Integrative Medicine Aaron J. Michelfelder, M.D., FAAFP, FAAMA Vice-Chair and Predoctoral Director, Family Medicine Associate Professor of Family Medicine,
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Integrative Medicine
Aaron J. Michelfelder, M.D., FAAFP, FAAMAVice-Chair and Predoctoral Director, Family Medicine
Associate Professor of Family Medicine, and Bioethics & Health PolicyBoard 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
• 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 TogetherUsed Together WithWith Conventional Medicine.”
• “Alternative Medicine is Used in Place ofUsed in Place of Conventional Medicine.”
Definitions
“Integrative Medicine CombinesCombines Mainstream Medical Therapies and CAM Therapies for Which There is Some High-Quality Scientific Evidence of Safety and Effectiveness.”
NCCAM
AlternativeMedicalSystems
Ayurveda, Chinese, Native American, Aboriginal, African,Middle Eastern, Tibetan, Central and South American cultures,Homeopathy, Naturopathy
Mind-BodyInterventions
cognitive-behavioral approaches, meditation, hypnosis, dance,music, art therapy, prayer, mental healing
BiologicalBased 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 Body-Based Methods
chiropractic, osteopathic manipulation, massage
Energy Therapies Qi gong, Reiki, therapeutic touch, bioelectromagnetic-basedtherapies (pulsed fields, magnetic fields, or alternating currentor direct current fields)
5 Domains of CAM
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?
• Looking for “cures”• Want to use “natural” products • Patient feels empowered• Focus on spirituality and emotional well-
being• 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.”•
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?
• 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 drug-related 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– Sham Acupuncture– Non Standardized Herbal Formulations– Difficult to Blind Patients and Practitioners– Treatments Very Individualized – Difficult to
Formulate Protocols
RCCT
• 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
CAM MODALITY LICENSURE
Chiropractors All states
Massage ther. 27 states
Naturopaths 13 states
Homeopaths 3 states
Acupuncturists 32 states
Licensing Issues
• 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)– 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• 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
• 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.
AlternativeMedicalSystems
Ayurveda, Chinese, Native American, Aboriginal, African,Middle Eastern, Tibetan, Central and South American cultures,Homeopathy, Naturopathy
Mind-BodyInterventions
cognitive-behavioral approaches, meditation, hypnosis, dance,music, art therapy, prayer, mental healing
BiologicalBased 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 Body-Based Methods
chiropractic, osteopathic, manipulation, massage
Energy Therapies Qi gong, Reiki, therapeutic touch, bioelectromagnetic-basedtherapies (pulsed fields, magnetic fields, or alternating currentor direct current fields)
5 Domains of CAM
As Defined by NCCAM
Unsafe/Proven Safe/Proven
Unsafe/Unproven Safe/Unproven
The Future of Integrative Medicine
• Nutrition• Exercise
• 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
• 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!
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