Title: Integrative Medicine: Building Bridges with Conceptual Models
1Integrative 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
2OBJECTIVES 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
3Complementary, Alternative and Mainstream
Therapies
Alternative
Mainstream
Complementary
4Holistic
- Caring for whole person - body, mind, emotions,
spirit, relationships -- in the context of
family, culture and community Contextual
pediatrics - Patient Centered care
5NIH NCCAM
6NCI OCCAM
7NIH 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.
8Consortium 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.
9CAM 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
10How 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
11Is 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
12Ethical framework for Therapies
Cohen M. Pediatrics, 2005
13Effectiveness?
- 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
14Nausea Does CAM work? Acupuncture
Effective
Cohen M. Pediatrics, 2005
15Nausea Does CAM work? Chiropractic
Effective
Cohen M. Pediatrics, 2005
16Effectiveness?
- 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
17Surgery for Appendicitis
Effective
Cohen M. Pediatrics, 2005
18Surgery for Common Cold
Effective
Cohen M. Pediatrics, 2005
19Chemotherapy for Cancer
Effective
Cohen M. Pediatrics, 2005
20Echinacea or Chicken Soup to Treat Common Cold
Effective
Cohen M. Pediatrics, 2005
21Effectiveness?
- 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
22Model 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
23Tools 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
24Models for Treatment
Disease in Organ or Tissue
Symptoms
QOL Well-being
Treatment
Yang
Primary
Secondary
Person
Symptoms or Disease
Peace Connection Trust Harmony
B
Yin
Primary
Secondary
25Yang Treatment Study
Remission
Chemotherapy/ XRT
HR-QOL Well-being
Primary
Cancer
Secondary
Treatment and Disease-focused research and care
26Yin Treatment/Therapy
Peace Connection Trust Harmony
Primary
Person
Less pain Less depression Less anxiety Better
immune function Less Heart Disease Less cancer
Secondary
Measurement issues?????
27Yang 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?
28Yin 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
29CAM - 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
30Which 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
31What 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)
32Why? 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
33Only 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
34THE 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?
35Be 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
36Alphabetical Approach
- Acupuncture
- Antibiotics, antidepressants, antihypertensives.
- Ayurveda
- Chiropractic
- Herbs
- Massage
- Meditation
- Osteopathy
- Probiotics
- Surgery
- Vitamins
- Zen meditation
37CAM 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
38Integrative Approach
- Biochemical
- Lifestyle
- Biomechanical
- Bioenergetic
39Biochemical
- 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
40Be Specific
- Do YOU use herbs regularly, ie. 4 or more days a
week?
41Be Persistent
- Dont stop at the first positive answer
- Dont stop at the first denial give examples
42Lifestyle
- 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!
43Environment
- 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?
44Mind-Body Therapies / Stress Management
- Hypnosis
- Guided Imagery
- Meditation
- Journaling
- Social Support
- Psychological Counseling
- Peer Support
45Biomechanical
- Surgery
- Massage / Bodywork
- Cranial, spinal or joint adjustment
46Bioenergetic
- Acupuncture
- Healing Touch/TT/Reiki/Qi Gung
- Prayer/Spirituality
- Homeopathy (remedies)
47Integrative Medicine Model
Biochemical
Lifestyle
Patient
Biomechanical
Bioenergetic
48Integrative Medicine and Academic Medicine
- Academic Medicine 3 legged stool
- Clinical care
- Research (expanding knowledge)
- Education (disseminating knowledge)
49WFUHS
- CLINICAL
- Baptist Hospital
- Brenner Childrens Hospital
- WFUP (physician services)
50http//www.besthealth.com/cam/
51WFUSM 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
52Largest 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
53Education 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
54Program for Holistic and Integrative Medicine at
WFUSM
www1.wfubmc.edu/phim
55PHIM 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
56Future 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
57Summary
- 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