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Mitchell Stargrove, ND: The Role of the Doctor–Patient Relationship

Interview by Craig Gustafson

Facilitated by the American Association of Naturopathic Physicians 2018 Convention and Exhibition, to be held July 12 to 14, 2018, in San Diego, California. For more information, please visit http://www.naturopathic.org/.

Mitchell Bebel Stargrove, ND, LAc, earned his acupuncture diploma from Oregon College of Oriental Medicine (OCOM) and his naturopathic degree from National College of Naturopathic Medicine (NCNM) and practices with Lori Beth Stargrove, ND, at A WellSpring of Natural Health, Inc, in Beaverton, Oregon. Since 1990, he has taught history of medicine at OCOM and NCNM (1990–1993). Dr Stargrove is a senior fellow of the Center of Excellence in Generative Medicine at the University of Bridgeport, in Bridgeport, Connecticut, and a member of the board of the Institute for Naturopathic Generative Medicine, American Association of Nurse Practitioners affiliate specialty society. He has served as an author and/or editor for several textbooks and journals on natural medicine and compiled the acupuncture section for the Integrative BodyMind Information System. In addition, he is chief medical officer of MedicineWorks. com, a division of Health Resources Unlimited, Inc, as well as a founder and board member of the Alchemical Medicine Research and Teaching Association. Dr Stargrove is coauthor of Naturopathic Medicine History and Professional Formation Timeline. In August 2012, the American Association of Naturopathic Physicians presented him with the Vis Medicatrix Naturae award in recognition of his activities. In 2015, Dr Stargrove was invited to be a founding member of the Naturopathic Council of Elders. The Oregon Association of Naturopathic Physicians and National University of Natural Medicine honored Dr Stargrove with the Living Legend Award in December 2017.

Integrative Medicine: A Clinician’s Journal (IMCJ): I understand you’ll be talking about the doctor-patient relationship at the American Association of Naturopathic Physicians, or AANP, this summer. What makes that relationship so critical to effective practice?

Dr Stargrove: In my observation, the single most important influence in therapeutic success is the self-healing, self-organizing processes within every living organism. The second most important thing is the therapeutic relationship. Ultimately, that is the one that the clinician has the most effect on. I think all the things about the particulars of therapy, whether you use herbs or drugs—or homeopathy or whatever—is actually third behind the therapeutic relationship, because you can have all the right prescriptions, but if the people don’t come in or follow through, you are not going to get very far. That is where the patient’s developing that sense of trust in the physician as well as trust in themselves also engenders hope—the sense of not necessarily knowing the answer, but of having a feeling of partnership and a sense of direction, not just being an object with a label. That relationship is, in general, important, and relationships beyond the therapeutic relationship are so important to people changing their illness and moving into health.

IMCJ: In the prevalent health care model, people are trained to abdicate control over their health and rely on doctors. How do you reeducate your patients and foster that kind of participation in their own care?

Dr Stargrove: The first thing I do is to try to show them that many of the things they have been told are “either/or” choices really exist on a continuum. In therapeutic care, many things are primarily in the hands of the patient in their daily life, and other things are in the hands of the practitioner. If someone needs their neck manipulated, that is very hard to do for yourself. I will help them with that, but if they keep having the same neck problem, then I want to look at what is going on in their life. So, for example, with right-sided midscapular tension associated with neck restriction and possibly migraines, I would look at their food, fat digestion, hormones, and/or their posture, keeping gall-bladder function in mind. When I can expand the frame of the dys-stress, we can reveal related foci of dysfunction and not just keep treating the same local problem, which enables us to move beyond the symptom expression to the pattern underlying it.

