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Title: Integrative Medicine: Building Bridges with Conceptual Models


1
Integrative Medicine Building Bridges with
Conceptual Models
  • Kathi J. Kemper, MD, MPH
  • Caryl J Guth Chair for Holistic
  • and Integrative Medicine
  • Professor of Pediatrics
  • Public Health Sciences
  • Family and Community Medicine
  • WFUSM

2
OBJECTIVES By the end of this session
  • 1. Define CAM, holistic, integrative medicine
  • 2. Compare and contrast two different types of
    healing goals, tools and research paradigms
  • 3. Contrast the NIH NCCAM model for CAM with the
    Kemper model integrating CAM and mainstream care
  • 4. Describe a model illustrating the ethics of
    recommending, tolerating, monitoring or avoiding
    therapies
  • 5. Understand progress to promote integrative
    medicine at WFUSM

3
Complementary, Alternative and Mainstream
Therapies
Alternative
Mainstream
Complementary
4
Holistic
  • Caring for whole person - body, mind, emotions,
    spirit, relationships -- in the context of
    family, culture and community Contextual
    pediatrics
  • Patient Centered care

5
NIH NCCAM
6
NCI OCCAM
7
NIH NCCAM- CAM Def
  • .a group of diverse medical and health care
    systems, practices, and products that are not
    presently considered to be part of conventional
    medicine.
  • While some scientific evidence exists
    regarding some CAM therapies, for most there are
    key questions that are yet to be answered through
    well-designed scientific studies
  • --questions such as whether these therapies
    are safe and whether they work for the diseases
    or medical conditions for which they are used.

8
Consortium of Academic Health Centers for
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.
  • It is founded on the principles and
    values of HUMANISTIC MEDICINE.

9
CAM is a SUBSET of tools within Integrative
Medicine
  • Integrative Medicine is a system of
    comprehensive care that emphasizes wellness and
    healing of the whole person, with special
    emphasis on patient participation, and attention
    to mental and spiritual health. The knowledge and
    use of Complementary and Alternative Medicine
    (CAM) is an important aspect of Integrative
    Medicine.
  • Section on Integrative Medicine, Internal
    Medicine, UNM

10
How does CAM fit with medical professionalism?
  • Core of medical professionalism is creating and
    nurturing a healing relationship
  • Values service, advocacy, altruism
  • Behaviors
  • 1) subordinate personal interests to those of
    others
  • 2) high ethical/moral standards
  • 3) respond to societal needs (greater good)
  • 4) show humanistic values of caring, compassion,
    altruism, empathy, respect for others,
    trustworthiness
  • 5) accountability
  • 6) commitment to excellence, scholarship and
    advancing knowledge
  • 7) reflective and able to deal with complexity
  • SwickHM. Acad Med, 200075(6) 612

11
Is it ETHICAL to integrate CAM therapies into
conventional practice?
  • Principles of ethics
  • Beneficence / Do no harm
  • Autonomy
  • Justice
  • Etc.
  • Common Sense
  • Patient-centered care
  • Improve health and well-being
  • Balance risks and benefits

12
Ethical framework for Therapies
Cohen M. Pediatrics, 2005
13
Effectiveness?
  • What therapy? (acupuncture is NOT chiropractic is
    NOT herbs is NOT massage)
  • For whom? (adults vs. kids men vs. women)
  • For what condition? (cancer, colds)
  • Under what circumstances/context?
  • For what desired outcome?
  • Costs/benefits immediate and long-term
  • Kemper. Arch Dis Child, 2001

14
Nausea Does CAM work? Acupuncture
Effective
Cohen M. Pediatrics, 2005
15
Nausea Does CAM work? Chiropractic
Effective
Cohen M. Pediatrics, 2005
16
Effectiveness?
  • What therapy? (acupuncture is NOT chiropractic is
    NOT herbs is NOT massage)
  • For whom? (adults vs. kids men vs. women)
  • For what condition? (cancer, colds)
  • Under what circumstances/context?
  • For what desired outcome?
  • Costs/benefits immediate and long-term
  • Kemper. Arch Dis Child, 2001

17
Surgery for Appendicitis
Effective
Cohen M. Pediatrics, 2005
18
Surgery for Common Cold
Effective
Cohen M. Pediatrics, 2005
19
Chemotherapy for Cancer
Effective
Cohen M. Pediatrics, 2005
20
Echinacea or Chicken Soup to Treat Common Cold
Effective
Cohen M. Pediatrics, 2005
21
Effectiveness?
  • What therapy? (acupuncture is NOT chiropractic
    is NOT herbs is NOT massage)
  • For whom? (adults vs. kids men vs. women)
  • For what condition? (cancer, colds)
  • Under what circumstances/context?
  • For what desired outcome? Patient goals
  • Costs/benefits immediate and long-term
  • Kemper. Arch Dis Child, 2001

