebo response is 80%, and for those who are not suggestible, it is 20%. It may be that in a clinical trial, those patients who are compliant with therapies get a better response than do those who are not, regardless of whether they receive the real medication or a placebo. Because we don’t know what the placebo response rates actually are, we can’t control for them even though we try. It may be that the people enrolled in any given clinical trial have, for any number of reasons, a very high placebo response rate. When you reproduce exactly the same time trial with exactly the same cohort of patients somewhere else in another part of the world, the nonspecific or placebo response may be totally different. I would not assume t hat because you get a 30% response in the first group, you will have a 30% response in the second group. Yet this is an unspoken assumption that is common in interpreting the results of medical research. It may be that the use of placebo in medical research has more to do with limiting observer bias than measuring effectiveness or efficacy.
AT: How about a favorite research project?
Riley: I am currently working on health services research that involves collecting practice-based data. We are collecting out comes data from patients and providers, offering practitioners a useful and simple way to collect information, and offering this data to the scientific and academic medical community as well as the providers who participate in the clinical trials. I believe this type of research effort is creating the balance and momentum necessary t o advance integrative medicine and impact the delivery of healthcare without CAM becoming just another therapy for a specific disease or condition. Patient involvement is critical, and patients’ perceptions of outcome and satisfaction are a key ingredient. And these outcomes should probably be collected independent of the practitioner to get a clear sense of the patient’s response. Practitioner involvement, particularly from those in a “real-world” medical setting, is necessary for understanding what is happening outside the rarified setting of academic medicine. In a real-world practice setting, this information can become part of the patients’ charts, and the forms should take less than 3-5 minutes to fill out. Then, of course, there is a scientific structure around the project provided by those with experience in health services research. The structure of this project respects the 3 stakeholders in integrative medicine: patients, providers, and science.
AT: You had a primary care integrative medicine practice for many years. Let’s talk about that.
Riley: My practice has evolved over the years and I am continuing to explore alternative therapies, how they influence the therapeutic environment, and how they affect me. Mostly I try to maintain a position of “not knowing” - not knowing what I am going to do when somebody comes in the door. The further I go in this exploration, the less of an agenda I try to have concerning what I think the patient will need before he or she arrives and before we’ve had the chance to be together. An encounter with a patient should be therapeutic for both of us. The patient may be coming with certain expectations; nevertheless, I try to stay in a space where I don’t know until I do know, and then move in that direction. There is always a delicate balance between intellectual knowledge, intuition, and what the patient wants. I try to use whatever knowledge I have to challenge my intuition, using my intuition to keep me in the state of not knowing, but trusting that I will. It is not easy; I often recognize the state of balance by noticing that I am not there.
AT: What diagnostic tools do you use?
Riley: I am board certified in internal medicine, so I use the biomedical model of conventional medicine as a grounding and a springboard into other therapies. I use homeopathy, therapeutic yoga, counseling, as well as, herbs and dietary supplements. I have a particular interest in manual medicine, probably beginning with yoga, and I am currently studying biodynamic osteopathy as developed and taught by Dr Jim Jealous and his colleagues.
AT: Can you give an example of how you have used homeopathy?
Riley: The practice of homeopathy is superficially similar to conventional medicine. You have a presenting set of symptoms; some are important, some are not. You do a physical exam and, based on an integration of this information, you select a medication. In some cases, on the surface at least, you might not be able to tell the difference between a conventional medical encounter and a homeopathic one. One big difference with homeopathy is that I am maintaining an awareness of and integrating symptoms experienced by a patient on different levels, from emotional to mental to spiritual, in addition to the physical manifestations of illness. The art of homeopathy is matching the symptom picture of the patient with symptoms associated with the remedy. It is also not uncommon for me to see patients on conventional medications t h at must be continued. I often will prescribe a single homeopathic remedy.
AT: One dose of a medicine?
Riley: One dose of a medicine. It is actually even stranger than that. It is often one dose of a medicine that, from a pharmacological point of view, has no material substance. And then I wait and see what happens.
AT: And does something usually happen?
Riley: Yes. I would say that 20% to 30% of the time I can have a significant impact on a patient’s problem, and between 60 and 70% of the time I have some impact on their condition. About 20% of the time homeopathy has no effect at all on my patients. I used to believe that whatever therapy I was passionate about was going to cure the world and that when enough practitioners and patients learned about it; everyone would begin to use that therapy. I am coming around to the belief that the therapy chooses the provider and the patient as much as or more than the other way around.
AT: What do you mean by that?
Riley: I began to realize that there are patients for whom homeopathy - or any therapy, for that matter - is just not going to work. I’ve had to learn to keep an open mind and to recognize what I can and cannot treat or whom I can or cannot treat. On another level, I believe that my job as a provider is to find the therapy that I can most effectively use as a fulcrum for healing, and to recognize that, at some very important level, all healing is self-healing. I have to learn to get out of the way.
