Transcript Integrative Medicine - Northeast Iowa Family Practice Center

Making Your Practice More
Integrative: Some Tips and Tricks
Adam Rindfleisch, MPhil, MD
Associate Professor, University of Wisconsin Department of
Family Medicine
Objectives
Help you make your practice more
“Integrative”
1. Define what IM is
2. Suggest a tool for evaluating therapies
3. Apply this technique to several ‘tools’ you can bring
into your practice – supplements, CAM, and beyond
4. Offer tips and resources along the way
Integrative Medicine at UW
UW Health Arboretum Family Medicine
A Key Web Resource:
www.fammed.wisc.edu/integrative
Some Disclosures…
NCCIH and ACIHM
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National Center for Complementary and Integrative Health
Originally created as Office of Alternative Med October 1991
Renamed 1998 under Clinton as NCCAM
2015: Became NCCIH
https://nccih.nih.gov/
• Academic Consortium for Integrative Medicine and Health
– www.imconsortium.org
– 69 members
What is Integrative Medicine (IM)?
• 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.
What is Integrative Medicine (IM)?
• Bottom line
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Based on respect for communication and individuality
Evidence-based
Prevention and health-focused
Enlists “CIM” approaches
Our Medical Culture
68,000 Codes
(ICD-9 has 13,000)
W6162XA =
V9107XA =
Struck by a duck
Burn due to water skis
catching on fire
Gauging an Approach…
ECHO
The ECHO Mnemonic for choosing
therapies
•Efficacy
•Cost
•Harms
•Opinions
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ECHO: Using it with Turmeric (Curcuma longa)
https://naturalmedicines-therapeuticresearch-com
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Efficacy
– ‘Possibly effective’ for knee OA
– 500 mg BID improved functionality
Costs (variable)
– $3 for 140 doses of powdered
– $35 for 120 high-end caps
Harms
– Likely safe, up to 8 months
– 6 g/day caused some flatulence and stool
changes
– NO reports of bleeding risk
Opinions
– My patients love it about 80% of the time
– Good to avoid NSAID adverse effects
My Conclusion: A potentially good choice
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Other supplements and ECHO – in brief
Supplement
Efficacy
Cost
Harms
Opinions
L-theanine
(anxiety)
Less clear
$$
Minimal
Usually
Positive
Red rice yeast
(cholesterol)
Good
$$$
Moderate
Moderate
Ashwagandha
(adaptogen)
Less clear
$
Minimal
Moderate
Grape seed extract Good
(venous insuff.)
$$
Minimal
Less familiar to
people
St. John’s wort
(depression)
Good
$$
Risky
Varied
Rhodiola
(adaptogen)
Less clear
$$
Minimal
Usually
positive
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Rhodiola Rosea
(Arctic or Golden Root)
Darbinyan V, et al. Clinical trial of Rhodiola rosea L. extract SHR-5 in the treatment
of mild to moderate depression. Nord JPsychiatry 2007;61:343348.
The Microbiome
VETERANS HEALTH ADMINISTRATION
……
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Ridaura, V.K., et al., Gut microbiota from twins discordant for obesity modulate
metabolism in mice. Science, 2013. 341(6150)
Probiotics Improve IBS
Bifidobacterium bifidum MIMBb75
• Improved global symptom score, pain,
distension/bloating and stool urgency.
• Adequate relief reported in 47% Tx group
and 11% in placebo.(P<0.0001)
• No adverse events compared to placebo.
Guglielmetti S, et al. RCT: Bifidobacterium bidfidum MIMBb75 significantly alleviates IBS
VETERANS
HEALTHQOL-a
ADMINISTRATION
and improves
DBPCS. Aliment Pharmacolo Ther. 2011. 33(10)
Probiotics also benefit Constipation
Bifiobacterium lactus.
“B” for Bowel Movement”
Dimidi et al. The effect of probiotics on functional constipation in adults: a systematic review and metaanalysis
of randomized
controlled trials. Am J Clin Nutr 2014
VETERANS
HEALTH ADMINISTRATION
Bailey, L.C., et al., Association of Antibiotics in Infancy With Early
Childhood Obesity. JAMA Pediatr, Sept. 29th, 2014.
L. rhamnosus and Mice Anxiety
• Prolonged
swimming in water
• Less stress and
depression
•  GABA receptor
stimulation
• No Δ when vagus
nerve cut
Bravo JA, et al. Ingestion of Lactobaccillus strain regulates emotional behavior and
central GABA receptor expression in a mouse via the vagus nerve. PNAS. July, 2011
VETERANS HEALTH ADMINISTRATION
Gut Directed Hypnotherapy:
The results seen at 3 months were sustained up to 1 year!
Lindfors, P., et al., Effects of gut-directed hypnotherapy on IBS in different clinical
settings-results from two randomized, controlled trials. Am J Gastroenterol, 2012.
