INTEGRATIVE
MEDICINE
What is it?
- “comprehensive
primary care system that emphasizes wellness and healing of the whole
person… as major goals, above and beyond suppression of specific
somatic disease” (Arch Intern
Med. 2002. 162. 144-140).
- “views patients as whole people with minds and spirits
as well as bodies and includes these dimensions into diagnosis and
treatment” (BMJ. 2001.
322. 133-140).
- “the
practice of medicine that reaffirms the importance of the relationship
between the practitioner and the 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 Steering Committee, revised in 2006, based on input
from the Academic Consortium for Complementary and Alternative Health
Care).
- In
part an extension of allopathic medicine, in part a philosophy of
treatment, in part integration of diverse providers rather than simply
integration of modalities by a M.D. or D.O.
- Allopathic
Medicine - a system of therapeutics based on production of a condition
incompatible with or antagonistic to the condition being treated (i.e. antibiotics,
antihistamines, antipyretics, anti-inflammatory medications).
What are some of the basic tenets of Integrative
Medicine?
- It is
a philosophic approach to treatment rather than just more tools in the
toolbox. In contrast, in terms of contemporary terminology, CAM (complementary and alternative medicine) is
about specific modalities of treatment.
- It is
patient-centered rather than physician-centered, and emphasizes the
centrality of the doctor/patient relationship in the healing process.
- Acknowledgement
that healing is innate - the role of the practitioner is to remove any
blocks to healing, and facilitate or stimulate one's own natural healing
potential.
- Recognition
that often the patient is the diagnostician and the practitioner is the
educator.
- Recognition
of the role of the mind and the spirit in good health. Health is a
cohesive balance of mind, body, and spirit.
- Recognition
of the role of nutrition and exercise in good health.
- Recognition
that health is more than the mere absence of disease.
- Use
of herbs and vitamins and dietary supplements in addition to or instead of
prescription medication.
- Use
of complementary modalities of treatment such as chiropractic, massage
therapy, acupuncture, homeopathy, and others, when indicated.
- Commitment
to the scientific method and evidence-based practice.
Why should physicians learn about it?
- Consumer
demand (i.e. chiropractic was covered by Medicare in 1966 despite the
Surgeon General warning against it, based in part on 12 million letters
sent by Americans to their Congressmen).
- Popularity of complementary
modalities (functionally defined as interventions neither taught widely in
medical schools nor generally available in U.S. hospitals, and by
definition includes relaxation techniques, herbal medicines, massage,
chiropractic, spiritual healing by others, megavitamins, self-help groups,
imagery, commercial diets, folk remedies, lifestyle diets, energy healing,
homeopathy, hypnosis, biofeedback, and acupuncture, in order of decreasing
popularity of use in the past 12 months in 1997).
- Popularity
in 1990 (Eisenberg DM, et al. Unconventional Medicine in the United States.
New Engl
J Med. 1993; 328: 246-252).
- One
in three adults in the U.S.
used unconventional care in 1990.
- The
use of unconventional care is distributed across all socioeconomic
groups.
- 83%
of users of unconventional care also used conventional treatment.
- The
number of visits to providers of unconventional care (425 million
visits) was greater than the number of visits to all primary care
medical doctors (388 million visits).
- Out-of-pocket
expenditures for unconventional care (10.3 billion dollars) were
approximately equal to out-of-pocket expenditures for all
hospitalizations.
- One
in four adults seeing a medical doctor for a serious health problem
are also using unconventional treatment, but seven in ten do not tell
their physician about the use of unconventional care.
- Popularity
reassessed in 1997 using the same definitions (Eisenberg DM, et al.
Trends in Alternative Medicine Use in the United States, 1990-1997. JAMA. 1998; 280:1569-1575).
- Use
of alternative therapies increased from 33.8% in 1990 to 42.1% in 1997,
with the largest percentage increases in use seen for herbal medicine,
massage, megavitamins, self-help groups, folk remedies, energy healing,
and homeopathy.
- The
probability of users visiting an alternative medicine provider increased
from 36.3% in 1990 to 46.3% in 1997.
