Integrative Medicine

January 21, 2020

Information

Dr. Gary Soffer

January 20, 2020

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

call: 203-785-4095

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00:00Support for Yale Cancer Answers comes from AstraZeneca, working side by side with leading scientists to better understand how complex data can be converted into innovative treatments. More information at astrazeneca-us.com.
00:13Welcome to Yale Cancer Answers with doctors Anees Chagpar and Steven Gore. Yale Cancer Answers features the latest information on cancer care by welcoming oncologists and specialists who are on the forefront of the battle to fight cancer. This week, it is a conversation about integrative medicine with Dr. Gary Soffer. Dr. Soffer is an Assistant Professor of Clinical Pediatrics at Yale School of Medicine, and Dr. Gore is a Professor of Internal Medicine and Hematology at Yale and Director of Hematologic Malignancies at Yale Cancer Center.
00:50<vGore>What I understand is that part of your life is in pediatrics, but the integrative medicine part is really mostly in adult oncology, is that right?
00:58<vSoffer>That is exactly right. I spend most of my time seeing pediatric allergy patients and then a portion of my time I get to see adult cancer patients for integrative medicine consult.
01:05<vGore> How did you get involved with that? I can imagine how you became a pediatric allergist, that seems like a straightforward path. But how did this other piece come into your life?
01:12<vSoffer>To me, the integrative medicine portion seems more logical based on where I am coming from. I really got into meditation when I was 5 years old and I was taking a Taekwondo course. And the teacher said sit in front of the class and just pay attention to your breathing. And so I did and that really informed a lot of how I lead my life moving forward.
01:37<vGore>Even at 5 years of age?
01:39<vSoffer>Well, I did not know what it was at that time.
01:41<vGore>Right. So, why did you adopt it? What did you notice that made it impactful, or just being cool like your Taekwondo teacher?
01:47<vSoffer>It was probably a little bit about being cool and being weird. But it was also a meaningful experience. I was able to focus on my thoughts and retrospect the way I was thinking and the way I was interacting with the world was very different as time moved on and I think I have a lot of that practice to thank for that.
02:06<vGore>So, you carried a mindfulness practice throughout your life starting at a young age?
02:12<vSoffer>Like anybody who practices meditation, it comes and goes. Like it is with anything. It is like going to the gym or something. Some days are good and some days are bad.
02:22<vGore>But it is something that you have always been interested in?
02:26<vSoffer>It is something that I have always been interested and engaged in. Yeah.
02:26<vGore>And then eventually you got to medical school.
02:30<vSoffer>So, I had a bit of circuitous route. After I left college, I worked in the music business for about 5 years. And then, after I left the music business, I did not really know what I wanted to do.
02:39<vGore>So, you went to medical school?
02:45<vSoffer>It is more or less that simple, but I had a cousin who had ulcerative colitis and Crohn's and he was in the hospital for about a week. And he was miserable. I had the time off and I went to go visit him for a couple of days in a row. We just had a blast. And we had a good time and I watched him starting to heal and I think that made me realize how much the experience of a disease is as important as the disease itself. And so, that is really what brought me to integrative medicine as a practice, was knowing that if we change the experience of the patient's disease, then we can actually change the disease course on some level.
03:21<vGore>And yet I assume, you went to a mainstream medical or osteopathic school, which tends to not focus on those elements right?
03:29<vSoffer>Yes. I actually had a really interesting experience. I went to a medical school in Israel and Israel I think, do not quote me on it, has one of the highest per capita of acupuncturists in the world. And so, integrative medicine is actually a really, really big part of how they handle medical care. One of the facilities I worked at there was run by an orthopedic surgeon whose requirement was if you want to do surgery, you need to go see the integrative practitioners first.
04:03<vGore>And is that covered by the healthcare system there?
04:10<vSoffer> Mostly, yeah.
04:12<vGore>And is it available within the mainstream medical centers?
04:15<vSoffer>Not all, but some. So, there are larger centers, different hospitals different situations.
04:19<vGore>Okay, so then you came here and somehow you decided to be a pediatrician, right?
