Integrative Medicine Aaron J. Michelfelder, M.D., FAAFP, FAAMA Vice-Chair and Predoctoral Director,...

Integrative Medicine

Aaron J. Michelfelder, M.D., FAAFP, FAAMAVice-Chair and Predoctoral Director, Family Medicine

Associate Professor of Family Medicine, and Bioethics & Health PolicyBoard Certified Medical Acupuncturist

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

• Definitions

• Why Should We Care About CAM?

• What Do Patients Want?

• What Can We Provide to Meet the Demand?

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?

“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

“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

Definitions

• “Complementary Medicine is Used TogetherUsed Together WithWith Conventional Medicine.”

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

Definitions

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

NCCAM

AlternativeMedicalSystems

Ayurveda, Chinese, Native American, Aboriginal, African,Middle Eastern, Tibetan, Central and South American cultures,Homeopathy, Naturopathy

Mind-BodyInterventions

cognitive-behavioral approaches, meditation, hypnosis, dance,music, art therapy, prayer, mental healing

BiologicalBased Therapies

dietary supplements, herbs, orthomolecular (varying concentrations of chemicals, such as, magnesium, melatonin, and mega-doses of vitamins), individual biological therapies (use of laetrile, shark cartilage, bee pollen).

Manipulative And Body-Based Methods

chiropractic, osteopathic manipulation, massage

Energy Therapies Qi gong, Reiki, therapeutic touch, bioelectromagnetic-basedtherapies (pulsed fields, magnetic fields, or alternating currentor direct current fields)

5 Domains of CAM

As Defined by NCCAM

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

Overall Supplement Use

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?

• 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 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?

• Between 40 and 70% of CAM users do not disclose their use to their physician.

WHY?

Eisenberg 2001

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?

• 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

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?

“Doctors concerned because several cases reported of liver failure with Kava Kava, a widely used natural remedy for anxiety”

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

http://www.consumerlabs.com/

Are Our Patients Reading This?

Or This?

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

RCCT

• Gleevec

• Albuterol

• Acupuncture

• Chinese Herbal Therapies

• How Can This Stand the Test of Time?

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

CAM MODALITY LICENSURE

Chiropractors All states

Massage ther. 27 states

Naturopaths 13 states

Homeopaths 3 states

Acupuncturists 32 states

Licensing Issues

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

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

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

• 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

• Integrative Medicine Curriculum Demanded by Students

• Integrative Medicine Interest Group• “Integrate Chicago” http://www.integratechicago.com/index.html

http://www.integratechicago.com/index.html

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 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


• Integrative Medicine Will Be A Skill Set Added on Just Like:– Electronic Health Records– New Medications– New Procedures


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

• 600 Million Visits a Year to Alternative Practitioners


The Future Is Sometimes Curing,

But Always Caring

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?


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 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?

• 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.

AlternativeMedicalSystems

Ayurveda, Chinese, Native American, Aboriginal, African,Middle Eastern, Tibetan, Central and South American cultures,Homeopathy, Naturopathy

Mind-BodyInterventions

cognitive-behavioral approaches, meditation, hypnosis, dance,music, art therapy, prayer, mental healing

BiologicalBased Therapies

dietary supplements, herbs, orthomolecular (varying concentrations of chemicals, such as, magnesium, melatonin, and mega-doses of vitamins), individual biological therapies (use of laetrile, shark cartilage, bee pollen).

Manipulative And Body-Based Methods

chiropractic, osteopathic, manipulation, massage

Energy Therapies Qi gong, Reiki, therapeutic touch, bioelectromagnetic-basedtherapies (pulsed fields, magnetic fields, or alternating currentor direct current fields)

5 Domains of CAM

As Defined by NCCAM

Unsafe/Proven Safe/Proven

Unsafe/Unproven Safe/Unproven


• Nutrition• Exercise

• Lycopene• Glucosamine• Peppermint Oil• Fish Oil• Soy


• Epocrates Rx Pro

• Micromedex

• Commission E

• Plus Many Other Databases

http://nccam.nih.gov/

Resources

• Commission E– Germany

– Ranks Quality of Evidence

– Evaluates Benefits and Risks


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

Review of Each Modality


• David Rakel, M.D., University of Wisconsin– Instructions on how to

put CAM into your own medical practice

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

http://nccam.nih.gov/

http://www.ahrq.gov/clinic/epcindex.htm

Resources

• American Academy of Medical Acupuncture– www.medicalacupuncture.org

• Online Resource– http://www.altmedicine.com

http://www.medicalacupuncture.org/

http://www.altmedicine.com/

Where Should We Go for Information?

• Product claims– www.quackwatch.com– www.snopes.com

• Product quality assurance– www.consumerlab.com

• Product ingredients– Natural Medicines Database www.naturaldatabase.com

• Product safety and efficacy– www.cfsan.fda.gov/~dms/ds-ind.html– www.naturaldatabase.com

– The Natural Pharmacist www.iherb.com or www.consumerlab.com

http://www.quackwatch.com/

http://www.snopes.com/

http://www.consumerlab.com/

http://www.naturaldatabase.com/

http://www.cfsan.fda.gov/~dms/ds-ind.html

http://www.naturaldatabase.com/

http://www.iherb.com/

http://www.consumerlab.com/

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

THANK YOU!

Integrative Medicine Aaron J. Michelfelder, M.D., FAAFP, FAAMA Vice-Chair and Predoctoral Director,...

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