Transcript Integrative Medicine

Integrative Medicine
Aaron J. Michelfelder, M.D., FAAFP, FAAMA
Vice-Chair and Predoctoral Director, Family Medicine
Associate Professor of Family Medicine, and Bioethics & Health Policy
Board Certified Medical Acupuncturist
Objectives
• By the end of this presentation, you should
be able to...
– Define “Integrative Medicine”
– Understand how Integrative Medicine relates to
Modern Medicine
– Prepare to practice Integrative Medicine in the
future
Presentation Outline
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Definitions
Why Should We Care About CAM?
What Do Patients Want?
What Can We Provide to Meet the Demand?
Real Patient
54 year-old female presents with peripheral neuropathy,
shoulder tendonitis, and carpal tunnel syndrome about 15
months after completing chemotherapy for breast cancer.
She is believed to be in complete remission currently. She
states that she is exercising, doing physical therapy, taking
a multi-vitamin and following all of the recommendations
of her physicians, but feels like she could be doing more
for her issues.
What more do you want to know?
What options would come to mind for you?
How would you find information about those options?
“Imagine a world - oriented toward healing rather than
disease, where physicians believed in the natural healing
capacity of human beings, and emphasized prevention
above treatment.
In such a world, doctors and patients would be partners
working toward the same ends.”
Definitions
“Complementary and Alternative Medicine is a
Group of Diverse Medical and Health Care
Systems, Practices, and Products That are Not
Presently Considered Part of Conventional
Medicine”
National Center for Complementary and Alternative Medicine
Definitions
• “Complementary Medicine is Used Together
With Conventional Medicine.”
• “Alternative Medicine is Used in Place of
Conventional Medicine.”
Definitions
“Integrative Medicine Combines Mainstream
Medical Therapies and CAM Therapies for Which
There is Some High-Quality Scientific Evidence
of Safety and Effectiveness.”
NCCAM
5 Domains of CAM
Alternative
Medical
Systems
Ayurveda, Chinese, Native American, Aboriginal, African,
Middle Eastern, Tibetan, Central and South American cultures,
Homeopathy, Naturopathy
Mind-Body
Interventions
cognitive-behavioral approaches, meditation, hypnosis, dance,
music, art therapy, prayer, mental healing
Biological
Based
Therapies
dietary supplements, herbs, orthomolecular (varying
concentrations of chemicals, such as, magnesium, melatonin, and
mega-doses of vitamins), individual biological therapies (use of
laetrile, shark cartilage, bee pollen).
Manipulative
And BodyBased Methods
chiropractic, osteopathic manipulation, massage
Energy Therapies
Qi gong, Reiki, therapeutic touch, bioelectromagnetic-based
therapies (pulsed fields, magnetic fields, or alternating current
or direct current fields)
As Defined by NCCAM
Why Should We Care?
• 30,000 herbs on the market currently
• Estimates of $30-40 billion dollars spent annually
Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569-1575
• Estimates of 42% of population use CAM
currently Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569-1575
• Sales of Metabolite 356 approached $1billion in
1999 Alternative Medicine Alert, January 2000
• Relacor $23 Million; 900,000 bottles by July 06
Overall Supplement Use
Why Should We Care?
• 600 Million Visits a Year to CAM Providers
– More Than to Primary Care Providers
• Why? What is Mainstream Medicine Not
Offering to Our Patients?
Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569-1575
Have We Missed the Boat?
• Dissatisfaction with health care providers and
medical outcomes
• Side effects of drugs and treatments
• High health costs
• Technology
• Lack of control in their own health care
practices
• Time spent with practitioner
Stephen Strauss, M.D., NCCAM Director
Have We Missed the Boat?
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Looking for “cures”
Want to use “natural” products
Patient feels empowered
Focus on spirituality and emotional wellbeing
• Health Care Provider provides the 3 T’s:
touch, talk, time
Stephen Strauss, M.D., NCCAM Director
What about communication?
• Between 40 and 70% of CAM users do
not disclose their use to their
physician.
WHY?
Eisenberg 2001
Why do patients not tell their physician
about their CAM use?
• 60% - “My doctor never asked.”
• 60% - “It wasn’t important for my doctor to
know.”
• 20% - “My doctor wouldn’t understand.”
• 14% - “My doctor would disapprove.”
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70% of patients see their Physician before or concurrent
with their visits to a CAM provider
Eisenberg DM. Ann Int Med 2001;135(5):344-51
Why would patients not trust us?