I sit down with patients and show them a 3-by-3 grid. This is the therapeutic map in what Lori Stargrove, ND, and I call person-centered care. I don’t use the word health care because health care is a modern industry term, and most of medical care is not necessarily health oriented. We provide care, and we provide it at 3 levels. The base of the 3×3 grid is labelled, “Problem” on the left, “Pattern,” bottom center, and bottom right is “Person.” Problem, pattern, person. What is our focus? How big is the frame? It is just like with a camera: Are you making it narrow or are you making it big? If the neck issue is here in the problem frame. That is something that external intervention is needed for. At the pattern level, we look for things that create that repetitive or obstinate symptom. And at the person level, we examine what can be learned from that problem and from working on that pattern to enhance who you are, because we ultimately approach every health problem as an opportunity for personal improvement and to activate each patient to be the true person who is latent inside. It is the art of living. The left side of the grid is “Repairing,” “Optimizing,” and “Activating.” What is the level of intervention? Are we just fixing a problem? Are we optimizing a tendency to a problem? Are we activating something and turning it into a solution or a benefit? We can really show people, that a neck adjustment fits in one square, or addressing a sore throat fits in this other little one-ninth of the map, but the pattern of sleep and what you eat and your stress and your posture in your chair, all of those contribute to the problem in a repetitive way, and that is part of the pattern. We use the nomenclature that medicine treats, and that is at the problem level; that nature cures, at the pattern level; and that life heals, at the person level. Medicine fixes things from outside, the person heals from inside, and in the middle is that place of relationship where patterns are formed. Nature cures because the rhythms of nature, as they move through the organism and through life, tend to smooth out the rumples over time—if we don’t just create the rut again. At our clinic, we show people this 3×3 map and we say, “At first we’re going to be working with you a little more in terms of your diagnosed complaints and I will be a little more the active one through prescribing and hands-on procedures. But we want to shift beyond fixing the it as soon as possible and move towards addressing the tendencies you have, the ruts of dysfunction you slip into, and then we want to move towards making this an opportunity for personal growth.” We work in that whole element of moving from dependency and training wheels to witnessing.

IMCJ: It sounds like your approach moves people toward assuming a mind-body perspective to health.

Dr Stargrove: As a historian and as a physician, I do not use the mind-body words because it is dualistic, and actually most traditional historical models have used 3 worlds of heaven, human, and Earth. In contemporary terms, the middle world between energy and matter is about information and relationships, and mind-body tends to still have the residues of Cartesian thinking, as in “mind over matter”—which I actually doubt that Descartes himself would’ve agreed with. We are really doing a whole-person approach, but it is also the whole-person in context. People are not isolated; it is the element of, “Who’s your family?” If you need pills—your herbs or your drug—who is going to get them for you? Do you have the money? There are elements of context that are so important, in the relationships particularly. We also tend to work a lot with concentric circles and address what people often call mind-body: the feedback system between the mental-emotional experience and the physical experience. But ultimately, we really look at the embodiment of health. You can have a great attitude and all of that, but you may still have a problem, and that may have to do with how you walk or what exercise you do or what food habits you have. I’m always wary of the notion of that “You’re sick because you don’t have a good attitude” interpretation of the mind-body phenomenon. In fact, for almost 30 years now, we have used the phrase bodymind. Starting in 1988, working on a giant software compilation with over 100 doctors and students coming out of National College of Naturopathic Medicine and Oregon College of Oriental Medicine, here in Portland, Oregon, we compiled about

 12 000 pages worth of clinical information in a database called IBIS, originally called the Interactive BodyMind Information System. That element of how our experience as an individual fits in a context becomes the focus, because we don’t really experience things separately as body or mind. We experience them as a whole. Sometimes you go to the doctor’s office and feel like they want you to send your stomach in and leave the rest of you in the waiting room. We really want to look at that whole-person phenomenon. I always liked Dr Pizzorno’s emphasis on the whole person—not just holistic, but the whole person including who they are, but who they are in their life.

IMCJ: You had mentioned that the doctor-patient relationship relies on going beyond just the therapeutic relationship. How is that used in a clinical situation?

