Clinical Preventive Medicine, Integrative Medicine, and Lifestyle Medicine: Current State and Future Opportunities in the Development of Emerging Clinical Areas

The United States (US) ranks last in life expectancy despite higher healthcare expenditures compared to similar countries.1 Among contributing factors, preventable chronic diseases have been implicated with notable disparities across demographic factors, yet equitable provision of preventive medicine is underfunded.2,3,4 Under the umbrella of General Preventive Medicine and complementing population management approaches, clinical preventive medicine practice is adaptable and flexible, including core clinical preventive medicine and components of emerging clinical areas, addressing public health threats through expanding skills and expertise to respond to population needs. Clinical preventive medicine should be maximized to address preventable illness, health inequities, and increasing healthcare costs. While the full scope of General Preventive Medicine is appropriately recognized as clinical by the American Board of Medical Specialties (ABMS), hereafter, “clinical” will refer to direct patient care activities (table 1). Traditional areas in core clinical preventive medicine assist with maintaining the health and wellbeing of patients across the lifespan while reducing risks of injury and disease through primary, secondary, and tertiary prevention measures.5 This includes clinical applications of United States Preventive Services Task Force (USPSTF) recommendations (e.g., education, screenings, counseling, preventive medication, and risk-reduction treatment related to noncommunicable and lifestyle-related diseases, communicable diseases, and injury prevention)6 and the Healthy People 2030 objectives, which provide evidence-based interventions that promote the health and wellbeing of patients and communities.7,8 Core clinical preventive medicine also includes specialized clinics, which use evidence-based practices supported by specialty literature. Specialized clinics may include communicable (e.g., travel medicine, HIV/STI, tuberculosis) and noncommunicable (e.g., obesity, addiction) diseases, with some traversing both (e.g., refugee health). Board-certified subspecialty areas of occupational medicine, aerospace medicine, and addiction medicine will not be covered here, except for components that general preventive medicine physicians without subspecialty boards can practice.Table 1Scope of practice for clinical preventive medicine direct patient care subset of General Preventive Medicine and Public Health specialty.Clinical Preventive MedicineCore Clinical Preventive MedicineEmerging Clinical AreasTraditional AreasSpecialized Clinics*Lifestyle MedicineIntegrative Medicine•Vaccinations•Health education•Behavior change strategies•Health screenings and counseling•Prescribing risk-reduction medications•HIV/STI clinics•TB clinic•Travel clinic•Obesity clinic•Addiction clinic•Occupational health clinic•Refugee health clinic•Diabetes clinic•Tobacco cessation clinic•Whole-food, plant-predominant eating pattern•Physical activity•Restorative sleep•Stress management•Avoidance of risky substances•Positive social connection•Natural remedies•Mind-body practices•Bodywork*Specialized clinics use evidence-based practices supported by specialty literature to assist with maintaining the health and well-being of patients across the lifespan while reducing risks of injury and disease through primary, secondary, and tertiary prevention measures for conditions that pose a challenge on the population-level. Open table in a new tab *Specialized clinics use evidence-based practices supported by specialty literature to assist with maintaining the health and well-being of patients across the lifespan while reducing risks of injury and disease through primary, secondary, and tertiary prevention measures for conditions that pose a challenge on the population-level. Emerging clinical areas in clinical preventive medicine include areas that are evidence-based, prevention-focused (maximizing wellness and addressing root causes), and correspond to a higher population-level need (Figure 1). Lifestyle medicine is based on data that nearly 80% of chronic conditions could be prevented by optimal lifestyle behaviors9 and that unhealthy lifestyle behaviors cause chronic diseases accounting for 63% of deaths.10 Lifestyle medicine physicians apply interventions focusing on six pillars (i.e., whole food plant-based nutrition, physical activity, stress reduction, toxic substance avoidance, sleep, and healthy relationships)11 and employ motivational interviewing techniques through frequent, extended patient encounters. Integrative medicine uses alternative and complementary treatments (e.g., natural remedies, mind-body practices, bodywork) to support wellness, improve symptoms, and manage adverse treatment effects. Multiple herbal remedies used by traditional healers have crossed over into established medical use through the drug development process.12 Important to this field is recognizing, respecting, and appreciating, rather than appropriating, the traditions from which these practices come. While components of functional medicine could also develop as an emerging clinical area, it has yet to have as significant uptake by clinical preventive medicine and thus will not be addressed within this paper. Reimbursement continues as a prevailing challenge. ICD codes are rooted in a disease-centered rather than wellness-centered model, leading to lower reimbursement for clinics that prioritize counseling or motivational interviewing, which require longer visits. Reimbursement models also favor reactionary rather than preventive approaches, which is economically counterintuitive given the disproportionate cost of preventable chronic diseases. These challenges contribute to clinics shifting to direct pay, concierge, or other