complementary, holistic and integrative medicine: does american experience help holland? kathi j....
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Complementary, Holistic and Integrative Medicine: Does
American experience help Holland?
Kathi J. Kemper, MD, MPHCaryl J Guth Chair for Holistic
and Integrative MedicineProfessor of Pediatrics, Public Health Sciences, Family and
Community MedicineWake Forest University Health
Sciences
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OBJECTIVE
To promote health and well-being and to enrich lives by empowering others
To acknowledge that change occurs in stages and that people are at different stages of readiness to change
To identify allies, resources To face barriers skillfully; share
concerns, values and needs; generate feasible alternatives and roll with resistance
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CAM Definition: NIH NCCAM (US)
Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. …
Resource: http://nccam.nih.gov/
Moving target?
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CAM US History• 1978 AHMA; individual MDs• 1991 US Congress establishes Office
of Alternative Medicine at NIH • 1990’s multidisciplinary clinics; medical
education• 1993 Eisenberg’s article in NEJM on
common CAM use in US; explosion in research
• 1996 publication of The Holistic Pediatrician
• 2000 CAHCIM; academic centers grow• 2002 White House Commission on
CAM report• 2005 Institute of Medicine CAM report
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Growth of CAM Studies
0
5000
10000
15000
20000
25000
30000
66-74 75-79 80-84 85-89 90-94 95-99 00-05
MEDLINECitations Under
“AlternativeMedicine”1966-2005
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Model: CAM Therapies
Alternative Mainstream biomedicine
Complementary
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Patient/Consumer Interest
• Use is high
• 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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Dutch CAM
• 75% public say Dutch health care institutions should provide (Oskam, 1998)
• 50-60% palliative care patients use CAM (DeGraeff, 1999)
• 50% mental health patients use CAM (Hoenders, 2004)
• Euros - 80 million on herbal remedies; 56 million on homeopathic remedies (Van Dijk, 2003); comparisons with out of pocket payments for conventional care?
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Common CAM Therapies - US
1716
1413
5 5 5
21 1
Percent
The Landmark Report on Public Perceptions of
Alternative Health Care, January, 1998
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Highest Users
• Well educated
• Upper income
• Women
• Chronically ill
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Pharma Promises…
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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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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/
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eResource: NIH NCCAM
• Patient information sheets 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.html
• Clinical trial information• Grant funding for
research projects
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eResource - Pediatrics
• American Academy of Pediatrics [email protected]
• IPIM - Dr. Larry Rosen [email protected]
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About what CAM tx do US families ask pediatricians?
• Herbs, dietary supplements (67%)• Nutrition and special diets,
vegetarian, macrobiotic diets (46%)• Homeopathy (36%)• Therapeutic exercise, yoga (34%)• Hypnosis, biofeedback or
meditation (23%)• Massage or other bodywork (17%)
Kemper, O’Connor. Amb Peds, 2004
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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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Resource
• Founded in 2000• 38 academic health centers (Harvard, Yale,
Duke, Stanford, WFUSM, others)• 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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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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Integrative Medicine = Good Medicine
Sustainable, Healing
Environment
Patient- Centered
Care
Wellness Orientation
Comprehensive Therapeutic
Options
*
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US Institute of Medicine’s Rules for the Twenty-First Century Health Care System
Current ApproachCare based primarily on visits
Professional autonomy drives variability
Professionals control care
Information is a record
Decision making is based on training and experience
New RuleCare 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 Medicine’s Simple Rules for the Twenty-First Century Health Care System
Current ApproachDo 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 RuleSafety is a system property
Needs are anticipated
Waste is continuously decreased
Cooperation among clinicians is a priority
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Social-ecologic framework: levels of influence on behavior.
