Integrative Medicine: Building Bridges with Conceptual Models

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Integrative Medicine Building Bridges with
Conceptual Models

• Kathi J. Kemper, MD, MPH
• Caryl J Guth Chair for Holistic
• and Integrative Medicine
• Professor of Pediatrics
• Public Health Sciences
• Family and Community Medicine
• WFUSM

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OBJECTIVES By the end of this session

• 1. Define CAM, holistic, integrative medicine
• 2. Compare and contrast two different types of
  healing goals, tools and research paradigms
• 3. Contrast the NIH NCCAM model for CAM with the
  Kemper model integrating CAM and mainstream care
• 4. Describe a model illustrating the ethics of
  recommending, tolerating, monitoring or avoiding
  therapies
• 5. Understand progress to promote integrative
  medicine at WFUSM

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Complementary, Alternative and Mainstream
Therapies
Alternative
Mainstream
Complementary
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Holistic

• Caring for whole person - body, mind, emotions,
  spirit, relationships -- in the context of
  family, culture and community Contextual
  pediatrics
• Patient Centered care

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NIH NCCAM
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NCI OCCAM
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NIH NCCAM- CAM Def

• .a group of diverse medical and health care
  systems, practices, and products that are not
  presently considered to be part of conventional
  medicine.
• While some scientific evidence exists
  regarding some CAM therapies, for most there are
  key questions that are yet to be answered through
  well-designed scientific studies
• --questions such as whether these therapies
  are safe and whether they work for the diseases
  or medical conditions for which they are used.

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Consortium of Academic Health Centers for
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.
• It is founded on the principles and
  values of HUMANISTIC MEDICINE.

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CAM is a SUBSET of tools within Integrative
Medicine

• Integrative Medicine is a system of
  comprehensive care that emphasizes wellness and
  healing of the whole person, with special
  emphasis on patient participation, and attention
  to mental and spiritual health. 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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How does CAM fit with medical professionalism?

• Core of medical professionalism is creating and
  nurturing a healing relationship
• Values service, advocacy, altruism
• Behaviors
• 1) subordinate personal interests to those of
  others
• 2) high ethical/moral standards
• 3) respond to societal needs (greater good)
• 4) show humanistic values of caring, compassion,
  altruism, empathy, respect for others,
  trustworthiness
• 5) accountability
• 6) commitment to excellence, scholarship and
  advancing knowledge
• 7) reflective and able to deal with complexity
• SwickHM. Acad Med, 200075(6) 612

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Is it ETHICAL to integrate CAM therapies into
conventional practice?

• Principles of ethics
• Beneficence / Do no harm
• Autonomy
• Justice
• Etc.
• Common Sense
• Patient-centered care
• Improve health and well-being
• Balance risks and benefits

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Ethical framework for Therapies
Cohen M. Pediatrics, 2005
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Effectiveness?

• What therapy? (acupuncture is NOT chiropractic is
  NOT herbs is NOT massage)
• For whom? (adults vs. kids men vs. women)
• For what condition? (cancer, colds)
• Under what circumstances/context?
• For what desired outcome?
• Costs/benefits immediate and long-term
• Kemper. Arch Dis Child, 2001

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Nausea Does CAM work? Acupuncture
Effective
Cohen M. Pediatrics, 2005
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Nausea Does CAM work? Chiropractic
Effective
Cohen M. Pediatrics, 2005
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Effectiveness?

• What therapy? (acupuncture is NOT chiropractic is
  NOT herbs is NOT massage)
• For whom? (adults vs. kids men vs. women)
• For what condition? (cancer, colds)
• Under what circumstances/context?
• For what desired outcome?
• Costs/benefits immediate and long-term
• Kemper. Arch Dis Child, 2001

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Surgery for Appendicitis
Effective
Cohen M. Pediatrics, 2005
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Surgery for Common Cold
Effective
Cohen M. Pediatrics, 2005
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Chemotherapy for Cancer
Effective
Cohen M. Pediatrics, 2005
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Echinacea or Chicken Soup to Treat Common Cold
Effective
Cohen M. Pediatrics, 2005
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Effectiveness?