- Alternative
therapies in both 1990 and 1997 were used most frequently for chronic
conditions, including back problems, anxiety, depression, and headaches.
- There
was no significant change in disclosure rates to physicians regarding
the use of alternative therapies (39.8% vs. 38.5%).
- The
percentage of users paying entirely out-of-pocket for services provided
by alternative medicine practitioners did not change significantly
(64.0% vs. 58.3%).
- Extrapolations
to the U.S.
population suggest a 47.3% increase in total visits to alternative
medicine practitioners, from 427 million visits in 1990 to 629 million
visits in 1997.
- 18.4%
of all prescription users in 1997 took herbal remedies and/or high dose
vitamins concurrently.
- Estimated
expenditures for alternative medicine professional services
increased 45.2% to 21.2 billion dollars, with an estimated 12.2 billion
dollars paid out-of-pocket.
- Total
out-of-pocket expenditures in 1997 for alternative therapies were
approximately 27 billion dollars, exceeding out-of-pocket expenditures
for all physician services in 1997.
- Popularity
reassessed in 2002 using the same definitions (Tindle
HA et al. Trends in use of complementary and alternative medicine by US
adults, 1997-2002. Altern Ther Health
Med. 2005. 11. 42-49).
- Since
1990 there have been 10 national surveys looking at popularity of CAM,
but each has used a different definition of CAM,
and the demographic makeup of the study group has varied from study to
study.
- The
most complete and comprehensive findings on Americans' use of CAM are derived from National Health Interview
Surveys (NHIS). The questions were developed by NCCAM and the data can be
viewed at http://nccam.nih.gov/news/camsurvey.
- Initially,
questions included in the 2002 survey, administered to 31,044
adults. This survey showed that
74.6% of adults surveyed had ever used CAM, with 62.1% of adults using CAM in the past 12 months. If prayer for health was excluded the
statistics were 49.8% of adults had ever used CAM, with 36.0% of adults
using CAM in the past 12 months. The ten most common CAM therapies
utilized were prayer/self 43%, prayer/others 24.4%, natural products
18.9%, deep breathing 11.6%, prayer group 9.6%, meditation 7.6%,
chiropractic 7.5%, yoga 5.1%, massage 5.0%, diets 3.5%. Note that only
12% of survey respondents sought care from a licensed CAM
provider. This survey also included data on reasons for CAM use.
- Based
on data from the 2007 survey,
38% of adults reported using CAM in the previous 12 months; 83 million
US adults spent $33.9 billion out of pocket on visits to CAM practitioners
and on purchases of CAM products, classes, and materials (11.2% of total
out of pocket expenditures on health care in the US); out of pocket
spending for supplements was $14.8 billion (1/3 the total of $47.6
billion in out of pocket expenditures for prescription drugs); out of
pocket spending for CAM practitioner visits was $11.9 billion (1/4 of
the total of $49.6 billion out of pocket expenditures for physician
visits) [Nahin RL et al. National Health Statistics Report; no 18, National Center for
Health Statistics. 2009].
- The
contemporary ecology of medical care in the U.S. in 2000 - it is
estimated in a typical month that 800 of 1000 persons report symptoms,
217 visit a physician's office, 113 of the 217 visit a primary care
physician's office, 65 visit a complementary or alternative medicine care
provider, and 8 are hospitalized (N
Engl J Med. 2001. 344. 2021-2025).
- More
options to offer your patients.
- Greater
job satisfaction.
Why are complementary modalities popular?
- Downer
SM, et al. Pursuit and Practice of Complementary Therapies by Cancer
Patients Receiving Conventional Treatment. Br Med J. 1994; 309. 86-89.
- These
authors surveyed all patients in a cancer registry in England -
600 surveys were sent and 415 were returned.
- The
results showed that 16% of the 415 patients used complementary
treatments, and 80% of these patients responded that they were satisfied
with their complementary treatment (even though other results showed no
survival advantage).
- Patients
cited a more hopeful outlook on the part of the practitioner and a
more supportive relationship as reasons for satisfaction.
- Astin JA. Why Patients Use Alternative Medicine:
Results of a National Study. JAMA.
1998; 279: 1548-1553.