Dr Stargrove: In addition to the 3×3 therapeutic map, we also teach physicians and students what we call the Four Cs. Those really come from work I have done over 20-some years on drug-herb and drug-nutrient interactions, issues of polypharmacy and deprescribing, and other things related to treating somebody who has several doctors and making it all fit together well. The Four Cs are about how to map out the influential factors in the care picture. The first is communication, the second is coordination, the third is collaboration, and the  fourth is contextualization. In many respects, they are sort of obvious, but you want to make sure the whole landscape is covered. The thing we really want to amplify in this presentation is that there are therapies to be coordinated, whether those are pills you take or activities you do— whatever interventions—and there are relationships where you do collaboration and that those 2 activities are sets of interactions. Having dealt with the substance interactions literature for a long time, everybody seems to forget all those things and talk about it like, “If we put licorice and some  high-blood pressure medicine together, what’s going to happen?” People want an answer for that, and with most potential interactions it is not very realistic because it depends on the person. The person is the biggest variable in the equation. But then you have to ask: Is the person is telling all the doctors the same story? Are the therapies compatible? Do they need to be sequenced in a certain way? Do you combine these 2 at the same time? You must figure out how to get the therapies to work together, safely and effectively, and then how to get the people to work together—the collaboration of the doctor and the patient, the collaboration among the various health care providers working with that person, and the collaboration of the other relationships in their life that play into their health and care. Contextualization describes what their values and needs are. What are their financial resources? What are their restrictions? How can we make this real? A lot of times, doctors give instructions, but the person doesn’t have a decent grocery store nearby or can’t afford the herbs, or all kinds of other variables, so we always look at all the ways we make someone’s health care functional, organized, and put them in charge to make the decisions that none of us can make for them. What we really need to do is to create a model that would work as well for a surgeon as it would for a bodyworker, an herbalist, a homeopath, a naturopath, or any profession or player within the medical team.

IMCJ: So this is all intended to come together in a way that can be used from the perspective of almost any healing modality?

Dr Stargrove: Yes. It brings up 2 important issues. Say a naturopathic physician or a broad-scope functional medicine physician is talking to somebody; I don’t want the discussion to just be, “What’s the safer, more effective way to treat your eczema?” and frame the problem in that narrow, short-term kind of way. If we can show someone, “I’m going to address your needs, but really, your eczema is related to your gut, to your blood, to your liver, and to this broader pattern. We can address that, but we need to frame it within a living systems perspective, and we need to see how all those aspects fit into your life situation.”

Literally, what I see is people saying, “I went to the naturopath and my skin got better.” I say, “Well, are you doing it now?” They answer, “Oh, no. It got better, so I stopped going.” Too often, clinicians frame the issue as, “We have a better way to treat your skin,” instead of, “We have a better way to make your system function more efficiently, to restore healthy function as your default.” That leads into the other question of what I see happening a lot in the naturopathic community, but more broadly in those who use natural therapies: Too often the argument is about drugs versus herbs or herbs versus hydrotherapy. It is all about the therapies. I think that is asking the wrong question. Sometimes in naturopathic circles, it becomes the green allopathy versus nature cure revival kind of debate. They are all valid, but the question shouldn’t be, “What therapy are we using?” The questions should be, “What is our therapeutic intent?”, “How does this treatment relate to the vital force and the self-healing processes?”, and, “How are we serving the person?” I see this as continuous with the original naturopathy of Lust and Collins and so many others as a big-tent approach bringing together practitioners from diverse therapeutic backgrounds based on their shared principles and goals. So in the circumstances of an infection, you ask what the safest, most effective way to treat a sore throat is. The next question becomes, how to judge an herb versus a Chinese herbal formula versus a homeopathic formula or a drug. I feel pretty confident that in most cases the natural therapies will win over as the best choice rather than a pharmaceutical treatment. If we need to use a pharmaceutical treatment, that might be a lower option on our list of preferences and we need to consider how to buffer and recover from adverse effects of that drug regime. If an antibiotic is needed, we ask how we make the antibiotic work. Then, [we ask about] what to do with timing of gut care and what to do with probiotics for rebuilding. How do you prevent the patient from getting another sore throat in 3 months? That issue of thinking on the level of intention goes back to the roots of Western classical physician training, particularly in ancient Greece There were schools of medicine that focused on treating the disease entity, the eidos, literally the “it,” and the schools of medicine that supported the health of the person. In one, the doctor’s in charge, in the other, the doctor serves. I don’t, again, see it as always an either/or. I see it as a fork-and-a-spoon kind of thing: Which tools are appropriate in which situations?