107(2): p. 276-85.
VETERANS HEALTH ADMINISTRATION
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Probiotics Practice Pointers
• Most commonly use Bifidobacterium or Lactobacillus
• Saccharomyces boulardii, a probiotic yeast, also quite powerful
– Red Star Yeast, 1 tsp daily
– Helpful with Inflammatory Bowel (Crohns Dz)
• Dose in colony forming units (CFU’s)
– 109 or 1010 CFU’s daily a good dose
– How long? – I do a few weeks
• I always give them with diarrhea
• I always recommend them with antibiotics
• Consider in pregnancy and in kids who were born via C/S or who are bottle
feeding or who’s mom needed antiobiotics prophylaxis for group B Strep.
Can read more in the chapter, “Prescribing Probiotics” in the Integrative Medicine
VETERANS HEALTH ADMINISTRATION
textbook.
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What about Other Approaches?
VETERANS HEALTH ADMINISTRATION
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Treatment A
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12 mth, multi-center, randomized,
DB study
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228 pts with sciatica
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Tx A vs saline injection
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Transient benefit for Tx A at 3
weeks
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Transient benefit for saline at 12
weeks
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No benefit @ 6,12,26 & 52 wks.
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Cost/QALY= $319,130.00
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Failed NICE threshold
Treatment B
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24 month, multi-center,
randomized, open study
241 pts with persistent low back
pain
Tx B vs usual care by PCP
10-15% improvement with Tx B at
12 and 24 months vs control
Cost/QALY: $8,097.00
Passed NICE threshold for cost
effective benefit
Treatment A vs Treatment B
Tx A
Tx B
Evidence of
Benefit
Cost/QALY
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Patient Cost
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Institutional
Profit
Potential Harm
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Practice
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How much it costs to gain one additional
quality adjusted life year (QALY).
Treatment
Hip Replacement
Cost/QALY
$2,164
Neurosurgery for malignant
brain tumor
Acupuncture for LBP
$197,647
Epidural Steroid Injection for
Sciatica
$319,130
$8,097
Sackett D, et al. Evidence Based Medicine. 2nd Ed. Churchill Livingstone. 2000.
Friedly JL, et al. A randomized trial of epidural glucocorticoid
injections for spinal stenosis. N Engl J Med 2014;371:11-21.
References:
Epidural Steroids
Acupuncture
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Arden NK, et al. A multicentre
randomized controlled trial of
epidural corticosteroid injections
for sciatica: the WEST study.
Rheumatology 2005;44:13991406
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Thomas KJ, et al. Randomized
controlled trial of short course of
traditional acupuncture compared
with usual care for persistent nonspecific low back pain. BMJ 2006
23;333(7569):623.
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Price C, et al. Cost-effectiveness
and safety of epidural steroids in
the management of sciatica.
Health Technol Assess.
2005;9(33):1-58.
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Ratcliffe J, et al. A randomized
controlled trial of acupuncture care
for low back pain: cost
effectiveness analysis. BMJ 2006
23;333(7569):626.
Hopton, A., et al., Acupuncture, counseling or usual care for depression and comorbid
pain: secondary analysis of a randomized controlled trial. BMJ Open, 2014.
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Practitioner Effects
McKay KM, Imel ZE, Wampold BE. Psychiatrist effects in the
psychopharmacological treatment of depression. J Affect. Disord.
2006;92:287-90.
NIH Placebo Research
(Harvard, U of Wisconsin)
 Good Doc
 Bad Doc
 No Doc
Page 28 in Binders:
CARE MEASURE by Dr. Stewart Mercer
Items for Empathy Scoring
Practitioner Effects on IBS
IBS Pts Randomized to: Improvement in Symptoms;
• Wait List Control............................28%
• Limited Clinical Visit........................44%
• Augmented Clinical Visit.................62%
Kaptchuk TJ. et al. Components of the Placebo Effect: RCT in patients
with IBS. BMJ 336 (7651), 2008
Perception of Perfect Empathy
50/50 on CARE Score
IL-8
No Visit
Standard
Neutrophils
Enhanced
No Visit
Standard
Enhanced
Effects of Perceived Empathy on Common Cold
No Visit < Perfect Perfect
P Value
Duration 6.75 days 7.0 days 5.89 days
0.003
Severity
0.04
262.19
270.58
223.38
Rakel, Hoeft, Barrett, et al. Fam Med. 2009; 41(7):494-501
Rakel, Barrett, Zhang, et al. Patient Ed & Counseling. 2011; 1-8.
Mnemonic for  Suffering
Relationship
Empathy and trust creates a positive environment where the clinician can
Listen to a complicated story that creates
Insight
Explanation that is consistent with the patient’s
Values
Empowerment
centered care built on
into a problem that results in an
leading to
and action towards health
Rakel, D., The salutogenesis-oriented session: creating space and time
for healing in primary care. Explore (New York, N.Y.), 2008. 4(1): p. 42-47.