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Avandia Kills – FDA Black Box Warning
Ketek Kills – taken off the market
Rezulin Kills – taken off the market
Trovan Kills - taken off the market
Vioxx Kills – taken off the market
PRESS RELEASE:
• Medication errors are among the
most common medical errors,
harming at least 1.5 million people
every year, says a new report from
the Institute of Medicine of the
National Academies. The extra
medical costs of treating drugrelated injuries occurring in
hospitals alone conservatively
amount to $3.5 billion a year, and
this estimate does not take into
account lost wages
and productivity or additional
health care costs, the report says.
- IOM July 2006
Why Would We Not Trust CAM?
“Doctors concerned because several cases
reported of liver failure with Kava Kava, a
widely used natural remedy for anxiety”
Government Not Helping Us?
• DSHEA 1994
– www.consumerlabs.com
• New FDA Regulations
– 8-24-07 – Interim Final Rule
– Identity, Purity, Strength, and Free from
Harmful Contaminants
– Food, Drug and Cosmetic Act
Are Our
Patients
Reading
This?
Or
This?
Evidence Based Medicine
• Difficulties With CAM Research
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Sham Acupuncture
Non Standardized Herbal Formulations
Difficult to Blind Patients and Practitioners
Treatments Very Individualized – Difficult to
Formulate Protocols
RCCT
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Gleevec
Albuterol
Acupuncture
Chinese Herbal Therapies
• How Can This Stand the Test of Time?
Comparison
• Mainstream Medicine
– Large Double Blind Placebo Controlled Trials
• Many Exclusions Such As Multiple Medicines,
Other Illnesses, Female, Pregnant, Children, Race
• “Placebo Effect” Discounted
• Apply These Narrow Results to The Individual
– Integrative Medicine
• Very Individualized
• “Placebo Effect” Not Discounted
Licensing Issues
CAM MODALITY
Chiropractors
Massage ther.
LICENSURE
All states
27 states
Naturopaths
13 states
Homeopaths
3 states
Acupuncturists
32 states
• Patients are choosing
integrative and
alternative medicine,
but what about
physicians?
Where Are We Today?
• Clinical Fellowships:
– University of Arizona
(Founding Program)
– University of Michigan
– University of Maryland
– University of Wisconsin
– Maine Medical Center
– Cooper Health System (NJ)
– Lawrence MA
– Beth Israel Medical Center
– UCLA
• Academic Fellowships
(Research)
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Harvard University
Tufts
Boston University
Stanford
Duke
• Residencies in Integrative
Medicine
– Oregon Health Sciences
University
– Montefiore Medical Center
(NY)
Where Are We Today?
CAHCIM Members
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Albert Einstein/Beth Israel
Columbia University
Duke University
George Washington
Georgetown
Harvard
Laval University
Mayo Clinic
OHSU
Stanford University
Yale University
Wake Forest University
University of Alberta
University of CA/Irvine
Thomas Jefferson
UMDNJ
University of Arizona
University of Calgary
University of Hawaii
University of Washington
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University of California/LA
University of California/SF
University of Colorado
University of Connecticut
University of Kansas
University of Maryland
University of Massachusetts
University of New Jersey
University of New Mexico
University of North Carolina-Chapel Hill
University of Michigan
University of Minnesota
University of Pennsylvania
University of Pittsburgh
University of Texas-Galveston
University of Vermont
University of Wisconsin
Loyola Integrative Medicine
Physician Faculty
• Mariadas Chinthagada, M.D., Anesthesiology, Acupuncture
• Youngran Chung, M.D., Peds Pulmonology, Acupuncture,
Hypnosis
• Chuck Dumont, M.D., Peds GI, Acupuncture, Herbal Therapies,
Homeopathy, Hypnosis
• Marypat Fitzgerald, M.D., Urogynecology, Acupuncture
• Aaron Michelfelder, M.D., Fam Med, Acupuncture, Herbal
Therapies, Hypnosis
• Kit Lee, M.D., Fam Med, Acupuncture
• Bo Rana, M.D., Anesthesiology, Acupuncture
• Nila Vora, M.D., IM, Ayurvedic Medicine
Loyola CAM Providers
• Amy Wu, L.Ac., Acupuncture, Chinese
Herbal Therapies
• Karen Wagner, RD, LD, Nutritionist
• Linda Moore, MT, Visceral, Pregnancy,
Deep Tissue, Muscular Massage
• Eva McCormick, PT, Biofeedback
• Marilyn Moore, Guided Imagery
• Thomas J. Rostafinski, Ph.D., Hypnosis
Medical Students
• Integrative Medicine Curriculum Demanded
by Students
• Integrative Medicine Interest Group
• “Integrate Chicago” http://www.integratechicago.com/index.html
The Future of Integrative Medicine
• Definition of Integrative Medicine From the
CAHCIM
“Integrative medicine is the practice of medicine that
reaffirms the importance of the relationship
between practitioner and patient, focuses on the
whole person, is informed by evidence, and makes
use of all appropriate therapeutic approaches to
achieve optimal health and healing.”
