Integrative Medicine = Good medicine

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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

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CAM US History

• 1970s American Holistic Medical Association
• 1980s popular books Our Bodies, Our Selves
• 1991 US Congress establishes Office of
  Alternative Medicine at NIH (2 million)
• 1993 Eisenbergs 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

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CAM Clinical History US

• 1970s and 80s scattered MD clinics, eg Norm
  Shealy, Chris Northrup, Andy Weil, Hugh Riordan,
  Jim Gordon, Bob Anderson
• 1990s stand-alone multidisciplinary clinics
  financially issues growth of CAM in medical
  schools and CME 2000s 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

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Growth of CAM Research
MEDLINE Citations Under Alternative Medicine 196
6-2005
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Old Model CAM Therapies
Alternative
Mainstream biomedicine
Complementary
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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
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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

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Licensed Health Professionals in US (selected)
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Popularity leads toeResources

• 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/

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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
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eResource NCI OCCAM

• Health information for patients
• http//www.cancer.gov/cam/health_understanding.htm
  l
• Clinical trial information
• Grant funding for research projects

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Highest CAM Users

• Well educated
• Upper income
• Women
• Chronically ill (pain fatigue, anxiety,
  depression)

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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

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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
  

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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

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Integrative Medicine Good Medicine
Sustainable, Healing Environment
Holistic Patient- Centered Care
Comprehensive Therapeutic Options
Wellness Orientation

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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

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US Institute of Medicines Rules for the
Twenty-First Century Health Care System

• 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

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Institute of Medicines Simple Rules for the
Twenty-First Century Health Care System

• New Rule
• Safety is a system property
• Needs are anticipated
• Waste is continuously decreased
• Cooperation among clinicians is a priority

• 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.

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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

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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
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eEducation about herbs / dietary supplements

• https//northwestahec.wfubmc.edu/learn/herbs_ce/in
  dex.cfm

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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
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Mind-Body Therapies

• Hypnosis
• Guided imagery
• Meditation
• Autogenic training
• Biofeedback
• Journaling
• Social Support
• Psychological counseling
• Peer support

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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

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Ethical framework
Effective
Yes No
Safe Yes Use/Recommend Tolerate
No Monitor closely Advise against
Cohen M. Pediatrics, 2005
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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

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What Kind of Integrative Services Do NC MDs Want?

1. Pain management (84)
2. Weight/Obesity management (80)
3. Diabetes-Lifestyle (73)
4. Stress management (73)
5. Heart healthy lifestyle (71)
6. Back pain (66)
7. Headache (63)
8. Cancer support (62)
9. Stroke recovery (51)

Kemper, et al. BMC CAM, 2007 75
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Service Models
CAM Center
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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

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THANK YOU!
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WHO 2000 ranking

• Netherlands is 17 for quality of health services
  (US is 37)
• Problems
• Waiting times
• Labor shortages

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Leading and Actual Causes of Death US 2000 Leading and Actual Causes of Death US 2000
Leading Cause of Death Rate/100,000
Heart disease (also 1 worldwide) Malignant neoplasm Cerebrovascular disease Chronic lower respiratory tract disease Unintentional injuries Diabetes Mellitus Influenza and pneumonia Alzheimer disease Nephritis, nephrotic syndrome, and nephrosis Septicemia Other Total 258.2 200.9 60.9 44.3 35.6 25.2 23.7 18.0 13.5 11.3 181.4 873.1
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Leading Causes of Death US 2000 Leading Causes of Death US 2000
Actual Cause of death n ()
Tobacco Poor diet and physical activity Alcohol consumption Microbial agents Toxic agents Motor vehicle Firearms Sexual behavior Illicit drug use Total 435,000 (18.1) 400,000 (16.6) 85,000 (3.5) 75,000 (3.1) 55,000 (2.3) 43,000 (1.8) 29,000 (1.2) 20,000 (0.8) 17,000 (0.7) 1,159,000 (48.2)
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Prevention Gap
Burden of disease, preventability, and research
and translation gaps. Ockene, et al. Am J Prev
Med, 2007 32(3) 244
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 Social-ecologic framework levels of influence
on behavior. (From the Institute of Medicine,
2002.7)
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Payment for Health Services - US

• Public (26)
• Medicare (gt65 14)
• Medicaid (poor, disabled 12 )
• Private variety, diverse coverage usually
  employer-based (58 of Americans)
• Uninsured (16 of Americans)

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Burden of Disease 2020 Expected in Developed
Countries

1. Ischemic heart disease
2. Cerebrovascular disease
3. Unipolar major depression
4. Trachea, bronchi, lung cancers
5. Road traffic injuries
6. Alcohol misuse
7. Osteoarthritis
8. Dementia and related.

Murray CJL. Lancet, 1997
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Pharma Promises