• What therapy? (acupuncture is NOT chiropractic
  is NOT herbs is NOT massage)
• For whom? (adults vs. kids men vs. women)
• For what condition? (cancer, colds)
• Under what circumstances/context?
• For what desired outcome? Patient goals
• Costs/benefits immediate and long-term
• Kemper. Arch Dis Child, 2001

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Model for Pt Goals for Healing

• YANG-type/ Specific
• Cure
• Manage symptoms
• Prevent specific disease
• Reduce or manage specific toxin

• YIN-type/Global
• Connection/Support/
• Trust
• Meaning/Transcendence
• Harmony
• Peace
• Well-being/ Resilience
• Reduce dependence

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Tools to Achieve Patient Goals

• YANG - type
• What we KNOW, e.g. differential dx EBM
• What we DO, e.g., specific skills

• YIN type
• WHO and WHY we are, e.g., intentionality
• HOW we are, e.g., present, centered, peaceful,
  hopeful, patient-focused, respectful,
  compassionate
• COMMUNICATION

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Models for Treatment
Disease in Organ or Tissue
Symptoms
QOL Well-being
Treatment
Yang
Primary
Secondary
Person
Symptoms or Disease
Peace Connection Trust Harmony
B

• Treatment

Yin
Primary
Secondary
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Yang Treatment Study
Remission
Chemotherapy/ XRT
HR-QOL Well-being
Primary
Cancer
Secondary
Treatment and Disease-focused research and care
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Yin Treatment/Therapy
Peace Connection Trust Harmony
Primary
Person
Less pain Less depression Less anxiety Better
immune function Less Heart Disease Less cancer

• Social
• Support

Secondary
Measurement issues?????
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Yang Model

• What treatments effectively treat this
  disease/condition/symptom? e.g., NCI, NHLBI
• What can diseases/conditions/symptoms can this
  treatment impact?, e.g., what can Minoxidil do
  for Blood pressure, hair growth what can Paxil
  do for depression, for PMDD?

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Yin Model

• How can we serve this person?
• Enhance well-being build resilience
• Remove barriers to optimal functioning (concept
  of toxins)
• How can we serve the community?
• Public health jobs, education, transportation,
  esthetics (music, arts)
• Ecology
• Civil rights, womens rights/social justice
• Peace movement

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CAM - Adult Epidemiology

• Growth from 34 adult Americans using CAM in 1991
  to 42 in 1997
• Out of pockets costs /27billion
• Only 40 talked with docs about CAM same true
  for peds
• Eisenberg, JAMA, 1998

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Which CAM therapies most commonly used?

• Prayer
• Herbal therapies, vitamins, minerals and other
  dietary supplements
• Chiropractic
• Massage
• Homeopathy
• Yoga
• Acupuncture/acupressure
• Biofeedback, hypnosis
• Largely affected by culture, spirituality,
  gender, income, education, chronic illness

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What about here at WFUBMC?

• Ronny Bell, PHS survey 2001
• 2309 surveys (292 MD, 1871 RN, 31 PA, 115
  researchers) herbs and supplements only
• 70 used nutraceuticals (Vitamins 40, Calcium,
  30 Vitamin C, 25 Vitamin E, 25 Echinacea,
  15 Glucosamine, 10)

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Why? What do you mean, why?

• Health promotion health maintenance improve
  symptoms
• Highest among women married higher education
  and income poorer health non-smokers cultural
  beliefs
• Consistent with values natural, safe, holistic
  orientation, environmentalist, feminist,
  spiritual growth orientation empowering/individua
  l responsibility non-chemical, meaningful,
  cultural, being respected, treated like person
  (1998 JAMA) when asked, 72 of pts prefer a
  non-drug, home remedy to a drug (1984 AJPH)
• NOT b/c dissatisfied with mainstream care
• NEARLY ALL integrate CAM with mainstream

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Only 40 of patients tell docs about CAM use

• Natural, not medical irrelevant, not
  important for the doctor to know 61
• Docs not interested the doctor never asked 60
• None of the doctors business 31
• Doctor would not understand 20
• Cultural practice - embarrassing or private, lt20
• Fear of physician reaction (disapproval,
  abandonment, worse medical care) lt 15
• Eisenberg DM, et al. Arch Intern Med, 2001 135
  344-51

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THE MOST IMPORTANT QUESTIONS IN CLINICAL MEDICINE

• What have you tried so far?
• How has that worked?
• What does the patient consider a success or
  failure?

