Tracy Gaudet, md: Being an Agent of Health Care Transformation

Tracy Gaudet, md, is director of the Department of Veterans Affairs’ Office of Patient Centered Care and Cultural Transformation, after serving as the executive director of integrative medicine at Duke University Medical Center. Before her work at Duke, Dr Gaudet served as the founding executive director of the University of Arizona Program in Integrative Medicine, helping to design the country’s first comprehensive curriculum in the new field (and oversaw Bill Benda, md, as one of the first residential fellows in the program). She is the author of Consciously Female,1 a book on integrative medicine and women’s health, and Body, Soul, and Baby.2

Integrative Medicine: A Clinician’s Journal (IMCJ): At what point in your life and career did you decide to pursue integrative medicine, and why?

Dr Gaudet: I don’t have any really overwhelming life story. The truth is I have always been wired this way. I wasn’t even premed—I was a psychology and sociology undergrad because I was much more into the holistic stuff, and I didn’t think medicine lined up with that. I finally decided that if I wanted to be a part of changing that particular system, I would have more of a shot at influencing it if I were actually part of the system. So, I finally bit the bullet, went back, did my premed stuff, and then went to med school. I didn’t have any life-altering experience that turned me onto it—I just had that more holistic perspective from the beginning. I’d have been a naturopath if I’d known about that as a career.

IMCJ: Were there any mentors at this early stage or anywhere throughout your career progression?

Dr Gaudet: I think I have had mentors and still do. I don’t think you are ever too old for mentors. What is interesting is that none have really been specific to integrative medicine in any way. The ways that they mentored me that I think have impacted my career are to say—I know it’s probably dorky, but it’s true—“follow your passion.” Even back when I was considering med school, I thought, “I’m not premed. I’m not like those people. I’m not hard-ass enough. I’m not a scientist.” The encouragement I received was not to worry whether there is a path from where you are to where you think you want to be—just keep stepping forward. I think it has influenced my career even more than people in the field, per se. They have been more out-of-the-box thinkers, or people who could show me it is possible to make things happen even where you least expect that kind of thing.

IMCJ: Why did you choose a transition to Veterans Affairs, or the VA, after leading the programs at the University of Arizona and Duke?

Dr Gaudet: That was actually a very big move for me. I had always been in academic medicine. I wasn’t really thinking of leaving Duke at the time. I always had a high regard for VA health care and medicine, but I did not really know about their vision for transforming to a holistic approach to health and well-being. When I was still at Duke, the VA contacted us and said, “You know, we’re starting up a new effort we call ‘patient-centered care and cultural transformation.’ We have a task force and we’re going to visit various institutions doing innovative work in these areas. Could our task force come and visit you at Duke?” I said, “Sure.” In preparing for their visit, they sent ahead their vision for this transformation. Per their language, it is the largest transformation of philosophy and approach to health and well-being that has ever been undertaken by this large of a health system. I read the stuff and it was like, “Holy cow. I didn’t know they were so forward thinking.” I mean, it was amazing. The vision was completely aligned with our vision at Duke and our vision at Arizona. They were not using the language of integrative medicine, but it was all the same concept. They came to Duke and I was thrilled because our work at Duke—our work at Arizona was more focused on how you transform the education of providers—was more focused on how to create model clinical approaches.

I realized that in order to really be impactful, I needed to partner with large systems. I couldn’t just do it in a corner of an institution. I needed to have partners like the veterans and health affairs to say, “Okay, how does it work when you translate it into a whole massive system?” I found myself excited about them coming, not because I wanted to leave Duke and work for the VA, but because I thought this to be the kind of large-system partner that Duke needed to show this paradigm to the world. Then, after they came to visit, one thing led to another. They said, “Would you consider leaving Duke and leading this initiative nationally?” And I said, “Oh I don’t think so.” They said “Well, let me send you the job description.”

It was so weird. I read this job description and it was like, “Oh my gosh—this is my job. I have to do this!” The platform, the ability to be able to do this in this massive health system with this large of a vision, was way too big of an opportunity that aligned with my passion just perfectly. And that’s why I transitioned. Long story, I know, but it was a big deal for me to leave Duke and join the VA. Even with all the recent trouble the VA has been having, we’ve still been able to make real headway in these areas, so it’s been pretty cool.