(From the Institute of Medicine, 2002.7)
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Patient-centered, compassionate care
Bioenergetic therapies: Acupuncture/Acupressure, Healing/Therapeutic
Touch, Prayer, Homeopathy
Biochemical Therapies:
Medications, Herbs, vitamins, minerals,
dietary supplements
Lifestyle Therapies: Mind-body; Environment; Exercise/Rest;
Diet/Smoking/Drinking
Biomechanical Therapies:
Surgery, Osteopathic/ Chiropractic;
Bodywork/Massage
Integrative Approach to Therapeutic Options
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Only 40% patients tell MDs about CAM
• “Natural”, not medical; irrelevant , “not important for the doctor to know” 61%
• Docs not interested; “the doctor never asked” 60%
• “None of the doctor’s business” 31%• “Doctor would not understand” 20%• Cultural practice - embarrassing or private,
<20%• Fear of physician reaction (disapproval,
abandonment, worse medical care) < 15%Eisenberg DM, et al. Arch Intern Med, 2001; 135: 344-51
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How do you know what your patients are doing?
Doctors need to ask!• Give examples• Ask in context• Use checklists; consider
electronic questionnaires• Listen reflectively; make sure
you understand the patient’s question
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Colic Case
You diagnose colic in an otherwise healthy crying baby.
Mom says, “I saw these HOMEOPATHIC colic tablets. What do you think about homeopathy for colic?”
So, do you reply immediately or ask more questions?
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Ask more! The mother replies…
Well, since it was so cheap and it was right there, I bought it.
It settled the baby right down, and I’ve tried it a couple of times since then and it works great.
I just wanted to know if you recommended any particular brands.
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CAM lessons: THE TWO MOST IMPORTANT QUESTIONS IN
CLINICAL MEDICINE:
– What have you tried so far (give examples)?
– How has that worked?
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Be systematic
A 13 year old with osteogenic sarcoma says she’s having trouble sleeping.
She doesn’t want any more medications.
“I’ve heard that valerian and kava kava may be helpful. What do you think?
I might go on-line to find out.”
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Have you already gone on line?
What have you learned so far?Have you brought any printouts with
you?Have you tried any products so far?
Do you have any with you?I’d like to see them and check them
out. Please bring everything you take for your health.
I want to see it and write it down accurately for your records.
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More resources:
• MD Anderson Cancer Center: http://www.mdanderson.org/departments/CIMER/
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Memorial Sloan Ketteringhttp://www.mskcc.org/mskcc/html/115
70.cfm
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The girls responds
“Yes, I’ve brought some valerian and kava kava.
Do they work?”
Do you answer immediately or ask more questions?
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Ask more! The teen replies,
Well, actually my mom thought it might be helpful just to take a hot bath and have a glass of milk or a turkey sandwich before bed. And my grandmother told me I should pray and count my blessings. What do you think about that?
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CAM Lesson: Be systematicLook at all options before leaping
• Efficient• Comprehensive; avoid missing
the key• Example: differential diagnosis;
organ system approach in ICU
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Comprehensive Options
• Biochemical• Lifestyle• Biomechanical• Bioenergetic
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Biochemical
• Medications• Dietary
Supplements, such as herbs, vitamins, minerals, glucosamine, etc.
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eEducation about herbs / dietary supplements
• https://northwestahec.wfubmc.edu/learn/herbs_ce/index.cfm
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Be specific
Do YOU use herbs regularly, ie. 4 or more days a week?
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Be persistent; give sound advice
• Don’t stop at the first positive answer
• Don’t stop at the first denial; give clinically relevant examples
• Discourage use of remedies KNOWN to have high risks, e.g. aristolochic acid, Chinese Patent Medicines, herbs imported from developing countries
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More Resources on Herbs and Dietary Supplements
• Natural Medicines Comprehensive Database: http://www.naturaldatabase.com/
• ConsumerLabs: http://www.consumerlab.com/
• Natural Standard http://www.naturalstandard.com/
• NIH NCCAM and OCCAM• http://www.nlm.nih.gov/medlinepl
us/druginformation.html• MedLinePlus:
http://www.nlm.nih.gov/medlineplus/druginformation.html
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Lifestyle - FOUNDATION
• Nutrition, Diet, Habits to avoid (tobacco, xs EtOH, drugs)
• Exercise and Rest• Mind-Body Therapies*• Environment*
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Environment
• No smoking; Clean house; lead, allergens, air filters
• Hygiene- handwashing• Reading; safety• Music therapy• Aroma• Heat, cold, mist, light,
phototherapy
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***Mind-Body Therapies***
• Hypnosis• Guided imagery (VPI)• Autogenic training• Meditation• Biofeedback• Journaling• Social Support• Psychological counseling• Peer support
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Biomechanical
• Surgery• Massage and bodywork
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ACUPUNCTURE
• Licensed in 43/50 US states• NIH strong evidence – post-op nausea
and dental pain; promising for many other kinds of pain; http://nccam.nih.gov/health/acupuncture/
• http://www.acupunctuur.com/ (Netherlands medical acupuncture)
• Insurance varies in US; 75% of Dutch insurance? MD referral unnecessary
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Ethical frameworkEffective
Yes No
Safe Yes Use/Recommend Tolerate
No Monitor closely Advise against
Cohen M. Pediatrics, 2005
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Hypericum vs. Imipramine
0
10
20
30
40
50
60
70
80
Effectiveness (%) Side Effects (%) Cost per Month ($)
Hypericum
Imipramine
Harrer, G. Phytomedicine. 1994;1:3-8.
