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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

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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


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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


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Presentation Outline

  • Definitions

  • Why Should We Care About CAM?

  • What Do Patients Want?

  • What Can We Provide to Meet the Demand?


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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?


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“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.”


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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


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Definitions

  • “Complementary Medicine is Used TogetherWith Conventional Medicine.”

  • “Alternative Medicine is Used in Place of Conventional Medicine.”


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Definitions

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

NCCAM


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5 Domains of CAM

As Defined by NCCAM


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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


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Overall Supplement Use


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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


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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


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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


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What about communication?

  • Between 40 and 70% of CAM users do notdisclose their use to their physician.

    WHY?

Eisenberg 2001


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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


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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


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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


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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”


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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


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Are Our Patients Reading This?


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Or This?


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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


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RCCT

  • Gleevec

  • Albuterol

  • Acupuncture

  • Chinese Herbal Therapies

  • How Can This Stand the Test of Time?


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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


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Licensing Issues


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  • Patients are choosing integrative and alternative medicine, but what about physicians?


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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?


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Where Are We Today?


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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


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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


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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


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Medical Students

  • Integrative Medicine Curriculum Demanded by Students

  • Integrative Medicine Interest Group

  • “Integrate Chicago” http://www.integratechicago.com/index.html


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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.”


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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


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The Future of Integrative Medicine

  • Integrative Medicine Will Be A Skill Set Added on Just Like:

    • Electronic Health Records

    • New Medications

    • New Procedures


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The Future of Integrative Medicine

  • What Cannot Be Added On is Empathy and Open-mindedness

  • 600 Million Visits a Year to Alternative Practitioners


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The Future of Integrative Medicine

The Future Is Sometimes Curing,

But Always Caring


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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?


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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


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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


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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.


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5 Domains of CAM

As Defined by NCCAM


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The Future of Integrative Medicine

  • Nutrition

  • Exercise

  • Lycopene

  • Glucosamine

  • Peppermint Oil

  • Fish Oil

  • Soy


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The Future of Integrative Medicine

  • Epocrates Rx Pro

  • Micromedex

  • Commission E

  • Plus Many Other Databases


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http://nccam.nih.gov/


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Resources

  • Commission E

    • Germany

    • Ranks Quality of Evidence

    • Evaluates Benefits and Risks


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Integrative Medicine

  • Donald Novey, M.D. – Lutheran General Hospital

    • Evidence Based Review of Each Modality


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Integrative Medicine

  • David Rakel, M.D., University of Wisconsin

    • Instructions on how to put CAM into your own medical practice


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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


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Resources

  • American Academy of Medical Acupuncture

    • www.medicalacupuncture.org

  • Online Resource

    • http://www.altmedicine.com


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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


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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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THANK YOU!


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