IMCJ: That is how you used to talk when you would explain why you left OB-GYN to go to the Arizona program. So, you had the same kind of motivation?

Dr Gaudet: Right, at least I’m consistent. It is true. I go where I think I can have the greatest impact. Once I think I can’t have an impact anymore, or I think I can have a bigger impact somewhere else, then I move on.

IMCJ: How is what you’re doing influencing the practices and politics at the VA?

Dr Gaudet: I have to say that the impact has been far greater than I anticipated, and it is not because of my work or the work of my office, quite honestly. It is because a lot of people who choose to practice medicine in the VA choose to do it for a variety of reasons, one of which is that the VA is very mission driven—the most mission-driven organization I’ve even been a part of. They want to help veterans. In this environment, they don’t have to be worried about managing the business of a practice, so they have more freedom, in a lot of ways, to do the right thing for their patients.

I found that there was so much innovation happening in different facilities in the health care system of the VA, but the people were really isolated and doing it without leadership. They were doing it because they were interested, or they were passionate, or their patients needed it or wanted it. Why I think the impact of our national office has been so great is because what we have done is catalyze the vision. It’s like suddenly these people who have been doing this work and trying to slog away in the different facilities around the nation now have a whole office dedicated to supporting them—to supporting veterans in this way.

That has been a huge deal. A lot of what I think we have done has been to catalyze the work and the people who are already on fire about it but were all siloed and did not feel supported from the top. A lot shifted when they set up this office. They said this is a national priority. The number-one strategic priority of the whole VA is to empower veterans to improve their health and well-being. The whole mission is about this. Suddenly, all the work was elevated and came out of the closet. Although we were able to give to support to places with funding, it was way more than the funding. It was more about us clarifying the vision and the future of VA health care in this way and then helping to remove barriers and obstacles. There are a lot of them—I don’t mean to make it sound like Pollyanna. There are so many people committed to this work, that a lot has been happening in a relatively short period of time.

IMCJ: Are there any particular integrative interventions that are more accepted, or more resisted, by the VA system that you’ve noticed?

Dr Gaudet: I think in terms of specific interventions or approaches, because we have a lot of veterans with PTSD, or posttraumatic stress disorder; pain; TBI—or traumatic brain injury—and things that cut-and-dried conventional approaches do not do particularly well. There is a lot of receptivity to what is going to actually help, so we don’t have a lot of resistance to the approaches: acupuncture, for example. The challenges are more about infrastructure and less about philosophy, and people support that veterans should have access to these approaches. One big challenge is that there are no jobs for LAc practitioners in the VA, so the physicians are doing the acupuncture. The barriers are that fundamental and that significant! Our office is creating this, and it’s going through the system, but it is just one illustration that I find where philosophies are not rejected as much as there are barriers to making them operational, if that makes sense.

IMCJ: Is there any particular research that is in the limelight at the moment?

Dr Gaudet: One of the things we are doing in the fall is supported by the VA’s huge research entity and initiative in general. This research organization, the Office of Research and Development, is cosponsoring with us a SOTA, which stands for State of the Art Conference. They are doing this SOTA conference specifically on nonpharmacologic approaches to pain. There will be a supplemental journal issue that will be published out of the convening. The purpose is to help define not only the research priorities of integrative health for the VA, but also the practical, clinical, and educational priorities. This is going to happen in November, and that is pretty exciting for us.

IMCJ: As an aside, my area of interest and research is equine-assisted therapy for chronic conditions, and there are a lot of therapeutic riding centers that are working with TBI and PTSD in veterans. Does the VA recognize any nonhuman modalities at this point?

Dr Gaudet: Oh yes, absolutely. I think the challenge we have is that it has not been uniformly available. There is a lot of support for equine therapy, and for canine therapy. You know, it is interesting that I have not encountered resistance to these ideas at all. It is funny because a lot of the hospitals will have pet therapy and dogs and other animals. There are always funny stories about different kinds of animals that are allowed in the VA centers. Philosophically, it is very much alive. I think the challenge we have is that it is not uniformly available to veterans nationally, with pockets where there is a lot of equine therapy and other parts of the country where there isn’t. The nice thing is we do not have to have everything offered within the VA. We can outsource them, and if the therapy isn’t available in the community, we can use the VA funds to have community providers develop those kinds of programs for veterans.