IMCJ: By excluding some modalities, tools are being left out of the toolbox.

Dr Stargrove: Yes, and ultimately, patients hate it when you, as the practitioner, want to fit them into your tool set instead of saying, “You need a tool I don’t have. I have a colleague who is really good at that.” At our clinic, we do lots of referrals, and we end up as the guides of the long-term process. We coordinate the people and do a lot of referring out because we want to have a broad set of tools that fit the situation, that fit the person, and none of it is static; it all fits within an evolving individualized strategy. PCP can be redefined as standing for “person-centered practitioner.” If you have to keep taking the same pill for 5 years to treat a diagnosed condition, I consider it a failure. The person should be a moving target, really an emergent process, because they’re changing and their therapies need to change. I rarely know past the next step what is going to happen. We’re watching to see how it shifts [and] how they respond. Ultimately, we are not trying to fix them. We are trying to fine-tune their response pattern. That’s why in natural medicine, when we’re not being risky with people, there is no wrong treatment because you always learn something. If you give a formula and only half of what you expect happens, you learn: This part of my hypothesis was true, but this part probably wasn’t. You probe and test and look for a response. All along the way, you help the person to fine-tune their ability to pay attention. In the long run, I would say my primary goal is to clear the noise in somebody’s system so they can pay attention and make good choices. If they say, “I ate at McDonald’s and it doesn’t bother me,” I’m going to say, “Well, you know, if you live in New York, it doesn’t sound noisy after a while.” What I want to do is remove the things that obscure their ability to pay attention, and then they start saying, “Oh, I ate that and I didn’t feel good.” You also have to reassure, “Hey, it wasn’t a moral failure. It was a good test. You ate the ice cream, and you got a sinus infection. Now you have the choice. Before, you didn’t have a conscious choice.” These things just sort of came out of nowhere. I cannot make people eat a certain way or exercise a certain way. I can just help cultivate their sense of feedback. They are paying attention and they are having some hope that what they do and what they choose is going to have some influence on how they feel.

IMCJ: In order to get patients to stick with things long enough to unlock their sense of perception and to have the patience through the probing and the trial and error, it all boils back down to patients trusting their relationship with the practitioner, doesn’t it?

Dr Stargrove: Yes. They are gaining trust, not just in me and my sincerity in working with them, but gaining trust in themselves. That is often the most important thing, and conventional disease-framed medicine has not taught people to trust themselves; it is mostly about being the hapless victim. We want them to understand that they have responsibility—not in a blame sense, because people have different starting points and different limitations— but in the sense of being the one who seeks the care. They are the ones who make the choices, and they are also working with us to determine, “Do we work on the small, the medium, or the big? What’s the timeframe?” and to offer that invitation. A lot of times, people come in looking to address “my eczema,” but really, stress in their relationship is what they really wish they could talk about. It may even be expressed in their eczema, but they have to get to trusting you before they start talking about their relationship, and more important, about what is important to them in their life as a whole. With trust, we can rekindle hope. When they know that someone wants to engage in that kind of discussion, rather than talk about pain on a 1-to-10 scale, then they are going to open up that relationship with the practitioner. It is going to set the standard for what they want from their health care providers.