Transcript Holland Slides Slotesvaart - American Academy of Pediatrics

Integrative Medicine = Good
medicine
Kathi J. Kemper, MD, MPH
Caryl J Guth Chair for Holistic
and Integrative Medicine
Professor of Pediatrics, Public
Health Sciences, Family and
Community Medicine
Wake Forest University Health
Sciences
CAM US History
• 1970’s American Holistic Medical Association
• 1980’s popular books – Our Bodies, Our Selves
• 1991 US Congress establishes Office of Alternative
Medicine at NIH ($2 million)
• 1993 Eisenberg’s article in NEJM on common CAM
use in US (34% of US adults)
• 1996 publication of The Holistic Pediatrician
• 2000 CAHCIM
• 2002 White House Commission on CAM report
• 2005 Institute of Medicine report on CAM
• 2005 AAP CHIM
CAM Clinical History US
• 1970’s and ’80’s – scattered MD clinics, eg Norm Shealy,
Chris Northrup, Andy Weil, Hugh Riordan, Jim Gordon,
Bob Anderson
• 1990’s –stand-alone multidisciplinary clinics; financially
issues; growth of CAM in medical schools and CME
2000’s – integration into existing clinics; integration into
hospital care –mind/body, massage, acupuncture,
nutrition, hospital formulary policies; start of CAM
education in residency education
• Financing – initially with philanthropy, wealthy self-pay;
moving toward advocacy for insurance coverage (See
John Weeks)
• Evidence-base
Growth of CAM Research
30000
MEDLINE
25000
Citations Under
“Alternative
20000
Medicine”
1966-2005
15000
10000
5000
0
66-74
75-79
80-84
85-89
90-94
95-99
00-05
Old Model: CAM Therapies
Alternative
Mainstream biomedicine
Complementary
Concerns about CAM
• Sylvia Millecam death from
breast cancer following
treatment with acupuncture,
faith, psychic healers
• Unfounded treatments (NOT
evidence-based)
• Poor oversight (poor
coordination)
• NOT complementary
BMJ, 28 Feb 2004
Patient/Consumer Interest
• Use is high; most use combinations
• 42% of Americans reported using
(1997)
• Consumers self-paid $27 billion; this
exceeds out of pocket expenses for
hospital care
• Out of pocket payments highest for
herbs and supplements, massage,
acupuncture, fitness training
Licensed Health Professionals in
US (selected)
% states licensed
120
100
80
60
40
20
0
M
D/
DO
Ps
yc
ho DC
Ac log
up ist
un s
ct
M u re
a
Na ssa
tu g e
Ho rop
m a th
eo y
pa
th
y
% states licensed
Popularity leads to…eResources
<>
• US Presidential Commission on
CAM, chaired by James Gordon, MD
http://www.whccamp.hhs.gov/
• Institute of Medicine report on CAM
in the US, chaired by Professor
Stuart Bondurant, MD;
http://www.nap.edu/books/03090927
01/html/
eResource: NIH NCCAM
NCCAM
Clearinghouse:
(US) 1-888-6446226
• Patient information sheets in
English and Spanish
• Ongoing research
projects/clinical trials
• Education and Training
opportunities
• http://nccam.nih.gov
eResource: NCI OCCAM
• Health information for
patients
http://www.cancer.gov/ca
m/health_understanding
.html
• Clinical trial information
• Grant funding for
research projects
Highest CAM Users
•
•
•
•
Well educated
Upper income
Women
Chronically ill (pain fatigue,
anxiety, depression)
Why use CAM?
• Consistent with patient values (ecological, spiritual,
political)
• Person-centered
• Gentler
• Empowering
• Esthetic
• Less drug dependent
• Less technology dependent
• Meaning – causes, what one can do
• Lifestyle emphasis
• Failures of medicine (antibiotic resistance; side effects,
costs; medical errors; limited access) poor success with
chronic illnesses
Resource
• Founded in 2000
• 38 academic health centers (Harvard, Yale,
Duke, Stanford, UAz, WFUSM, UMi, UMn, UNM,
U Alberta, etc)
• International Research Conference
• Collaborative research
• Developing “best practices” clinical models
• Education (residency and undergrad)
• http://www.imconsortium.org/cahcim/about/home
.html
Definition: Integrative Medicine
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, healthcare
professionals and disciplines to
achieve optimal health and healing.
Consortium of Academic Health
Centers for Integrative Medicine,
5/05
Integrative Medicine =
Good Medicine
Sustainable,
Healing
Environment
Wellness
Orientation
Holistic
PatientCentered
Care
Comprehensive
Therapeutic
Options
*
Patient-centered care = holistic
Caring for whole person - body,
mind, emotions, spirit,
relationships -- in the context
of family, culture and
community
Biopsychosocial model
Culturally sensitive care
Can a surgeon be holistic?
YES
US Institute of Medicine’s Rules for the
Twenty-First Century Health Care System
Current Approach
New Rule
Care based primarily on visits
Care is based on continuous
healing relationships
Care is customized according
to patient needs and values
The patient is the source of
control
Knowledge is shared and
information flows freely
Decision making is evidencebased
Professional autonomy drives
variability
Professionals control care
Information is a record
Decision making is based on
training and experience
Institute of Medicine’s Simple Rules for the
Twenty-First Century Health Care System
Current Approach
New Rule
Do no harm is an individual
responsibility
The system reacts to needs
Cost reduction is sought
Safety is a system property
Preference is given to
professional roles over the
system.
