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Integrative Medicine. Aaron J. Michelfelder, M.D., FAAFP, FAAMA Vice-Chair and Predoctoral Director, Family Medicine Associate Professor of Family Medicine, and Bioethics & Health Policy Board Certified Medical Acupuncturist. Objectives.

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integrative medicine

Integrative Medicine

Aaron J. Michelfelder, M.D., FAAFP, FAAMA

Vice-Chair and Predoctoral Director, Family Medicine

Associate Professor of Family Medicine, and Bioethics & Health Policy

Board Certified Medical Acupuncturist

objectives
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
Presentation Outline
  • Definitions
  • Why Should We Care About CAM?
  • What Do Patients Want?
  • What Can We Provide to Meet the Demand?
real patient
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?

slide5
“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
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

definitions7
Definitions
  • “Complementary Medicine is Used TogetherWith Conventional Medicine.”
  • “Alternative Medicine is Used in Place of Conventional Medicine.”
definitions8
Definitions

“Integrative Medicine Combines Mainstream Medical Therapies and CAM Therapies for Which There is Some High-Quality Scientific Evidence of Safety and Effectiveness.”

NCCAM

5 domains of cam
5 Domains of CAM

As Defined by NCCAM

why should we care
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
why should we care12
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
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 boat14
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
What about communication?
  • Between 40 and 70% of CAM users do notdisclose their use to their physician.

WHY?

Eisenberg 2001

why do patients not tell their physician about their cam use
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
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
slide18
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
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
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
evidence based medicine
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
slide24
RCCT
  • Gleevec
  • Albuterol
  • Acupuncture
  • Chinese Herbal Therapies
  • How Can This Stand the Test of Time?
comparison
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
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

CAHCIM Members
loyola integrative medicine physician faculty
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
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
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
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 medicine36
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 medicine37
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 medicine38
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 medicine39
The Future of Integrative Medicine

The Future Is Sometimes Curing,

But Always Caring

real patient40
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 medicine41
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 medicine42
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
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.
5 domains of cam44
5 Domains of CAM

As Defined by NCCAM

the future of integrative medicine46
The Future of Integrative Medicine
  • Nutrition
  • Exercise
  • Lycopene
  • Glucosamine
  • Peppermint Oil
  • Fish Oil
  • Soy
the future of integrative medicine47
The Future of Integrative Medicine
  • Epocrates Rx Pro
  • Micromedex
  • Commission E
  • Plus Many Other Databases
resources
Resources
  • Commission E
    • Germany
    • Ranks Quality of Evidence
    • Evaluates Benefits and Risks
integrative medicine51
Integrative Medicine
  • Donald Novey, M.D. – Lutheran General Hospital
    • Evidence Based Review of Each Modality
integrative medicine52
Integrative Medicine
  • David Rakel, M.D., University of Wisconsin
    • Instructions on how to put CAM into your own medical practice
resources54
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
resources55
Resources
  • American Academy of Medical Acupuncture
    • www.medicalacupuncture.org
  • Online Resource
    • http://www.altmedicine.com
where should we go for information
Where Should We Go for Information?
  • Product claims
    • www.quackwatch.com
    • www.snopes.com
  • Product quality assurance
    • www.consumerlab.com
  • Product ingredients
    • Natural Medicines Databasewww.naturaldatabase.com
  • Product safety and efficacy
    • www.cfsan.fda.gov/~dms/ds-ind.html
    • www.naturaldatabase.com
    • The Natural Pharmacistwww.iherb.com or www.consumerlab.com
summary
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
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