04:23<vSoffer> Yeah, kids make me happy. The best part about being with kids and I think what I try to apply to integrative medicine as well, is kids do not really want to be sick. If you are with a kid with a fever and they are miserable, but all of a sudden you give them Motrin or Tylenol, and they are just running around going crazy like they were before. And so, how do we apply that to adult patients is, we try to take them out of their disease and their existence. You know, I get sick and I am miserable and in bed for 3 days.
04:54<vGore>Me too. I am wreck. My wife stays away from me because I moan, I get semi-delirious and my fever gets to 103 or something like that. I am just a wreck. So needy.
05:07<vSoffer> Exactly. But it is also that chatter in our head, right. I might feel fine now, but how am I going to feel in an hour from now. And I think managing that is a lot of what I do with cancer patients. Cancer patients have, when they get their diagnosis, they have a lot going on in their head, and so they are asking themselves what did I do to deserve this, what could I have modified in my past to change that, is the cancer getting worse, and then even when they survive that, they have that chatter, is it coming back? Do I have to worry, should I go to the doctor? And so, what kids are really good at is not paying attention to any of that. And so, I think practices like meditation or yoga can really allow us to sort of be in the present moment and just be where we are.
05:57<vGore>Did you do formal training in this integrative piece or is it just stuff that you have acquired here and there?
06:03<vSoffer>It is a little bit of both. There is a formal training program at the University of Arizona, that is a fellowship that I am participating in now. I am also trained as a meditation instructor and have a lot of experience in integrative medicine as well.
06:17<vGore> Very interesting. So, let us say that I am a cancer patient and I do not know anything about integrative medicine, but I heard this radio show and sounded like something I should be interested, what do I do, I know I am sure I can get on the web and find 5 million different kinds of advice about things I should and should not do and things I should and should not eat and all this stuff, there is a lot out there and some of it is really worrisome right?
06:45<vSoffer>Yeah. I mean, that is the beauty of being in some place like Yale where we can have this open communications with the patients, oncologists and patients can feel comfortable presenting these questions to us, should I take this, should I take that, should I do this, should I do that. You know, the amount of nondisclosure for integrative practices with conventional doctors is staggeringly high.
07:08<vGore>I am not sure I got what you meant there?
07:10<vSoffer>Most patients just are not sharing with their oncologists or even with their doctors what they are taking.
07:17<vGore>They do not tell about the supplements. And doctors do not ask a lot of times.
07:20<vSoffer>Exactly. Absolutely. And so, what we are doing is creating a safe space for those patients to have these conversations and ask these questions. And we are also creating a safe space for the oncologists who intuitively just say, do not take it. You know, who intuitively say I do not really know about it, these medications can interact with your chemotherapy, just do not take it. And so, I think by creating that space, we are giving patients a little bit more autonomy in their care, that is essentially what they are looking for from us, and we are giving oncologists a little bit more space to say I do not know, but this person might.
08:03<vGore>So, a patient can ask to be referred to your group, is that right?
08:04<vSoffer>Yeah, they can ask to be referred or it can be offered to them.
08:10<vGore>Well, right. I am assuming that a lot of us do not even know that you exist, I am afraid. But let us just that they are seeing Dr. Gore and Dr. Gore is not really tuned into that, but they could say, Gee I hear there is an integrative practice here, is it possible to see that person and I could make a referral then right?
08:32<vSoffer>Absolutely.
08:35<vGore>And so, what happens when the patient sees you then?
08:38<vSoffer>Each patient is different and that is sort of the beauty of my job, is that I get to tailor each management plan to each patient. So, if I have a patient in pain, there are so many different modalities that might connect with different patients. For some people, it might just be a body scan meditation. A body scan meditation basically lets you focus on each body part and you slowly move through the body as you follow your breath. Acupuncture might be better for some patients and yoga might even be good for some pain patients. First of all, it depends on the pain itself, but it also depends on the patient and what they are seeking and how much they want to participate in their own care.
09:13<vGore>What are some of the things that patients present to you asking for? You have mentioned pain control, pain management. That is I am sure a big one, what are some of the other symptoms that patients might not know that integrative medicine might be helpful for?
09:35<vSoffer>The overarching question is how do I modify my disease. And so, nutrition comes up quite a bit, patients do ask about supplements often, meditation, yoga, they want to know about the services that we are offering at Smilow, like yoga, like Zoomba, like art therapy and how to get more involved in those things.
