Transcript Complementary, Holistic and Integrative Medicine: Does American experience help Holland? Kathi J. Kemper, MD, MPH Caryl J Guth Chair for Holistic and Integrative Medicine Professor of Pediatrics,

Complementary, Holistic and
Integrative Medicine: Does
American experience
help Holland?
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
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
CAM Definition: NIH NCCAM (US)
Moving target?
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/
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
Growth of CAM Studies
30000
MEDLINE
25000
Citations Under
“Alternative
20000
Medicine”
1966-2005
15000
10000
5000
0
66-74
75-79
80-84
85-89
90-94
95-99
00-05
Model: CAM Therapies
Alternative
Mainstream biomedicine
Complementary
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
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?
Common CAM Therapies - US
Percent
17
16
14
13
5
5
5
2
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The Landmark Report on Public Perceptions of
Alternative Health Care, January, 1998
Highest Users
•
•
•
•
Well educated
Upper income
Women
Chronically ill
Pharma Promises…
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
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/03090927
01/html/
eResource: NIH NCCAM
NCCAM
Clearinghouse:
(US) 1-888-6446226
• Patient information sheets
Ongoing research
projects/clinical trials
• Education and Training
opportunities
• http://nccam.nih.gov
eResource: NCI OCCAM
• Health information for
patients
http://www.cancer.gov/ca
m/health_understanding
.html
• Clinical trial information
• Grant funding for
research projects
eResource - Pediatrics
• American Academy of Pediatrics
[email protected]
• IPIM - Dr. Larry Rosen
[email protected]
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
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
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
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
Integrative Medicine =
Good Medicine
Sustainable,
Healing
Environment
Wellness
Orientation
PatientCentered
Care
Comprehensive
Therapeutic
Options
*
US Institute of Medicine’s Rules for the
Twenty-First Century Health Care System
Current Approach
New Rule
Care based primarily on visits
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 evidencebased
Professional autonomy drives
variability
Professionals control care
Information is a record
Decision making is based on
training and experience
Institute of Medicine’s Simple Rules for the
Twenty-First Century Health Care System
Current Approach
New Rule
Do no harm is an individual
responsibility
The system reacts to needs
Cost reduction is sought
Safety is a system property
Preference is given to
professional roles over the
system.
Needs are anticipated
Waste is continuously
decreased
Cooperation among clinicians
is a priority
Social-ecologic framework: levels of influence on behavior.
(From the Institute of Medicine, 2002.7)
Integrative Approach to Therapeutic Options
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
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
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
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?
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.
CAM lessons: THE TWO MOST
IMPORTANT QUESTIONS IN
CLINICAL MEDICINE:
– What have you tried so far (give
examples)?
– How has that worked?
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.”
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.
More resources:
• MD Anderson Cancer Center:
http://www.mdanderson.org/departments/CIM
ER/
Memorial Sloan Kettering
http://www.mskcc.org/mskcc/html/1157
0.cfm
The girls responds
“Yes, I’ve brought
some valerian and
kava kava.
Do they work?”
Do you answer
immediately or ask
more questions?
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?
CAM Lesson: Be systematic
Look at all options before leaping
• Efficient
• Comprehensive; avoid missing
the key
• Example: differential diagnosis;
organ system approach in ICU
Comprehensive Options
•
•
•
•
Biochemical
Lifestyle
Biomechanical
Bioenergetic
Biochemical
• Medications
• Dietary
Supplements, such
as herbs, vitamins,
minerals,
glucosamine, etc.
eEducation about herbs /
dietary supplements
• https://northwestahec.wfubmc.edu/learn/herbs_ce/index
.cfm
Be specific
Do YOU use herbs
regularly, ie. 4 or
more days a week?
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
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/medlinepl
us/druginformation.html
Lifestyle - FOUNDATION
• Nutrition, Diet, Habits to
avoid (tobacco, xs EtOH,
drugs)
• Exercise and Rest
• Mind-Body Therapies*
• Environment*
Environment
• No smoking; Clean
house; lead, allergens,
air filters
• Hygiene- handwashing
• Reading; safety
• Music therapy
• Aroma
• Heat, cold, mist, light,
phototherapy
***Mind-Body Therapies***
•
•
•
•
•
•
•
•
•
Hypnosis
Guided imagery (VPI)
Autogenic training
Meditation
Biofeedback
Journaling
Social Support
Psychological counseling
Peer support
Biomechanical
• Surgery
• Massage and bodywork
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
Ethical framework
Effective
Yes
Safe Yes Use/Recommend
No
Monitor closely
No
Tolerate
Advise against
Cohen M. Pediatrics, 2005
Hypericum vs. Imipramine
80
Hypericum
Imipramine
70
60
50
40
30
20
10
0
Effectiveness (%)
Side Effects (%)
Cost per Month ($)
Harrer, G. Phytomedicine. 1994;1:3-8.
Effective for what?
• Patients may have more than
one goal
• Non-articulated goals are often
as important as spoken goals
Model: Therapeutic
Goals
YANG-type/ Specific
Cure
Manage symptoms
Prevent specific disease
Reduce or manage
specific toxin
Kemper K. Explore, 2007;
3(1): 37-41
YIN-type/Global
Connection/Support/
Trust
Meaning/Transcendence
Harmony
Peace
Well-being/ Resilience
Reduce dependence
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
Models for Treatment
Treatment
Disease in
Organ or
Tissue
Yang
Primary
Treatment
Person
Yin
Symptoms
Peace
Connection
Trust
Harmony
QOL
Well-being
Secondary
Symptoms
or
Disease
Primary
Secondary
Tools for Change
• Understand that change is a process (precontemplative; 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?
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”
We are creating the future today
THANK YOU!
Service Models
Heart Center
Oncology
Neuroscience
Bone & Joint
Fitness
Acupuncture
Acupuncture
Acupuncture
Biofeedback
Fitness
CAM
Center
Massage
Nutrition
Pharmacy
Pastoral Care
Physician Use of CAM
N=572
Blumberg DL, ATHM, 1(3):31 (1995)
US Physician Use of CAM
N=572
Blumberg DL, ATHM, 1(3):31 (1995)
What kinds of services do NC MDs
want to provide in hospital?
• Nutrition services – 84%
• Fitness services – 80%
• Stress management
services – 75%
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
Integrative Medicine =
Good Medicine
Sustainable,
Healing
Environment
Wellness
Orientation
*
Patient
Centered
Care
Comprehensive
Therapeutic
Options
Fellowship training – North America
Complementary and
Alternative Research and
Education Program
• University of Arizona
(Tucson) – general on-line.
http://www.integrativemedicine.
arizona.edu/index.html
• CARE (Edmonton, Alberta) –
pediatric
http://www.care.ualberta.ca/
WHO 2000 ranking
• Netherlands is #17 for quality of health
services (US is #37)
• Problems
– Waiting times
– Labor shortages
Prevention Gap
Burden of disease, preventability, and research and translation gaps.
Ockene, et al. Am J Prev Med, 2007; 32(3) :244