- This
paper reports the results of a survey of 1035 randomly selected
Americans.
- Response
rate was 69%.
- 40%
of respondents used alternative therapies, but only 4.4% relied primarily
on alternative therapies.
- Other
than in the 4.4% who relied primarily on alternative therapies,
dissatisfaction with conventional medicine did not predict use of
alternative therapies.
- Use
was associated with subjective reports of poorer health status.
- Furthermore,
users were more likely to have had a
self-reported transformational life experience, and users were
more likely to report that health care alternative treatments were more
congruent with their individual values (i.e. a more holistic attitude
toward health).
- Note:
Other surveys fail to verify the notion of widespread fraud amongst
practitioners of complementary modalities, and find that most
practitioners are dedicated, caring individuals.
- Positive
motivations for seeking out complementary modalities
- Perceived
effectiveness and safety
- Fits
with the patients philosophy
- Seeking
a particular kind of practitioner/patient relationship
- Non-invasive
- Negative
motivations for seeking out complementary modalities
- Conventional
medicine ineffective
- Side
effects of conventional medicine
- Rejection
of “the establishment”
- Desperation
- Limitations
of allopathic medicine:
- Operational
weaknesses:
- Not
very effective at treating viral illnesses, nutritional and metabolic
diseases, allergies, autoimmune diseases, cancer, and the mental
illnesses.
- Inherent
weaknesses:
- Focus
on a paradigm of war and external forces as a cause of disease instead
of a paradigm of balance and internal forces or the terrain as a cause
of disease (i.e. focuses on meningococcemia rather than focusing on the
individuals colonized with meningococcus who
do not get sick, focuses on strep throat rather than focusing on
individuals colonized with streptococcus who do not get sick).
- Weapons
can backfire (antibiotic resistance).
- Model
does not work well for chronic disease.
- Defines
health only in the negative sense as the absence of disease.
- Lack
of adjustment for biochemical individuality.
- Defies
a precise definition of the approach to illness in a positive sense.
- Acquired
weaknesses:
- Focus
on dissection of dead bodies (i.e. lack of appreciation of "life
force").
- Focus
on abnormal psychology (Maslow and self actualization is the exception).
- Based
on 19th Century physics.
- Focus
on separation of the mind and the body
- Failure
to take into account important social, spiritual, emotional, and
environmental factors (i.e. not holistic).
- Failure
to listen and to spend enough time with each patient (distorted
reimbursement).
- Failure
to communicate effectively.
- Failure
to empathize/become emotionally attached.
- Physician
centered care instead of patient centered care.
- Pessimism.
- Paradoxes
of Complementary Medicine (Davidoff F. Ann
Intern Med. 1998; 129: 1069-1070).
- Responsibility
paradox:
- Patient
controls his/her own destiny.
- Paradox
of therapeutic failure blamed on the patient, not on the complementary
modality.
- Truth
telling paradox:
- Optimistic
viewpoint gives hope.
- Paradox
of unrealistic optimism that can distort reality.
- Self
scrutiny paradox:
- Conventional
medicine is constantly subject to self scrutiny.
- Paradox
of conventional medicine in trouble due to self scrutiny.
What are the myths about complementary medicine
users? [British Journal
of Clinical Psychology. 1996. 35. 37-48]
- Disillusioned
with medicine in general - national survey data do not support the view
that users of CAM are dissatisfied with
conventional medical care. Furthermore, adults who use both CAM and
conventional care are less concerned about their doctor's disapproval than
their doctor's inability to understand or incorporate CAM therapy use
within the context of their medical management (Eisenberg DM, Kessler RC,
et al. Perceptions about complementary therapies relative to conventional
therapies among adults who use both: results from a national survey. Ann Intern Med. 2001. 135.
344-351).
- Anti-science.
- Largely
motivated by lower cost.
- Using
it because it was the only choice available.
- Unusual
characteristics or attitudes when compared to non-users.
How do I practice Integrative Medicine?
- Communication
skills.
- Empathy.
- Humanistic,
patient-centered approach.