22
Model for Pt Goals for Healing
  • YANG-type/ Specific
  • Cure
  • Manage symptoms
  • Prevent specific disease
  • Reduce or manage specific toxin
  • YIN-type/Global
  • Connection/Support/
  • Trust
  • Meaning/Transcendence
  • Harmony
  • Peace
  • Well-being/ Resilience
  • Reduce dependence

23
Tools to Achieve Patient Goals
  • YANG - type
  • What we KNOW, e.g. differential dx EBM
  • What we DO, e.g., specific skills
  • YIN type
  • WHO and WHY we are, e.g., intentionality
  • HOW we are, e.g., present, centered, peaceful,
    hopeful, patient-focused, respectful,
    compassionate
  • COMMUNICATION

24
Models for Treatment
Disease in Organ or Tissue
Symptoms
QOL Well-being
Treatment
Yang
Primary
Secondary
Person
Symptoms or Disease
Peace Connection Trust Harmony
B
  • Treatment

Yin
Primary
Secondary
25
Yang Treatment Study
Remission
Chemotherapy/ XRT
HR-QOL Well-being
Primary
Cancer
Secondary
Treatment and Disease-focused research and care
26
Yin Treatment/Therapy
Peace Connection Trust Harmony
Primary
Person
Less pain Less depression Less anxiety Better
immune function Less Heart Disease Less cancer
  • Social
  • Support

Secondary
Measurement issues?????
27
Yang Model
  • What treatments effectively treat this
    disease/condition/symptom? e.g., NCI, NHLBI
  • What can diseases/conditions/symptoms can this
    treatment impact?, e.g., what can Minoxidil do
    for Blood pressure, hair growth what can Paxil
    do for depression, for PMDD?

28
Yin Model
  • How can we serve this person?
  • Enhance well-being build resilience
  • Remove barriers to optimal functioning (concept
    of toxins)
  • How can we serve the community?
  • Public health jobs, education, transportation,
    esthetics (music, arts)
  • Ecology
  • Civil rights, womens rights/social justice
  • Peace movement

29
CAM - Adult Epidemiology
  • Growth from 34 adult Americans using CAM in 1991
    to 42 in 1997
  • Out of pockets costs /27billion
  • Only 40 talked with docs about CAM same true
    for peds
  • Eisenberg, JAMA, 1998

30
Which CAM therapies most commonly used?
  • Prayer
  • Herbal therapies, vitamins, minerals and other
    dietary supplements
  • Chiropractic
  • Massage
  • Homeopathy
  • Yoga
  • Acupuncture/acupressure
  • Biofeedback, hypnosis
  • Largely affected by culture, spirituality,
    gender, income, education, chronic illness

31
What about here at WFUBMC?
  • Ronny Bell, PHS survey 2001
  • 2309 surveys (292 MD, 1871 RN, 31 PA, 115
    researchers) herbs and supplements only
  • 70 used nutraceuticals (Vitamins 40, Calcium,
    30 Vitamin C, 25 Vitamin E, 25 Echinacea,
    15 Glucosamine, 10)

32
Why? What do you mean, why?
  • Health promotion health maintenance improve
    symptoms
  • Highest among women married higher education
    and income poorer health non-smokers cultural
    beliefs
  • Consistent with values natural, safe, holistic
    orientation, environmentalist, feminist,
    spiritual growth orientation empowering/individua
    l responsibility non-chemical, meaningful,
    cultural, being respected, treated like person
    (1998 JAMA) when asked, 72 of pts prefer a
    non-drug, home remedy to a drug (1984 AJPH)
  • NOT b/c dissatisfied with mainstream care
  • NEARLY ALL integrate CAM with mainstream

33
Only 40 of patients tell docs about CAM use
  • Natural, not medical irrelevant, not
    important for the doctor to know 61
  • Docs not interested the doctor never asked 60
  • None of the doctors business 31
  • Doctor would not understand 20
  • Cultural practice - embarrassing or private, lt20
  • Fear of physician reaction (disapproval,
    abandonment, worse medical care) lt 15
  • Eisenberg DM, et al. Arch Intern Med, 2001 135
    344-51

34
THE MOST IMPORTANT QUESTIONS IN CLINICAL MEDICINE
  • What have you tried so far?
  • How has that worked?
  • What does the patient consider a success or
    failure?