09:54<vGore>Gotcha. So, the patient talks to you about it, you have to be familiar with their care plan I guess because you do not want to interfere with their conventional care plan right?
10:07<vSoffer>Absolutely. There is a lot of misconception about supplements and the belief is that because they are natural, they are safe for you. But, these supplements go through the same sort of systems as the regular drugs do and can prevent the drugs from doing their best or can actually cause the drugs to do worse.
10:29<vGore>And I am sure, you are likely familiar with the study that came out of Yale last year where, as I recall, they looked at patients who opted for non-conventional treatments strictly as opposed to conventional therapies and showed that the survival of patients who did only non-conventional was inferior, which is different than using integrative medicine in a supplementary way or in a complementary way, I guess complementary is probably a better word right?
11:05<vSoffer> Yeah, ultimately it is just good medicine. Most of what I am doing is evidence based, so I am asking myself 2 questions: The first question is, does it work, because that is pretty important and then the second question I ask myself is, is this invasive to the patient and their care? And so, I weigh those two things out. Meditation to me is the perfect example because we know it works on a molecular level directly with patient care and it is not really invasive at all, maybe to a smaller degree but other things can be quite invasive and quite damaging to the patient and they may not be safe, but they may not be invasive at all. So, we try to balance those things out. One of the important things about opening up integrative centers at places like Yale is that we have these conversations so we can do the best for the patient. We have to ask ourselves why patients are really seeking out alternative care and again, it goes back to that point of autonomy. Patients really do want some control over their care. You just told them that their body is sort of working against themselves, acting against themselves and I do not think there is a more powerless feeling than hearing something like that. And so, once patients go online and they start looking for things, I think they are just seeking that autonomy, and so if we can hand them that and we can work with them while they are getting their conventional chemotherapy, then I think what you are going to see is that that is probably the best patient care that we can give.
12:36<vGore>So, lets say the patient sees you and lets say that your prescription, and tell me if I am making a stupid assumption here, is going to include some meditation practice, maybe some yoga, maybe some acupuncture or whatever it is, and they set that up, do they come back then in a follow-up visit to get reassessed?
13:00<vSoffer>Yeah, absolutely. What I am doing takes work from the patient. It is not a passive process and not everything that I give to a patient is going to work for them, and I just want them to try it. So, I have patients that come see me several times and we try to find a plan that works best for them.
13:16<vGore>And what is the interval, how long do you give meditation practice, is 2 weeks of daily meditation going to be enough to see if it is helping or?
13:29<vSoffer>I usually see patients at about 1-month intervals if that works for them, but once they find a system that works best for them, then I send them off.
13:40<vGore>And they are on auto-pilot but they can come back for refreshing. Great. Well, this is fascinating. Right now, we need to take a short break for a medical minute. Please stay tuned to learn more about integrative medicine with Dr. Gary Soffer.
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14:48<vGore> Welcome back to Yale Cancer Answers. This is Dr. Steven Gore. I am joined tonight by my guest Dr. Gary Soffer and we have been discussing the field of integrative medicine, particularly as it applies to cancer patients. Gary, before the break you were talking about a variety of modalities of complementary care, which can be helpful to patients in symptom management including meditation practice, yoga, you mentioned acupuncture and so on. So, is that stuff that your group supplies or do you refer out? It seems like a lot of people might want those services, but there are not that many of you?
15:30<vSoffer> Yes, so it depends on the practice. We offer classes like yoga, meditation, inpatient we offer massage therapy that is probably one of the biggest pieces of what we do and Reiki as well. Acupuncture at this point is something that we have to refer out, but when we think about the long-term trajectory of where we want to take our program, acupuncture is definitely going to be big piece of that.
15:56<vGore> Right, and I think there is quite a number of acupuncturists in the area in Connecticut?
16:02<vSoffer> There are. You know, the question becomes and this is with all of integrative medicine, is how do you standardize it and how do you seek out the right practitioner. The standard which I go by is that Sloan Kettering actually has an acupuncture training program that people can do, and so what I generally recommend to patients is that they seek out practitioners who have gone through that program.
16:24<vGore>Wow! And how common is that, can't be that common?
