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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 l.jpg

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 disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment.

“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 disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment.

  • “Complementary Medicine is Used TogetherWith Conventional Medicine.”

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


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Definitions disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment.

“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 disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment.

As Defined by NCCAM


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Why Should We Care? disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment.

  • 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 disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment.


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Why Should We Care? disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment.

  • 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? disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment.

  • 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? disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment.

  • 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? disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment.

  • 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? use?

  • 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: use?

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? use?

“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? use?

  • 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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Or This? use?


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Evidence Based Medicine use?

  • 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 use?

  • Gleevec

  • Albuterol

  • Acupuncture

  • Chinese Herbal Therapies

  • How Can This Stand the Test of Time?


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Comparison use?

  • 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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Clinical Fellowships: but what about physicians?

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? but what about physicians?


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Albert Einstein/Beth Israel but what about physicians?

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 but what about physicians?

  • 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 but what about physicians?

  • 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 but what about physicians?

  • 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 but what about physicians?

  • 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 but what about physicians?

  • 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 but what about physicians?

  • 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 but what about physicians?

  • 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 but what about physicians?

The Future Is Sometimes Curing,

But Always Caring


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Real Patient but what about physicians?

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 but what about physicians?

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 but what about physicians?

  • 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? but what about physicians?

  • 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 but what about physicians?

As Defined by NCCAM


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The Future of Integrative Medicine but what about physicians?

  • Nutrition

  • Exercise

  • Lycopene

  • Glucosamine

  • Peppermint Oil

  • Fish Oil

  • Soy


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The Future of Integrative Medicine but what about physicians?

  • Epocrates Rx Pro

  • Micromedex

  • Commission E

  • Plus Many Other Databases


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http://nccam.nih.gov/ but what about physicians?


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Resources but what about physicians?

  • Commission E

    • Germany

    • Ranks Quality of Evidence

    • Evaluates Benefits and Risks


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Integrative Medicine but what about physicians?

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

    • Evidence Based Review of Each Modality


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Integrative Medicine but what about physicians?

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

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


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Resources but what about physicians?

  • 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 but what about physicians?

  • American Academy of Medical Acupuncture

    • www.medicalacupuncture.org

  • Online Resource

    • http://www.altmedicine.com


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Where Should We Go for Information? but what about physicians?

  • 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 but what about physicians?

  • 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! but what about physicians?