Needs are anticipated
Waste is continuously
decreased
Cooperation among clinicians
is a priority
CAM is a SUBSET of tools
within Integrative Medicine
•
•
•
•
Integrative Medicine emphasizes
wellness and healing of the whole person,
with special emphasis on patient participation,
and attention to mental and spiritual health;
Communication, empowerment, cultural awareness
The knowledge and use of Complementary and
Alternative Medicine (CAM) is an important aspect of
Integrative Medicine.
Section on Integrative Medicine, Internal Medicine, UNM
Integrative Approach
Bioenergetic therapies:
Acupuncture/Acupressure, Healing/Therapeutic
Touch, Prayer, Homeopathy
Biomechanical
Therapies:
Surgery,
Osteopathic/
Chiropractic;
Bodywork/Massage
Patient-centered,
compassionate care
Biochemical
Therapies:
Medications, Herbs,
vitamins, minerals,
dietary supplements
Lifestyle Therapies:
Mind-body; Environment; Exercise/Rest;
Diet/Smoking/Drinking
eEducation about herbs /
dietary supplements
• https://northwestahec.wfubmc.edu/learn/herbs_ce/index
.cfm
What kinds of services do NC MDs
want to provide in hospital?
• Nutrition services – 84%
• Fitness services – 80%
• Stress management
services – 75%
Kemper K. BMC CAM 2007
***Mind-Body Therapies***
•
•
•
•
•
•
•
•
•
Hypnosis
Guided imagery
Meditation
Autogenic training
Biofeedback
Journaling
Social Support
Psychological counseling
Peer support
Is it ETHICAL to integrate CAM
therapies into conventional
practice?
• Principles of ethics
– Beneficence / Do no harm
– Autonomy
– Justice
• Common Sense
– Balance risks and benefits
Ethical framework
Effective
Yes
Safe Yes Use/Recommend
No
Monitor closely
No
Tolerate
Advise against
Cohen M. Pediatrics, 2005
Effective? Safe?
– What therapy?
– For whom?
– For what condition? (cancer,
colds)
– Under what circumstances?
– For what desired outcome?
– When? immediate versus longterm
Kemper. Arch Dis Child, 2001
What Kind of Integrative Services Do
NC MDs Want?
1. Pain management (84%)
2. Weight/Obesity management
(80%)
3. Diabetes-Lifestyle (73%)
4. Stress management (73%)
5. Heart healthy lifestyle (71%)
6. Back pain (66%)
7. Headache (63%)
8. Cancer support (62%)
9. Stroke recovery (51%)
Kemper, et al. BMC CAM, 2007; 7:5
Service Models
Heart Center
Fitness
Oncology
Acupuncture
Fitness
Neuroscience
Bone & Joint
Acupuncture
Acupuncture
Biofeedback
Fitness
CAM
Center
Massage
Nutrition
Pharmacy
Mind-Body
Sustainability
• Consistent with cultural values, e.g., evidencebased, compassionate, comprehensive,
common sense, cost-effective – strengthens and
restores the heart and soul of medicine
• Insurance coverage
• Collaborative with public health, community of
health care providers, patient advocacy groups
• Integrated, not marginalized
THANK YOU!
WHO 2000 ranking
• Netherlands is #17 for quality of health
services (US is #37)
• Problems
– Waiting times
– Labor shortages
Leading and Actual Causes of Death
US 2000
Leading Cause of Death
Rate/100,000
Heart disease (also #1 worldwide)
Malignant neoplasm
Cerebrovascular disease
Chronic lower respiratory tract disease
Unintentional injuries
Diabetes Mellitus
Influenza and pneumonia
Alzheimer disease
Nephritis, nephrotic syndrome, and nephrosis
Septicemia
Other
Total
258.2
200.9
60.9
44.3
35.6
25.2
23.7
18.0
13.5
11.3
181.4
873.1
Leading Causes of Death US 2000
Actual Cause of death
n (%)
Tobacco
Poor diet and physical activity
Alcohol consumption
Microbial agents
Toxic agents
Motor vehicle
Firearms
Sexual behavior
Illicit drug use
435,000 (18.1)
400,000 (16.6)
85,000 (3.5)
75,000 (3.1)
55,000 (2.3)
43,000 (1.8)
29,000 (1.2)
20,000 (0.8)
17,000 (0.7)
Total
1,159,000 (48.2)
Prevention Gap
Burden of disease, preventability, and research and translation gaps.
Ockene, et al. Am J Prev Med, 2007; 32(3) :244
Social-ecologic framework: levels of influence on behavior.
(From the Institute of Medicine, 2002.7)
Payment for Health Services - US
• Public (26%)
– Medicare (>65; 14%)
– Medicaid (poor, disabled; 12% )
• Private – variety, diverse
coverage; usually employerbased; (58% of Americans)
• Uninsured (16% of Americans)
Burden of Disease: 2020
Expected in Developed Countries
1.
2.
3.
4.
5.
6.
7.
8.
Ischemic heart disease
Cerebrovascular disease
Unipolar major depression
Trachea, bronchi, lung cancers
Road traffic injuries
Alcohol misuse
Osteoarthritis
Dementia and related….
Murray CJL. Lancet, 1997
Pharma Promises…