16:29<vSoffer>So, it is actually fairly common because acupuncturists have some degree of continuing medical education requirements and so if you say, hey these are the practitioners that I am referring out to, they are more motivated to take classes like that.
16:44<vGore> Right. And so, if they have taken classes like that, that helps them understand how to use their modality better, particularly for the treatment of cancer?
16:55<vSoffer>Yeah, exactly.
16:58<vGore> Gotcha. Gary, I am going to challenge you a little bit and I really want to say first of all that I come from a place where I am very interested in the kind of work that you are talking about and I buy into it conceptually, so I do not mean this to be hostile.
17:13<vSoffer>No, challenge away.
17:16<vGore>But I am also a scientist and what do you think about the issue about patients while they want autonomy and ownership of their disease, if you will, the worry that then when things do not work out the way they want, that somehow they are self-blamed, do you find that at all, or worry about it?
17:44<vSoffer>I don't. And I think there is actually more self-blame if they have the instinct to take the autonomy, but don't. And I think if they do not explore the questions that they are internally asking themselves about should I try this, maybe this will work, simply because they are in a conventional medical system, if they do not get better, they begin to question themselves, should I have done this or should I have done that.
18:13<vGore>I think back, again this is just anecdotally, to a really wonderful young man that I took care of when I was at Johns Hopkins, he was on his 20s or 30s, avid soccer player, who had a bad leukemia or at least the leukemia that turned out to be bad and he had done a lot of stuff about focusing on the stem cells and thinking about his healthy stem cells, and I think he had a stem cell transplant and did a lot of visualizing, and we had people there who helped with visualization therapy and stuff like that. I think maybe it was social work, I don't remember. And then, when his leukemia returned, he felt like Gee and I did all that visualizing and it still came back.
18:56<vSoffer>And I think they ask themselves the same thing about chemotherapy when their cancer comes back.
19:00<vGore>Good point. And of course, I did my best to assuage him that yeah you did your best and cancer is really tough and so wonderful that you did that and I would not stop doing that if it is meaningful to you.
19:18<vSoffer>And that's the biggest issue, how do you change that experience of the disease because while he was going through what he was going through and doing the visualization, it was meaningful for him.
19:27<vGore> And it was very empowering. I do remember that sour feeling, bitter feeling that he had, but I think your point is well taken that I went through 8 months of chemo and I had stem cell transplant and my leukemia came back like that is just not right, and of course it is not right.
19:49<vSoffer> No of course.
19:49<vGore>>Where is the boundary between what you do and spiritual practice and how do you interface with the chaplaincy and people's spiritual sides, I realize meditation practice can be a very important part of many religious walks?
20:05<vSoffer>Yeah, absolutely. There is no boundary between what I do and spiritual practice and it is a big part of what I do. Oftentimes, I am in a room with a patient and we talk about their spiritual practice and a lot of times, they have sort of just let it go to the wayside and they are finally seeking it out again, but they do not know how because it has been so many years. I do interface quite a bit with chaplaincy and what is interesting is I am actually getting referrals from chaplains.
20:30<vGore> Oh! I am not surprised. You will be a very spiritual chaplain group.
20:33<vSoffer> Which is awesome. Part of my prescription a lot of times is giving patients readings by books by Thomas Merton or by a Tibetan Lama called Mingyur Rinpoche who talks about death and dying. Connecting with the greater world and a spiritual higher level, whatever that means to you, whether that is god or anything else, is so important in these diseases because as we were discussing before, you do sort of start to ask yourself all these existential questions that may not have answers and sometimes faith can give you that answer.
21:16<vGore> Well, suffering and end-of-life issues and post-end-of-life issues are really at the heart of so many religious seekings I guess, and teachings.
21:25<vSoffer> Absolutely. Look, this is a little bit more esoteric, but I am of the firm belief that you can die healed from your disease, I mean it is no secret that everybody dies but how we die is a really important question and how we live our lives up until the moment of our death is a really important question, and I think spirituality whether that is religion or not can give you a really nice foundation for approaching those moments.
