1、Integrative Medicine,Aaron J. Michelfelder, M.D., FAAFP, FAAMA Vice-Chair and Predoctoral Director, Family Medicine Associate Professor of Family Medicine, and Bioethics & Health Policy Board Certified Medical Acupuncturist,Objectives,By the end of this presentation, you should be able to. Define “I
2、ntegrative 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 pre
3、sents 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 al
4、l 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 physicia
5、ns 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, Pr
6、actices, and Products That are Not Presently Considered Part of Conventional Medicine”,National Center for Complementary and Alternative Medicine,Definitions,“Complementary Medicine is Used Together With Conventional Medicine.”“Alternative Medicine is Used in Place of Conventional Medicine.”,Definit
7、ions,“Integrative Medicine Combines Mainstream Medical Therapies and CAM Therapies for Which There is Some High-Quality Scientific Evidence of Safety and Effectiveness.”NCCAM,5 Domains of CAM,As Defined by NCCAM,Why Should We Care?,30,000 herbs on the market currently Estimates of $30-40 billion dol
8、lars 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 bo
9、ttles 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
10、 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” produ
11、cts Patient feels empowered Focus on spirituality and emotional well-being Health Care Provider provides the 3 Ts: 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 d
12、o patients not tell their physician about their CAM use?,60% - “My doctor never asked.” 60% - “It wasnt important for my doctor to know.” 20% - “My doctor wouldnt understand.” 14% - “My doctor would disapprove.”70% of patients see their Physician before or concurrent with their visits to a CAM provi
13、derEisenberg 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
14、 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 estim
15、ate 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
16、 Us?,DSHEA 1994 New FDA Regulations 8-24-07 Interim Final Rule Identity, Purity, Strength, and Free from Harmful Contaminants Food, Drug and Cosmetic Act,Are Our Patients Reading This?,Or This?,Evidence Based Medicine,Difficulties With CAM Research Sham Acupuncture Non Standardized Herbal Formulati
17、ons Difficult to Blind Patients and Practitioners Treatments Very Individualized Difficult to Formulate Protocols,RCCT,Gleevec Albuterol Acupuncture Chinese Herbal TherapiesHow Can This Stand the Test of Time?,Comparison,Mainstream Medicine Large Double Blind Placebo Controlled Trials Many Exclusion
18、s 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,Licensing Issues,Patients are choosing integrative and alternative medicin
19、e, 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 (Rese
20、arch) 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
21、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 Califo
22、rnia/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 Univer
23、sity 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,
24、 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 Pr
25、oviders,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 Medicin
26、e Curriculum Demanded by Students Integrative Medicine Interest Group “Integrate Chicago” http:/ 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 a
27、nd 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 Future of Integrative Medicine,The Term “Integrative Medicine” Will Die Our Patients Will Demand Integrative Medicine From All of Us T
28、raining Will Be Demanded by Medical Students Training Will Be Demanded by Residents,The Future of Integrative Medicine,Integrative Medicine Will Be A Skill Set Added on Just Like: Electronic Health Records New Medications New Procedures,The Future of Integrative Medicine,What Cannot Be Added On is E
29、mpathy and Open-mindedness 600 Million Visits a Year to Alternative Practitioners,The Future of Integrative Medicine,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
30、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.
31、What more do you want to know? What options would come to mind for you? How would you find information about those options?,Integrative Medicine,requires a paradigm shift from the disease-centered approach of conventional biomedicine to an approach in which patient values and participation of patien
32、ts are central.,Maizes 1999,Integrative Medicine,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 conventi
33、onal 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.,5 Domains of CAM,As Defined by NCCAM
34、,The Future of Integrative Medicine,Nutrition ExerciseLycopene Glucosamine Peppermint Oil Fish Oil Soy,The Future of Integrative Medicine,Epocrates Rx Pro Micromedex Commission EPlus Many Other Databases,http:/nccam.nih.gov/,Resources,Commission E Germany Ranks Quality of Evidence Evaluates Benefits
35、 and Risks,Integrative Medicine,Donald Novey, M.D. Lutheran General Hospital Evidence Based Review of Each Modality,Integrative Medicine,David Rakel, M.D., University of Wisconsin Instructions on how to put CAM into your own medical practice,Resources,National Center for Complementary and Alternativ
36、e Medicine http:/nccam.nih.gov/ Agency for Healthcare Research and Quality http:/www.ahrq.gov/clinic/epcindex.htm,Resources,American Academy of Medical Acupuncture www.medicalacupuncture.orgOnline Resource http:/,Where Should We Go for Information?,Product claims Product quality assurance Product
37、 ingredients Natural Medicines Database Product safety and efficacy www.cfsan.fda.gov/dms/ds-ind.html The Natural Pharmacist or ,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!,