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Be systematicDo not jump in with your answer
until you have assessed ALL the therapies of
interest

• Efficient
• Comprehensive avoid missing the key
• Example differential diagnosis organ system
  approach in ICU

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Alphabetical Approach

• Acupuncture
• Antibiotics, antidepressants, antihypertensives.
• Ayurveda
• Chiropractic
• Herbs
• Massage
• Meditation
• Osteopathy
• Probiotics
• Surgery
• Vitamins
• Zen meditation

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CAM approach

• 1. Ask about mainstream therapies
• 2. Ask about complementary therapies
• 3. Ask about alternative therapies and systems

TCM, Homeopathy Native American Ayurveda Etc.
BiologicallyBased
Energy medicine
Manipulative/Body-based
Mind-Body
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Integrative Approach

• Biochemical
• Lifestyle
• Biomechanical
• Bioenergetic

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Biochemical

• Medications
• Dietary Supplements, such as herbs
• When asking about meds, also ask about OTC and
  vitamins, minerals, other supplements and herbs
• Give examples
• Be specific

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Be Specific

• Do YOU use herbs regularly, ie. 4 or more days a
  week?

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Be Persistent

• Dont stop at the first positive answer
• Dont stop at the first denial give examples

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Lifestyle

• Nutrition, Diet, Habits to avoid (tobacco, xs
  EtOH, drugs)
• Exercise and Rest
• Mind-Body Therapies
• Environment
• When asking about smoking, alcohol, also ask
  about diet, exercise, stress management, social
  support and environment. FORMS!

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Environment

• No smoking Clean house lead, allergens, air
  filters
• Minimize exposure to sick people
• Read Avoid guns
• Heat, cold, mist, sound, magnets, color,
  phototherapy,
• Social environment who is at home who helps
  connections church?

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Mind-Body Therapies / Stress Management

• Hypnosis
• Guided Imagery
• Meditation
• Journaling
• Social Support
• Psychological Counseling
• Peer Support

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Biomechanical

• Surgery
• Massage / Bodywork
• Cranial, spinal or joint adjustment

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Bioenergetic

• Acupuncture
• Healing Touch/TT/Reiki/Qi Gung
• Prayer/Spirituality
• Homeopathy (remedies)

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Integrative Medicine Model
Biochemical
Lifestyle
Patient
Biomechanical
Bioenergetic
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Integrative Medicine and Academic Medicine

• Academic Medicine 3 legged stool
• Clinical care
• Research (expanding knowledge)
• Education (disseminating knowledge)

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WFUHS

• CLINICAL
• Baptist Hospital
• Brenner Childrens Hospital
• WFUP (physician services)

• WFUSM
• Research
• Education

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http//www.besthealth.com/cam/
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WFUSM Research

• Coin of realm NIH dollars, other grant dollars,
  publications in peer-reviewed journals, other
  publications such as book chapters in texts
• Integrative medicine-related research dollars gt
  25 million (NIH and non-NIH)
• 115 peer-reviewed publications
• 20 review articles, chapters, books
• 80 faculty doing research

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Largest Topics for Research

• Herbs and dietary supplements soy, fatty acids,
  ginkgo, vitamin D, lycopene, etc.
• Basic Research
• Clinical Research
• Health Services Research
• Educational Research
• Mind-body Therapies
• Music
• Meditation
• Biofield
• Healing Touch and Therapeutic Touch

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Education at WFUSM

• Medical students and PA students
• Cases
• Lectures
• Role play and seminars
• Residents
• Fellows
• Faculty and staff lecture series like this, GCRC
  and visiting professors
• CME/ CE through Northwest AHEC

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Program for Holistic and Integrative Medicine at
WFUSM

www1.wfubmc.edu/phim
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PHIM Committees, Task Forces, Councils

• CAM and the Community
• Herb and Dietary Supplement Task Force
• Council on Mind-Body Medicine
• Council on Bioenergetic Healing
• Committee for Holistic and Integrative Medical
  Education
• Spirituality and Medicine
• Nutrition Committee

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Future Integrative Medicine at WFUSM

• Build on existing strengths and experience
• Center for Holistic and Integrative Medicine
• Graduate Program
• PhD
• MS
• National leader for on-line CME programs
• Novel programs on communication across
  disciplines
• Novel programs on cultivating compassion

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Summary

• 1.CAM are a subset of tools within Integrative
  medicine integration is preferable to Alt vs.
  Mainstream
• 2. Conceptual Model yin and yang healing goals,
  tools, research models
• 3. Conceptual model ethics of recommending tx
  balance safety/effectiveness
• 4. Integrated model of four types of therapy
• 5. Present and future of Integrative Med at WFUSM
  -- progress