- Focus
on recognition of patient suffering as well as diagnosis and treatment
(three roles of the physician in caring for the sick include skilled
diagnosis, effective treatment, and human recognition of suffering).
- Focus
on nutrition, exercise, lifestyle issues, prevention, and wellness.
- Offer
reassurance when indicated.
- Prescribe
vitamins, minerals, herbs, and dietary supplements when indicated.
- Refer
to one of a network of complementary practitioners when indicated.
How do I decide when and where to refer?
- I
invoke a complementarity model:
- Allopathy
is the most effective modality for treating trauma, acute medical and
surgical emergencies, and acute bacterial, fungal, and protozoa
infections.
- Allopathy
is less effective at treating most viral illnesses, nutritional and
metabolic diseases, allergies, auto immune diseases, and the mental
illnesses.
- I rely
on a classification of complementary treatment modalities:
- Those
which address structural imbalances in the body (osteopathy,
chiropractic, physical therapy, massage therapy, shiatsu, rolfing). NCCAM labels this category as
“MANIPULATION & BODY-BASED PRACTICES,” with
sub-categories including chiropractic, massage, Pilates, and Feldenkreis.
- Those
which focus on maintaining or restoring biochemical balance (herbal
medicine, environmental medicine).
NCCAM labels this category as “BIOLOGICALLY BASED
PRACTICES,” with sub-categories including food supplements,
herbals, animal products, and special diets.
- Those
that seek to restore mental and emotional balance at a physiological
level (biobehavioral methods, including
meditation, guided imagery, and biofeedback). NCCAM labels this category as
“MIND-BODY MEDICINE,” with sub-categories including hypnosis,
meditation, tai chi, and yoga.
- Those
that address the energetic levels of the body (therapeutic touch,
homeopathy, Bach flower essences).
NCCAM labels this category as “ENERGY MEDICINE,” with
sub-categories including healing touch, qi
gong, and reiki.
- Complete
systems (naturopathy, TCM, Ayurvedic medicine). NCCAM labels this category as
“WHOLE MEDICAL SYSTEMS.”
- I recognize
that belief is central to healing:
- Healing
often will not occur in the absence of belief.
- Belief
alone may be adequate to achieve healing (this is the placebo effect).
How does one find a practitioner?
- American Board of Integrative Holistic Medicine
– www.holisticboard.org
– this lists MDs and DOs with who are
board certified in integrative/holistic medicine.
- Institute of Functional
Medicine – www.functionalmedicine.org
– this lists practitioners who have taken a one week course in
functional medicine
- American Holistic Medical Association
– www.holisticmedicine.org.
– this is a membership organization
- International
College of Integrative Medicine - www.icimed.com - this is a membership organization
- American College for Advancement in Medicine – www.acamnet.org - this is a membership
organization
Are complementary modalities efficacious?
- More
and more research is appearing, but much is published in peer review
scientific journals not read by physicians.
- Nonetheless,
there are still relatively few controlled clinical trials of complementary
modalities.
- Much
of the efficacy of complementary modalities may be due to the placebo
response.
- Placebo
response rates may be as high as 60 - 70% when the patient believes in the
treatment ordered, the practitioner believes in the treatment ordered, and
the practitioner-patient relationship is characterized by trust.
- These
are the three elements of the placebo response, as per Dr. Herbert
Benson.
- Consider
using the placebo effect as a therapeutic ally, as per Dr. Andrew Weil.
- Remember
that the history of medicine is the history of the placebo response.
- Issues of a level playing field
- A
Congressional Office of Technology Assessment report in 1978 which
indicated that only 10-20% of conventional medical practice was based on
controlled studies (Office of
Technology Assessment. Assessing the Efficacy and Safety of
Medical Technologies. Washington, D.C.: U.S. Govt. Printing Office;
1978).
- In
1991, it was estimated that 15% of medical interventions were supported
by solid scientific evidence (BMJ.
1991. 303. 798-799).
- A
2003 study concluded that only about half of medical treatments are
supported by evidence (Hardern RD et al.
How evidence based are therapeutic decisions taken on a medical
admissions unit? Emerg Med J. 2003. 20. 447-448).