21:58<vGore>That's really fascinating Gary because I think a lot about my patients or patients of colleagues who near the end of life, and in my own personal experience and family members at the end of life and there are some who come to the end of life with an amazing grace, literally, and whether it is spiritually or religiously founded or not I think is variable, some people come with what I would describe as true grace in accepting the end of their life and making it meaningful and all that and then there are people like my mom who were just going to go screaming and fighting until the end, until her body did not let her and it makes us a little sad in retrospect because we were not really allowed to talk about death with her, that was pretty clear that we could not do that; so, I guess some are looking to you probably unrealistically about what distinguishes those people and what approaches you can offer to help move people in the direction of grace and I use that word not in a technical sense, really in kind of my emotional response to it if that is their goal, it is maybe too complicated.
23:38<vSoffer>No. You touched on a point that is actually really important and it does not directly answer your question, which I want to do. You know, treating the family around the patient is so important in what we do. I have had patients come see me with their loved ones and I will often turn to the loved ones and say, what are you doing to take care of yourself, and on more than one occasion, they have just broken down because I think it is the first time somebody asked them that. And the trauma and the tragedy and the guilt that you are dealing with as somebody you love is dying and doing your best to be in service to them but not being in service to yourself is a really challenging experience. So, what distinguishes a patient who is able to deal with their own mortality versus one that is not? I think that is a very big question that a lot of religions have done their best to answer. But what I do think is back to mindfulness meditation, because it does stem from Tibetan Buddhism, which is actually very focused on death and dying, it really gives us a nice opportunity to work on being present in the moment. If we are not so much caught up in the chatter like I was talking about before of what is going to happen next as opposed to what is happening right now, those moments of death and dying can actually be transformative and really change us and change the people around us.
25:21<vGore> Focusing on the process of just being there.
25:24<vSoffer>Yeah. There is a lot of overlap between what I do and what palliative care is doing. Because so much of that is deeply, deeply connected.
25:42<vGore> Yeah, I could tell you as you may have gathered from my last question that I experienced that with my patients, the patients who really have this kind of acceptance and grace impacts me, impacts me as a physician and impacts me as a person, and I want that, I want what that person has. I would like it all the time and I certainly hope that I can have that when the time comes for end of life, but I do not know, I chatter a lot.
26:11<vSoffer>Yeah. There is a great documentary about Ramdas who is a big spiritual leader in the 60s and Ramdas had a stroke and he was talking in the documentary about his experience with the stroke and he said all I could think about is I do not want to die, I do not want to die, I do not want to die and here I had been this big spiritual leader who is talking about death and dying and all this, and he said I realized I had some growth to do even at that moment when I thought I was about to die.
26:42<vGore>Recently I had the wonderful opportunity to do a workshop at the Omega Institute in Ryback, New York which as you may know sponsors a lot of alternative medicine things and meals are done communally for people, there are 6 different workshops going on at a time or something like that and what I did not know was there was a workshop going on about exceptional healing or something like that and people with cancer and other problems were looking to mindfulness and other features as part of their healing and wow! it was really interesting for me to share meals with them, many of them with cancer and of course I understood that, but they did not talk a lot about their cancer, they really were talking about the process and what you said about the feeling of ownership and just thinking about some of these people were travelling quite a long ways to come to Omega Institute to do that and I am sure there are many other places that do similar things.
27:54<vSoffer>Yeah, I think there is a profound difference between a cancer patient and a patient with cancer. Meaning, it does not have to be who you are and there are so many more elements of who you are and how you live your moments in your day to day, and I think that is what a lot of people are really seeking out.
28:10<vGore> Yeah, I mean, one of the beautiful things that a gentleman with brain cancer, glioblastoma, who was cognitively pretty normal to me and his wife was, she had a lot of grace and she would kind of talk to us on the side once in a while showing that there were limitations of his that she was dealing with, but in such a generous and loving fashion, I mean those are pretty amazing.
28:38<vSoffer> Yeah, it is how we interact with these diseases and how we interact with the people around us that I think is at the heart of integrative medicine.
28:45Dr. Gary Soffer is an Assistant Professor of Clinical Pediatrics at the Yale School of Medicine specializing in Integrative Medicine. If you have questions, the address is canceranswers@yale.edu and past editions of the program are available in audio and written form at YaleCancerCenter.org. We hope you will join us next week to learn more about the fight against cancer here on Connecticut Public Radio.