IMCJ: As far as the VA practitioners themselves, do they tend to be more collaborative, or more resistant to integrative medicine, or is it a mixed bag?

Dr Gaudet: Well, it is a huge health care system, and there are 340 000 employees. Can you believe that? So I think that there are probably pockets of resistance. One of the charges of our office is to educate the employees and clinicians. In the VA, if you say integrative medicine, they often will think only of the therapies and not of a different paradigm. They really equate integrative health and integrative medicine to the approaches and not the philosophies, so we’ll often use the language “whole health.” We have partnered with Dave Rakel, md, at the University of Wisconsin, Madison, to help design and provide education for clinicians. Of course, one of the goals there is to take people from really not understanding the philosophy and approaches to not only understanding it, but being receptive. Those courses are extraordinarily successful. Again, I think I have not found a lot of resistance, but I have found there are a lot of people who don’t necessarily have a lot of knowledge about this, and our job is to help bridge that gap.

IMCJ: As far as the patients themselves, are military personnel similar or different than civilians with regard to motivation and results using integrative modalities or ideology?

Dr Gaudet: Of course, I am going to make a gross generalization: I would say if anything, they are more receptive and more motivated. Particularly I think that the veterans who are dealing with complex kinds of conditions like PTSD, and the others we have discussed—those men and women just want help. They want to heal. They want relief from the suffering, and because they are dealing with those kinds of conditions and issues, I think they are really very receptive to other approaches. We have stories, after stories, after stories, of people who say, “Oh man. I was just on all these drugs.” More drugs, more drugs, more drugs, more drugs. They are just suffering. Certainly that veteran population who is dealing with those kinds of issues is very motivated and very open in general.

IMCJ: With regard to approaches and efficacy, the things we as the American public hear about veterans are PTSD, depression, anger issues, suicide, drug use, alcoholism, and TBI. Is there any particular approach that you found to be exceptionally useful for any of these?

Dr Gaudet: What is interesting is that we have clinics and places where they will integrate the integrative health therapies, and that is good and helpful. But what we really have been trying to advance, which we are finding is more sustainable and even more impactful, is a 9-week program where we walk veterans through a deeper reflection of their lives and what matters to them. Then they expand to think about different areas of their self-care, and that is more of a paradigm shift, right? Instead of only having them come in for acupuncture, or receive battle field acupuncture, or whatever. This approach is a bigger stretch and it requires more of the veterans. Do you know Henri Roca, md?

IMCJ: He was on the board of the American Holistic Medical Association with me.

Dr Gaudet: Well believe it or not, he is now in Little Rock, Arkansas. He has this great program for veterans with pain that is very much based on an 8-week exploration of what they really want for their health, as well as real motivation and deeper reflection of what gives them a sense of meaning and purpose. Then he links their health and their health choices to that thing that matters most to them in their life. There is a tool we have created, a kind of a personal health inventory, that helps walk people through some of that reflection and helps them get more clear about what really matters and what they want for their health. In that context, using these different approaches and modalities has a bigger impact because it is not just about, “I’ll have this acupuncture needle instead of this pill.” It really is a new relationship with themselves, with each other, and with their health. That is really pretty awesome. With issues like the ones you have listed, which are common and complex, this kind of an approach, which really engages people where they are and starts and ends with what matters to them, has been really wonderful.

IMCJ: Do you have any contact with or influence on the medical training in the military, or are you pretty much working with veterans themselves?

Dr Gaudet: Not so much. I have relationships with the folks who do have leadership in those areas. It is interesting, because the VA has so many academic affiliations. For example Duke had a VA right across the street. I don’t know the statistics on it, but the number of residents and students—the professional students—who do part of their training in the VA is really massive. So there is possibility. We want to really use those relationships to bring this approach to residents and other learners. We have not gone that route yet, but it is high on the list for us for strategy. There is a real opportunity that is within our reach because of those academic affiliations.

IMCJ: Is there a particular emphasis on any distinct ideology, such as functional medicine, or do you pretty much have a variety of inherent philosophies? I recall our definition of integrative in the Arizona program is that you don’t follow an ideology—you do what is best for this individual patient for that individual condition. Does the VA focus on or pay attention to anything such as functional medicine that already is developed as a specific approach?