I would say that most patients come to me expecting to get some sort of complementary therapy in addition to a conventional medical evaluation. My commitment is to try and develop a plan with my patients that will work for them. Interestingly, my most difficult patients are often those who I believe need conventional medical treatment and for whatever reason chose to not go that route. One of the dilemmas in alternative medicine is that patients have such high expectations and hopes, yet we also have a culture in which patients are desperately searching for the right pill or the ultimate cure. People have come to me sometimes with shopping bags of stuff that they were taking - literally a shopping bag full. When a person is on 10 nutritional supplements, 2 or 3 Chinese herbal medical formulas, 2 or 3 Western botanical formulas, maybe some conventional medications, and a combination of homeopathic remedies, I don’t know where to start except to tell them to stop and listen to what their body is telling them. What I want to create is a partnership -a relationship that works both ways. I believe this is one of the things that makes an encounter therapeutic. Finding a balance, though, is challenging.
AT: How did you learn to be effective?
Riley: By learning from my mistakes and continuing to explore. Yoga and meditation have been 2 gifts for me personally – they have taught me to be more patient. I continually practice being more patient and learning to watch and wait. The answer will come at some point. It may already have come, in which case I have to go back and take a look at it in terms of my previous encounters with the patient, or it may come at the end of a patient visit. I have to fight the tendency to interject or jump right in and “get to the bottom of things.” The most valuable information is usually somewhere around the edges or in the nuances of a patient encounter. Maybe it’s in the way they are dressed, or what they say in the first 5 minutes. More often than not, particularly with chronic medical problems, these subtle things, which are directly related to why the patient was in my office, are important.
AT: How do you use yoga?
Riley: Yoga was actually my introduction into alternative medicine, though I didn’t realize it at the time. When I was a medical student in Salt Lake City I took a yoga class and went on to become a certified yoga teacher, traveling to India to study and attending yoga intensives throughout the United States. After I started teaching yoga I discovered a wonderful community of friends through yoga and gradually became aware that the experiences I was having while teaching yoga were quite similar to what I wanted to have while I was practicing medicine. I can still remember going to my first extended yoga workshop in Austin, Texas, and doing yoga for 6 to 8 hours a day for about 2 weeks. I came out of that workshop with a different experience of my body than I went in with - my understanding of it, the way I moved, my knowledge of what the possibilities were; it was a transformative experience. After that, I started teaching yoga classes and discovered a wonderful community of friends in Salt Lake City around yoga classes. I gradually became aware that the experiences I was having while teaching yoga were what I wanted to have while I was practicing medicine. Over time I incorporated therapeutic yoga and what you would call restorative yoga into the therapeutic encounters with my patients. Getting people in touch with their breath, teaching them some simple postures, working with them to develop flexibility and strength - all seemed to be useful and helpful for my patients.
AT: What happens when you get a person in touch with his or her own breath?
Riley: The breath is a doorway between the body and other levels of consciousness and can be a fulcrum for the process of integration. When I’m doing yoga - and for some time afterwards, particularly if I go to a meditation retreat where I am focusing on the breath - I become much clearer on what is going on inside of me and around me. It’s as though I’m accumulating reserves of energy and insight. The more I can strengthen a person’s internal reserves, the more likely she is to activate her own self-healing process.
AT: Tell me more about yoga and the philosophy of yoga.
Riley: Yoga is one of the philosophical systems that evolved in India. One of the classic yoga texts was written by Patanjali 1000 to 2000 years ago. Interestingly enough, Patanjali hardly discussed the postures, but over the years they seem to have evolved into a preparation for meditation practice and a physical discipline in their own right. Patanjali focused on yoga as a path to self-realization. There is a well-described 8-fold path in yoga that begins with right living, a sort of “golden rule,” and evolves through the postures, breathing, and meditation to Samadhi, a state in which the person can become unified with Paramatma, or the collective universal mind. In this respect, yoga overlaps with other Eastern philosophical and religious traditions such as Buddhism, which also originated in India. One of my favorite stories is about the Buddha and an encounter he had after he became “enlightened.” As he was passing through a village, people looked at him because they recognized him as a prince but knew that something was different. So they asked him a number of questions: “A re you this, are you that, are you a god?” And he would say no. They finally gave up trying to figure it out and asked, “What or who are you?” The Buddha’s response was, “I am awake.” That is a nice place to be - to be awake. It is a continuous state that is available all the time. One of the most profound realizations I ever had was the idea that at the moment you realize you are not awake, you are awake. The very act of realizing that you are not awake can only come from a state of being awake. I find it comforting to realize that each moment holds the potential to awaken once again.
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