Integrative Medicine = Good medicine

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

CAM US History• 1970’s American Holistic Medical Association• 1980’s popular books – Our Bodies, Our Selves• 1991 US Congress establishes Office of Alternative

Medicine at NIH ($2 million)• 1993 Eisenberg’s 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

CAM Clinical History US

• 1970’s and ’80’s – scattered MD clinics, eg Norm Shealy, Chris Northrup, Andy Weil, Hugh Riordan, Jim Gordon, Bob Anderson

• 1990’s –stand-alone multidisciplinary clinics; financially issues; growth of CAM in medical schools and CME 2000’s – 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

Growth of CAM Research

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

Old Model: CAM Therapies

Alternative Mainstream biomedicine

Complementary

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 complementaryBMJ, 28 Feb 2004

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

Licensed Health Professionals in US (selected)

Popularity leads to…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/

               <>

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

eResource: NCI OCCAM

• Health information for patients

http://www.cancer.gov/cam/health_understanding.html

• Clinical trial information• Grant funding for

research projects

Highest CAM Users

• Well educated

• Upper income

• Women

• Chronically ill (pain fatigue, anxiety, depression)

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

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

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

Integrative Medicine = Good Medicine

Sustainable, Healing

Environment

Holistic Patient-

Centered Care

Wellness Orientation

Comprehensive Therapeutic

Options

*

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

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

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

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

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

eEducation about herbs / dietary supplements

• https://northwestahec.wfubmc.edu/learn/herbs_ce/index.cfm

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

***Mind-Body Therapies***

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

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

Ethical frameworkEffective

Yes No

Safe Yes Use/Recommend Tolerate

No Monitor closely Advise against

Cohen M. Pediatrics, 2005

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

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

Service Models

Heart Center

Fitness

Oncology

Acupuncture

Fitness

Neuroscience

Acupuncture

Biofeedback

Bone & Joint

Acupuncture

Fitness

Mind-Body

Nutrition

Pharmacy

Massage

CAM Center

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

THANK YOU!

WHO 2000 ranking

• Netherlands is #17 for quality of health services (US is #37)

• Problems– Waiting times– Labor shortages

Leading and Actual Causes of Death

US 2000Leading 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

Leading Causes of Death US 2000Actual 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)

Prevention Gap

Burden of disease, preventability, and research and translation gaps. Ockene, et al. Am J Prev Med, 2007; 32(3) :244

 Social-ecologic framework: levels of influence on behavior.

(From the Institute of Medicine, 2002.7)

Payment for Health Services - US

• Public (26%)– Medicare (>65; 14%)– Medicaid (poor, disabled; 12% )

• Private – variety, diverse coverage; usually employer-based; (58% of Americans)

• Uninsured (16% of Americans)

Burden of Disease: 2020 Expected in Developed Countries

1. Ischemic heart disease2. Cerebrovascular disease3. Unipolar major depression4. Trachea, bronchi, lung cancers5. Road traffic injuries6. Alcohol misuse7. Osteoarthritis8. Dementia and related….

Murray CJL. Lancet, 1997

Pharma Promises…