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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.

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Integrative medicine good medicine l.jpg

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


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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


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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


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Growth of CAM Research

MEDLINE

Citations Under

“Alternative

Medicine”

1966-2005


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Old Model: CAM Therapies

Alternative

Mainstream biomedicine

Complementary


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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


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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



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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/0309092701/html/

              <>


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eResource: NIH NCCAM

  • Patient information sheets in English and Spanish

  • Ongoing research projects/clinical trials

  • Education and Training opportunities

  • http://nccam.nih.gov

NCCAM Clearinghouse:(US) 1-888-644-6226


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eResource: NCI OCCAM

  • Health information for patients

    http://www.cancer.gov/cam/health_understanding.html

  • Clinical trial information

  • Grant funding for research projects


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Highest CAM Users

  • Well educated

  • Upper income

  • Women

  • Chronically ill (pain fatigue, anxiety, depression)


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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


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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


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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


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Integrative Medicine = Good Medicine

Sustainable, Healing Environment

Holistic Patient- Centered Care

Comprehensive Therapeutic Options

WellnessOrientation

*


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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


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Current Approach

Care based primarily on visits

Professional autonomy drives variability

Professionals control care

Information is a record

Decision making is based on training and experience

New Rule

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 evidence- based

US Institute of Medicine’s Rules for the Twenty-First Century Health Care System


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Current Approach

Do no harm is an individual responsibility

The system reacts to needs

Cost reduction is sought

Preference is given to professional roles over the system.

New Rule

Safety is a system property

Needs are anticipated

Waste is continuously decreased

Cooperation among clinicians is a priority

Institute of Medicine’s Simple Rules for the Twenty-First Century Health Care System


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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


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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


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eEducation about herbs / dietary supplements

  • https://northwestahec.wfubmc.edu/learn/herbs_ce/index.cfm


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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


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***Mind-Body Therapies*** hospital?

  • Hypnosis

  • Guided imagery

  • Meditation

  • Autogenic training

  • Biofeedback

  • Journaling

  • Social Support

  • Psychological counseling

  • Peer support


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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


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Ethical framework practice?

Cohen M. Pediatrics, 2005


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Effective? Safe? practice?

  • What therapy?

  • For whom?

  • For what condition? (cancer, colds)

  • Under what circumstances?

  • For what desired outcome?

  • When? immediate versus long-term

    Kemper. Arch Dis Child, 2001


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What Kind of Integrative Services Do NC MDs Want? practice?

  • Pain management (84%)

  • Weight/Obesity management (80%)

  • Diabetes-Lifestyle (73%)

  • Stress management (73%)

  • Heart healthy lifestyle (71%)

  • Back pain (66%)

  • Headache (63%)

  • Cancer support (62%)

  • Stroke recovery (51%)

Kemper, et al. BMC CAM, 2007; 7:5


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Heart Center practice?

Fitness

Oncology

Acupuncture

Fitness

Neuroscience

Acupuncture

Biofeedback

Bone & Joint

Acupuncture

Fitness

Nutrition

Pharmacy

Massage

Mind-Body

Service Models

CAM Center


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Sustainability practice?

  • Consistent with cultural values, e.g., evidence-based, 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


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THANK YOU! practice?


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WHO 2000 ranking practice?

  • Netherlands is #17 for quality of health services (US is #37)

  • Problems

    • Waiting times

    • Labor shortages


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Prevention Gap practice?

Burden of disease, preventability, and research and translation gaps.

Ockene, et al. Am J Prev Med, 2007; 32(3) :244


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 Social-ecologic framework: levels of influence on behavior.

(From the Institute of Medicine, 2002.7)


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Payment for Health Services - US behavior.

  • Public (26%)

    • Medicare (>65; 14%)

    • Medicaid (poor, disabled; 12% )

  • Private – variety, diverse coverage; usually employer-based; (58% of Americans)

  • Uninsured (16% of Americans)


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Burden of Disease: 2020 behavior. Expected in Developed Countries

  • 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



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