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

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)

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?

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

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

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

1716

1413

5 5 5

21 1

Percent

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/0309092701/html/

               <>

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

eResource: NCI OCCAM

• Health information for patients

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

• Clinical trial information• Grant funding for

research projects

eResource - Pediatrics

• American Academy of Pediatrics jspeller@aap.org

• IPIM - Dr. Larry Rosen ldrdoc@alum.mit.edu

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

Patient- Centered

Care

Wellness Orientation

Comprehensive Therapeutic

Options

*

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

 Social-ecologic framework: levels of influence on behavior.

(From the Institute of Medicine, 2002.7)

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

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/CIMER/

Memorial Sloan Ketteringhttp://www.mskcc.org/mskcc/html/115

70.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 systematicLook 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/medlineplus/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 frameworkEffective

Yes No

Safe Yes Use/Recommend Tolerate

No Monitor closely Advise against

Cohen M. Pediatrics, 2005

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.

Effective for what?

• Patients may have more than one goal

• Non-articulated goals are often as important as spoken goals

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

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

TreatmentDisease inOrgan orTissue

SymptomsQOL

Well-being

TreatmentPerson

PeaceConnection

TrustHarmony

Symptoms or

Disease

PrimarySecondary

PrimarySecondary

Yang

Yin

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?

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 ModelsHeart Center

Fitness

Oncology

Acupuncture

Neuroscience

Acupuncture

Biofeedback

Bone & Joint

Acupuncture

Fitness

Pastoral Care

Nutrition

Pharmacy

Massage

CAM Center

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)

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)

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

Patient Centered

Care

Wellness Orientation

Comprehensive Therapeutic

Options

*

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

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