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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


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    1. 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

    2. 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

    3. 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

    4. Growth of CAM Research MEDLINE Citations Under “Alternative Medicine” 1966-2005

    5. Old Model: CAM Therapies Alternative Mainstream biomedicine Complementary

    6. 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

    7. 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

    8. Licensed Health Professionals in US (selected)

    9. 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/               <>

    10. 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

    11. eResource: NCI OCCAM • Health information for patients http://www.cancer.gov/cam/health_understanding.html • Clinical trial information • Grant funding for research projects

    12. Highest CAM Users • Well educated • Upper income • Women • Chronically ill (pain fatigue, anxiety, depression)

    13. 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

    14. 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

    15. 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

    16. Integrative Medicine = Good Medicine Sustainable, Healing Environment Holistic Patient- Centered Care Comprehensive Therapeutic Options WellnessOrientation *

    17. 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

    18. 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

    19. 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

    20. 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

    21. 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

    22. eEducation about herbs / dietary supplements • https://northwestahec.wfubmc.edu/learn/herbs_ce/index.cfm

    23. 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

    24. ***Mind-Body Therapies*** • Hypnosis • Guided imagery • Meditation • Autogenic training • Biofeedback • Journaling • Social Support • Psychological counseling • Peer support

    25. 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

    26. Ethical framework Cohen M. Pediatrics, 2005

    27. Effective? Safe? • 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

    28. What Kind of Integrative Services Do NC MDs Want? • 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

    29. Heart Center Fitness Oncology Acupuncture Fitness Neuroscience Acupuncture Biofeedback Bone & Joint Acupuncture Fitness Nutrition Pharmacy Massage Mind-Body Service Models CAM Center

    30. Sustainability • 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

    31. THANK YOU!

    32. WHO 2000 ranking • Netherlands is #17 for quality of health services (US is #37) • Problems • Waiting times • Labor shortages

    33. Prevention Gap Burden of disease, preventability, and research and translation gaps. Ockene, et al. Am J Prev Med, 2007; 32(3) :244

    34.  Social-ecologic framework: levels of influence on behavior. (From the Institute of Medicine, 2002.7)

    35. Payment for Health Services - US • Public (26%) • Medicare (>65; 14%) • Medicaid (poor, disabled; 12% ) • Private – variety, diverse coverage; usually employer-based; (58% of Americans) • Uninsured (16% of Americans)

    36. Burden of Disease: 2020 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

    37. Pharma Promises…