The Future of Integrative Medicine
• The Term “Integrative Medicine” Will Die
– Our Patients Will Demand Integrative Medicine
From All of Us
– Training Will Be Demanded by Medical
Students
– Training Will Be Demanded by Residents
The Future of Integrative Medicine
• Integrative Medicine Will Be A Skill Set
Added on Just Like:
– Electronic Health Records
– New Medications
– New Procedures
The Future of Integrative Medicine
• What Cannot Be Added On is Empathy and
Open-mindedness
• 600 Million Visits a Year to Alternative
Practitioners
The Future of Integrative Medicine
The Future Is Sometimes Curing,
But Always Caring
Real Patient
54 year-old female presents with peripheral neuropathy,
shoulder tendonitis, and carpal tunnel syndrome about 15
months after completing chemotherapy for breast cancer.
She is believed to be in complete remission currently. She
states that she is exercising, doing physical therapy, taking
a multi-vitamin and following all of the recommendations
of her physicians, but feels like she could be doing more
for her issues.
What more do you want to know?
What options would come to mind for you?
How would you find information about those options?
Integrative Medicine
requires a paradigm shift from
• the disease-centered approach of
conventional biomedicine
to
• an approach in which patient values
and participation of patients are
central.
Maizes 1999
Integrative Medicine
• Integrative Medicine is healing-oriented medicine
that takes account of the whole person (body,
mind, and spirit), including all aspects of lifestyle.
• It emphasizes the therapeutic relationship and
makes use of all appropriate therapies, both
conventional and alternative.
www.integrativemedicine.ariazona.edu
PIM – U of Arizona
How do We Add On These Skills?
• Build your database.
• Build a referral team.
• Ask your patients
whom they see.
• Look for summaries of
available data.
• Have an open dialogue
with your patients.
5 Domains of CAM
Alternative
Medical
Systems
Ayurveda, Chinese, Native American, Aboriginal, African,
Middle Eastern, Tibetan, Central and South American cultures,
Homeopathy, Naturopathy
Mind-Body
Interventions
cognitive-behavioral approaches, meditation, hypnosis, dance,
music, art therapy, prayer, mental healing
Biological
Based
Therapies
dietary supplements, herbs, orthomolecular (varying
concentrations of chemicals, such as, magnesium, melatonin, and
mega-doses of vitamins), individual biological therapies (use of
laetrile, shark cartilage, bee pollen).
Manipulative
And BodyBased Methods
chiropractic, osteopathic, manipulation, massage
Energy Therapies
Qi gong, Reiki, therapeutic touch, bioelectromagnetic-based
therapies (pulsed fields, magnetic fields, or alternating current
or direct current fields)
As Defined by NCCAM
Unsafe/Proven
Safe/Proven
Unsafe/Unproven
Safe/Unproven
The Future of Integrative Medicine
• Nutrition
• Exercise
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Lycopene
Glucosamine
Peppermint Oil
Fish Oil
Soy
The Future of Integrative Medicine
• Epocrates Rx Pro
• Micromedex
• Commission E
• Plus Many Other Databases
http://nccam.nih.gov/
Resources
• Commission E
– Germany
– Ranks Quality of
Evidence
– Evaluates Benefits and
Risks
Integrative Medicine
• Donald Novey, M.D. –
Lutheran General
Hospital
– Evidence Based
Review of Each
Modality
Integrative Medicine
• David Rakel, M.D.,
University of
Wisconsin
– Instructions on how to
put CAM into your
own medical practice
Resources
• National Center for Complementary and
Alternative Medicine
– http://nccam.nih.gov/
• Agency for Healthcare Research and Quality
– http://www.ahrq.gov/clinic/epcindex.htm
Resources
• American Academy of Medical Acupuncture
– www.medicalacupuncture.org
• Online Resource
– http://www.altmedicine.com
Where Should We Go for
Information?
• Product claims
– www.quackwatch.com
– www.snopes.com
• Product quality assurance
– www.consumerlab.com
• Product ingredients
– Natural Medicines Database www.naturaldatabase.com
• Product safety and efficacy
– www.cfsan.fda.gov/~dms/ds-ind.html
– www.naturaldatabase.com
– The Natural Pharmacist www.iherb.com or www.consumerlab.com
Summary
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Dialogue with your patients
Build your database
Build your referral base
Develop patient care teams
Consider all available options
Be open-minded
• Above all: caring, concern and compassionate
THANK YOU!