From Jerusalem to Jericho: a study of
situational and dispositional variables in helping behavior
J Personality and Social Psychol. 1973;27:100-108
Group #1
Group #2
Group #3
Reduction in Empathy with
Medical School Training
Newton et al. Acad Med, 83(3) 2008
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Nationalgeographic.com
When are you most…
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Aware
Present
Centered
Focused
Calm
http://wallpapers916.blogspot.com
Definition of Mindful Awareness
• Way of being
• In the present
moment
• On purpose
• Nonjudgmentally
Mindful awareness is an opportunity
to be in the wholeness of life…
including suffering, joy, peace,
unrest, creativity, fullness, emptiness
– everything…
…Not merely a technique for coping
with a specific problem.
Drop beneath your mind’s thoughts and …..observe
Thoughts
Judgment
Emotions
Awareness
Mindfulness and Medicine
Promega Study
Methods:
• 48 right handed subjects employees of Promega in Fitchburg, WI
• Subjects randomized into Meditation group (N=25, 19 females)
and a wait-list control group (N=16, 10 females)
• Mean age 36 years
• Wait-list controls were provided
8-wk MBSR training program
after completion of study
Richard J. Davidson, Ph.D., Jon Kabat-Zinn, Ph.D., et al. Alterations in brain and immune
function produced by mindfulness meditation. Psychosomatic Medicine. Aug/Sept. 2003
Negative emotions:
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right prefrontal cortex
Anger
Fear
Anxiety
Depression
Positive emotions:
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Enthusiasm
Vigor
Optimism
Buoyancy
Left prefrontal cortex
fMRI
Brefczynski-Lewis, et al. 2007104(27):11483-8
Mindfulness for Clinicians and Staff
Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated
Mindfulness Intervention for Job Satisfaction, Quality of Life, and
Compassion in Primary Care Clinicians: A Pilot Study. Ann Fam Med.
11(5); 412-420. 2013
Significant improvements with
depression, anxiety and stress
How can your clinical stool or chair
become your meditation cushion?
Suggestions for practice
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Listen with your whole body
Deep breath before each patient
Threshold exercise
Stethoscope use as a reminder to be mindful
Call room/office centering
– The moment you sit in your chair…
• Supportive group
• Daily practice
• Others?
http://www.virtualtoolbox.ca/
www.fammed.wisc.edu/mindfulness
Indicators of Clinician Burnout
Burnout effects half of physicians,
and even more nurses.
Key indicators of burnout include:
(the shadow side of resilience)
1.
Emotional exhaustion
2.
Depersonalization & decreased
empathy
3.
Lack of personal accomplishment
http://www.headingtoninstitute.org/Portals/32/Resources/Test_Are_you_bur
nout.pdf
Significant improvements with Maslach
Burnout Inventory
What Contributes to Burnout?
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Perfectionism
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Lack of coping skills for stress
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Personal bad habits (smoking, recreational drug use)
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Lack of control over office processes
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Lack of control over schedule
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Poor relationships with colleagues
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Lack of time for self care
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Difficult and complicated patients
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Not enough time in the day
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Excessive paperwork
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Regret over chosen career
Eckleberry-Hunt et al, Acad Med 2009; 84:269-277.
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Burnout—What helps?
Strongest correlation medications
Moderate correlation—
• Use of meditation, relaxation,
massage, etc.
• Use of support group for
physicians
• Talking about feelings
• Use of professional counseling
• Feeling like one has some
control over one’s schedule
Eckleberry-Hunt et al, Acad Med 2009; 84:269-277.
What else?
• Having a plan for the future
• Having enough money
• Having a supportive work
environment
• Feeling connected to, and
compassionate toward
patients
• Shared mission at work
• Having good coping skills
• Being very happy with child
care
-Eckleberry-Hunt et al, Acad Med
2009; 84:269-277.
Resilience Can Be Learned!
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Positive attitude
Cognitive flexibility
Moral compass
Role model
Face fears
Develop active coping skills
Social support
Physical well-being
Train regularly
Recognize and foster signature strengths
Can also do a web search for
“The Resilience Prescription”
for a summary
Cultivating Resiliency – 3 questions
1. Am I living according to my
values?*
2. Am I taking care of myself?
3. Am I making a conscious
effort to cultivate
resilience?
From Nedrow, et al., Family Practice
Management, 2013; Jan/Feb: 25-30.
* http://www.wellesley.edu/sites/default/files/assets/departments/cws/files/values.pdf
In Summary
• To make your practice more ‘Integrative,’ consider
the following…
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Use the ECHO Approach
Consider supplements that meet ECHO criteria
Consider acupuncture for pain
Explore the power of probiotics
Remember the power of therapeutic presence
Incorporate mindfulness
Minimize burnout and enhance resilience
Take care of yourself!
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