out-of-pocket models, which may further inequity. Despite some improvements in this area, pressure to see more patients over less time and for less pay poses challenges to the sustainability of the field and equitable provision of services. Furthermore, research on prevention is limited compared to other fields. Much of the evidence is based on observational data (e.g., cross-sectional surveys) and with underrepresentation of racial, ethnic, and other minorities.13 Interventional studies are further challenged by the complexities of human behavior within different environments. With limited funding to perform high-quality prevention studies (e.g., only 3.7% of funding for the National Institutes of Health is specifically allocated towards prevention14) evidence may continue to fall behind. Finally, inadequate education in medical training has created a system in which individuals seeking care don't consistently receive clinical preventive medicine recommendations.15 Only 27% of US medical schools provide the minimum required number of nutrition education hours,16 with medical students receiving little formal training to prevent chronic diseases.17 With such little exposure, there is less awareness of preventive medicine as a specialty option. A cultural shift from reactive clinical care to preventive care supported by equitable population-level policy, funding, and programmatic efforts would facilitate the success of clinical preventive medicine in overcoming social determinants and environmental barriers (e.g., lack of sidewalks for physical activity, unsafe housing conditions where communicable diseases rapidly spread) and providing access to basic needs (e.g., nutrient-dense foods, mental health services). With population-level changes, patients can be supported in the environments in which they live, work, and play to facilitate equitable preventive care and a more level field for making healthy choices. Learners have advocated for inclusion of clinical preventive medicine in medical training by creating preventive medicine, lifestyle medicine, integrative medicine, and wellness interest groups. Lifestyle medicine18 and integrative medicine curricula have been incorporated into some US residency training programs. The recent passing of a resolution requiring adequate clinical nutrition education within medical training may support further widespread preventive care education.19 Further investment is needed into preventive medicine training programs and pre-health pipelines into preventive medicine. Whereas integrative medicine is recognized as a distinct specialty by the American Board of Physician Specialties (ABPS), lifestyle medicine is not part of ABPS or ABMS. With the strong relationship between lifestyle factors and disease prevention, Preventive Medicine should consider adding Lifestyle Medicine as an ABMS subspecialty. The COVID-19 pandemic has also raised awareness to several key areas. Data suggest that worse COVID-19-related outcomes are associated with several health conditions,20 many of which, if caught early, could be treated early or even reversed (e.g., type 2 diabetes). Clinical preventive medicine could also play a significant role in helping patients facing emerging diseases like long COVID, including approaches to some of the most common symptoms (e.g., brain fog, headaches, post-exertional malaise).21 Setting-specific wellness programs (e.g., school, employee-based) are valuable targets for expansion and can include access to services such as fitness classes and nutrition counseling. Employee wellness programs encourage a healthier workforce while optimizing productivity and decreasing insurance costs.22 There are also opportunities to use innovative technology (e.g., wearable devices, health apps) for patients to take an active role in monitoring their health and using a combination of telehealth and other technologies to reach patients more conveniently. Clinical preventive medicine expertise is needed to promote health, contain infectious diseases, provide symptom management, and manage or reverse chronic health conditions that sicken our communities. Immediate attention is warranted towards policies, programmatic efforts, funding and rapid implementation of payment models to support equitable provision of clinical preventive medicine, from research to education, training, and reimbursement of services to curb the morbidity, mortality, and healthcare costs for all communities. Jennifer Chevinsky, MD, MPH assumed the leading role in the work encapsulated in this publication, having primary responsibility for the conception, design, and execution of the research, as well as the drafting and revising of the manuscript. Siri Chirumamilla, DO MS, Silvia Caswell, DO, MPH, Lola Melody Nyoni, MS, and Karen Studer, MD MBA MPH all played crucial and equal roles in the project. They significantly contributed to drafting and critical review of the manuscript. Each author has approved the final version of the manuscript and has agreed to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 1. 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Pennington AF, Kompaniyets L, Summers AD, Danielson ML, Goodman AB, Chevinsky JR, Preston LE, Schieber LZ, Namulanda G, Courtney J, Strosnider HM, Boehmer TB, Mac Kenzie WR, Baggs J, Gundlapalli AV, Risk of Clinical Severity by Age and Race/Ethnicity Among Adults Hospitalized for COVID-19—United States, March–September 2020, Open Forum Infectious Diseases, Volume 8, Issue 2, February 2021. https://doi.org/10.1093/ofid/ofaa638 21. Preventive and Lifestyle/Integrative Medicine and Long COVID. www.youtube.com. Accessed January 31, 2023. https://www.youtube.com/watch?v=X3kqYa7cttQ 22. Berry, L. L., Mirabito, A. M., & Baun, W. B. (2014, August 1). What's the Hard Return on Employee Wellness Programs? Harvard Business Review, 88(12), 104–112. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.