35
Be systematicDo not jump in with your answer
until you have assessed ALL the therapies of
interest
  • Efficient
  • Comprehensive avoid missing the key
  • Example differential diagnosis organ system
    approach in ICU

36
Alphabetical Approach
  • Acupuncture
  • Antibiotics, antidepressants, antihypertensives.
  • Ayurveda
  • Chiropractic
  • Herbs
  • Massage
  • Meditation
  • Osteopathy
  • Probiotics
  • Surgery
  • Vitamins
  • Zen meditation

37
CAM approach
  • 1. Ask about mainstream therapies
  • 2. Ask about complementary therapies
  • 3. Ask about alternative therapies and systems

TCM, Homeopathy Native American Ayurveda Etc.
BiologicallyBased
Energy medicine
Manipulative/Body-based
Mind-Body
38
Integrative Approach
  • Biochemical
  • Lifestyle
  • Biomechanical
  • Bioenergetic

39
Biochemical
  • Medications
  • Dietary Supplements, such as herbs
  • When asking about meds, also ask about OTC and
    vitamins, minerals, other supplements and herbs
  • Give examples
  • Be specific

40
Be Specific
  • Do YOU use herbs regularly, ie. 4 or more days a
    week?

41
Be Persistent
  • Dont stop at the first positive answer
  • Dont stop at the first denial give examples

42
Lifestyle
  • Nutrition, Diet, Habits to avoid (tobacco, xs
    EtOH, drugs)
  • Exercise and Rest
  • Mind-Body Therapies
  • Environment
  • When asking about smoking, alcohol, also ask
    about diet, exercise, stress management, social
    support and environment. FORMS!

43
Environment
  • No smoking Clean house lead, allergens, air
    filters
  • Minimize exposure to sick people
  • Read Avoid guns
  • Heat, cold, mist, sound, magnets, color,
    phototherapy,
  • Social environment who is at home who helps
    connections church?

44
Mind-Body Therapies / Stress Management
  • Hypnosis
  • Guided Imagery
  • Meditation
  • Journaling
  • Social Support
  • Psychological Counseling
  • Peer Support

45
Biomechanical
  • Surgery
  • Massage / Bodywork
  • Cranial, spinal or joint adjustment

46
Bioenergetic
  • Acupuncture
  • Healing Touch/TT/Reiki/Qi Gung
  • Prayer/Spirituality
  • Homeopathy (remedies)

47
Integrative Medicine Model
Biochemical
Lifestyle
Patient
Biomechanical
Bioenergetic
48
Integrative Medicine and Academic Medicine
  • Academic Medicine 3 legged stool
  • Clinical care
  • Research (expanding knowledge)
  • Education (disseminating knowledge)

49
WFUHS
  • CLINICAL
  • Baptist Hospital
  • Brenner Childrens Hospital
  • WFUP (physician services)
  • WFUSM
  • Research
  • Education

50
http//www.besthealth.com/cam/
51
WFUSM Research
  • Coin of realm NIH dollars, other grant dollars,
    publications in peer-reviewed journals, other
    publications such as book chapters in texts
  • Integrative medicine-related research dollars gt
    25 million (NIH and non-NIH)
  • 115 peer-reviewed publications
  • 20 review articles, chapters, books
  • 80 faculty doing research

52
Largest Topics for Research
  • Herbs and dietary supplements soy, fatty acids,
    ginkgo, vitamin D, lycopene, etc.
  • Basic Research
  • Clinical Research
  • Health Services Research
  • Educational Research
  • Mind-body Therapies
  • Music
  • Meditation
  • Biofield
  • Healing Touch and Therapeutic Touch

53
Education at WFUSM
  • Medical students and PA students
  • Cases
  • Lectures
  • Role play and seminars
  • Residents
  • Fellows
  • Faculty and staff lecture series like this, GCRC
    and visiting professors
  • CME/ CE through Northwest AHEC

54
Program for Holistic and Integrative Medicine at
WFUSM

www1.wfubmc.edu/phim
55
PHIM Committees, Task Forces, Councils
  • CAM and the Community
  • Herb and Dietary Supplement Task Force
  • Council on Mind-Body Medicine
  • Council on Bioenergetic Healing
  • Committee for Holistic and Integrative Medical
    Education
  • Spirituality and Medicine
  • Nutrition Committee

56
Future Integrative Medicine at WFUSM
  • Build on existing strengths and experience
  • Center for Holistic and Integrative Medicine
  • Graduate Program
  • PhD
  • MS
  • National leader for on-line CME programs
  • Novel programs on communication across
    disciplines
  • Novel programs on cultivating compassion

57
Summary
  • 1.CAM are a subset of tools within Integrative
    medicine integration is preferable to Alt vs.
    Mainstream
  • 2. Conceptual Model yin and yang healing goals,
    tools, research models
  • 3. Conceptual model ethics of recommending tx
    balance safety/effectiveness
  • 4. Integrated model of four types of therapy
  • 5. Present and future of Integrative Med at WFUSM
    -- progress
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