Dr Gaudet: That is an interesting question, particularly now because it has come up a lot more in the last 6 months. I don’t know that we would use functional medicine as a brand per say, but we’re having more and more clinicians trained in functional medicine, and we are actually thinking of creating our own educational kind of clinical course for therapeutic nutrition and other aspects of that. Henri is doing a lot of that approach in Little Rock. Terry Wahls, md, is a physician who has multiple sclerosis, or MS, and really went head over heels into paleo and functional medicine approaches to her MS. She has been in and out of a wheelchair for 12 years now, and she runs a clinic in Iowa for veterans, bringing the benefit of this approach in a sustainable way. We are finding there are a lot of programs that are pulling these approaches into their work with veterans—they will say “based in functional medicine.” They don’t do all the testing, for example, and all of the supplements. They find that they can make great inroads with a few kinds of basic labs and a lot of nutritional changes—pretty dramatic nutritional changes. I think that is a part of the picture.

IMCJ: Okay. Enough of the boring stuff. Let’s get to politics.

Dr Gaudet: That is always exciting, right?

IMCJ: Do you see any significant partisanship when it comes to integrative medicine? Does either party seem more or less intuitively open to it, or rejecting of it? Can you generalize in this way?

Dr Gaudet: It is quite interesting, actually. I would say a couple things. I have never had any exposure to the political universe as it relates to health care until I took this job. I mean, I am totally new to this part of the job. For me, it has been quite fascinating to see it, learn about it, and experience it. The bottom line is that it is very bipartisan. There are passionate supporters on both sides of the aisle. When bills come through or are proposed, there is usually bipartisan support for them. There has been a lot of congressional support for integrative health and the veteran population, and that has helped us. Every time we get legislation from the Hill, even if it does not end up getting passed, it still comes to the VA as proposed legislation, and it has helped the VA focus on it and say, “We have to pay attention to this.” Whether the legislation passes or not, we have to do a better job at offering this to our veterans.

It has been really cool, and I have to say it has been really positive. You will appreciate this: We just got questions 2 weeks ago on equine therapy. What is the VA doing about equine therapy? Well, that is good. Those kinds of questions are helpful because it brings the attention of the organization to those matters, and we’ve gotten a lot of support from Congress on both sides of the aisle, so it is really quite cool.

IMCJ: It seems like a lot of our supporters in the past, such as Barbara Mikulski, the senior senator from Maryland and Tom Harkin, the senator from Iowa, have been leaving Congress. I am curious about the newcomers. Can you identify any Congress people who are considered strong supporters at this point?

Dr Gaudet: You know, my office could probably get you the names of some of the people who have sponsored. If that’s of interest. The thing the public can do, and it really does make a difference, is if some of these legislators are not conscious about integrative medicine. Really, truly, the constituents need to reach out to their legislators and say, “Hey we care about this. Can you get involved?” I guess I didn’t know how this world worked at all until I took the Washington, DC, job. It really does make a difference.

IMCJ: When I was with the naturopaths, every year we attended the DC Federal Legislative Initiative, and we would all go to Washington and meet mostly with staffers. Once in a while, we would meet with an actual legislator. Then we would have a display in the Rayburn House Office Building, where we would have all healthy food, and chocolate, and the good stuff. Of course, all the staffers would pour into it for the free food. I enjoyed it because I got a good feel for the fact that you can actually speak to your congressional office. It was obvious whose offices were open and friendly and whose were just going through the motions. It was an education.

Dr Gaudet: It is interesting, right? It is the staffers. They are the ones who get stuff in front of legislators. They are the ones who write it. They are the ones who drive it.

IMCJ: Have you been able to affect the breadth of practitioners serving at the VA to include those providing other modalities?

Dr Gaudet: I get a lot of questions from naturopaths who are hoping we will be able to create an occupational code for them within the VA—a position that they can be hired into—and our office is actually working on that. It is a very long process. To some degree I think the greater impact for veterans is to get more and more care in the community. I think there is more of an opportunity for them to get integrative health from community practitioners—they do not have to be on the staff of the VA, for example. So, I think it is going in the right direction. From the perspective of integrative health, that is a great thing. There are so many great clinicians and providers doing phenomenal work in the community. I think that is good for all of us.