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Effective for what?
• Patients may have more than one goal
• Non-articulated goals are often as important as spoken goals
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Model: TherapeuticGoals
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 dependenceKemper K. Explore, 2007; 3(1): 37-41
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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; compassion
• HOW we are, e.g., present, centered, peaceful, hopeful, patient-focused, respectful, compassionate
• COMMUNICATION
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Models for Treatment
TreatmentDisease inOrgan orTissue
SymptomsQOL
Well-being
TreatmentPerson
PeaceConnection
TrustHarmony
Symptoms or
Disease
PrimarySecondary
PrimarySecondary
Yang
Yin
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Tools for Change
• Understand that change is a process (pre-contemplative; contemplative; preparation; active; maintenance)
• Focus on contemplative and preparation; support those who are changing; learn from those who have achieved maintenance
• Face barriers - tradition, threatened status, income, power, fear
• Focus on early adopters and early majority• Do not resist naysayers; waste little energy on
them; honest engagement on shared goals?
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Dealing with Negativity
• Maintain center; focus on goal• Elicit concerns, needs, values• Get to same side of table• Help generate feasible alternatives to meet
those• Open-ended, reflective• Roll with resistance; don’t push (engenders push
back)• “Getting to Yes” “Getting Past No”
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We are creating the future today
THANK YOU!
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Service ModelsHeart Center
Fitness
Oncology
Acupuncture
Neuroscience
Acupuncture
Biofeedback
Bone & Joint
Acupuncture
Fitness
Pastoral Care
Nutrition
Pharmacy
Massage
CAM Center
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Physician Use of CAM
Relax Biof. Masg. Hypn. Acup. Med. Diet Yoga
86
22
85
2
66
3
63
5
56
1
54
5
48
17
47
10
10
20
30
40
50
60
70
80
90
Per
cent
Relax Biof. Masg. Hypn. Acup. Med. Diet Yoga
Refer
Use
N=572N=572
Blumberg DL, ATHM, 1(3):31 (1995)Blumberg DL, ATHM, 1(3):31 (1995)
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US Physician Use of CAM
Imag Spirit Homeo Energy Rolf Herb MegaVit
37
7
24
5
15
1
14
3
10
0
6
0
63
0
5
10
15
20
25
30
35
40
Per
cen
t
Imag Spirit Homeo Energy Rolf Herb MegaVit
Refer
Use
N=572N=572
Blumberg DL, ATHM, 1(3):31 (1995)Blumberg DL, ATHM, 1(3):31 (1995)
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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%
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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; 7:5
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Integrative Medicine = Good Medicine
Sustainable, Healing
Environment
Patient Centered
Care
Wellness Orientation
Comprehensive Therapeutic
Options
*
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Fellowship training – North America
• University of Arizona (Tucson) – general on-line.
http://www.integrativemedicine.arizona.edu/index.html
• CARE (Edmonton, Alberta) – pediatric http://www.care.ualberta.ca/
Complementary and Alternative Research and
Education Program
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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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Prevention Gap
Burden of disease, preventability, and research and translation gaps. Ockene, et al. Am J Prev Med, 2007; 32(3) :244