- Another
2003 paper concluded that a range of 11% to 70% of decisions in various
medical specialties follow the rules of evidence-based medicine
(Pelletier K. Focus Altern Complement Ther.
2003. 8. 3-6).
- Recognize
that even in "evidence-based medicine," most decision-making
takes place in areas of scientific uncertainty.
- Safety
versus efficacy
- From
a societal standpoint, especially with regard to limited resources, we
should probably require the strictest evidence of efficacy (i.e. large
RCTs) for the treatments whether conventional or unconventional which can
do the most harm.
- Issues
of a level playing field
- A
meta-analysis of 39 prospective studies in U.S. hospitals found that in
1994, 2,216,000 hospitalized patients had an adverse drug reaction, and
106,000 had fatal adverse drug reactions (JAMA. 1998. 279. 1200-1205).
- There
are 16,000 deaths and 100,000 hospitalizations in the U.S. each year from NSAID's (New Engl J Med. 1999. 340. 1888-1899). It is
estimated that only 1 in 5 individuals who GI bleed from a NSAID have
any warning symptoms.
How does the ‘trajectory’ of CAM differ from that of conventional medicine?
- Conventional medicine: T>P>E>S.
Technical advances (basic research, clinical trials) usually precede
political factors (support of the medical establishment), which usually
precedes economic factors (determination of economic viability), which
usually precedes social factors (public acceptance).
- CAM: S>E>P>T. Social factors
(popular demand) in combination with economic factors (affordability)
usually precede political factors (political support) which usually
precedes technical factors (clinical trials).
What is the current status of Integrative Medicine?
- OAM
(Office of Alternative Medicine) at the NIH.
- Created
in 1992 by Congressional mandate (Senator Harkin’s bill, passed by
Congress 11/22/91).
- Budget
of 2.2 million dollars in 1992/3, budget of 3.5 million dollars in 1994,
5.4 million dollars in 1995, 7.4 million dollars in 1996, 12 million
dollars in 1997, and 20 million dollars for 1998.
- Initially
in 1993 funded 30 pilot proposals – response to request for
proposals was largest in the history of NIH, with over 6000 requests for
applications, 800 letters of intent, and 452 applications.
- Expanded
research base by funding 10 exploratory centers in 1995.
- Status
changed to a Center within the NIH in 1998, entitled National Center
for Complementary and Alternative Medicine, and budget increased to
50 million dollars for 1999.
- Budget
68.7 million dollars in 2000, 123 million dollars in 2005, 121.6 million
dollars in 2008, 132 million dollars in 2011
- Collaborative
research funded in part by other Centers within the NIH. In 2008, CAM research at more than 260 institutions supported
by NCCAM funding.
- Since
1999, NCCAM continues to add Research Centers, and these are now
categorized as either Centers for Excellence for Research on CAM or Developmental Centers
for Research on CAM. The current list of centers (2/09) is:
1. Bastyr
University
HIV/AIDS
2. Columbia
University
Women's health issues
3. Harvard Medical School General
medical conditions
4. Kessler Institute for Rehabilitation
Stroke and neurologic conditions
5. Palmer Center for Chiropractic Research Chiropractic
6. Stanford
University
Aging
7. University
of Arizona
Pediatric conditions
8. University of California, Davis
Asthma, allergy, and immunology
9. University
of Maryland
Pain/Arthritis
10. University of
Michigan
Cardiovascular disease
11. University of
Minnesota
Addiction
12. University of
Texas
Cancer
13. University of
Virginia
Pain
14. Kaiser in Portland, OR
Craniofacial disorders
15. Oregon Health Sciences
University
Neurological disorders
16. Maharishi University
in Fairfield, IA
CV disease and aging in African
Americans
17. Johns Hopkins University Cancer
18. University of
Pennsylvania
Cancer
19. Univ
of Calif, San Francisco Mindfulness-based
stress reduction and HIV
20. Harvard Alcohol
and drug abuse
21. Univ
of N Carolina, Chapel Hill Asthma
22. Univ
of Minnesota Mushroom
extracts and immune response
23. Oregon Health and Science Univ, etc Placebo
effects
24. Univ
of North Texas, etc Mechanisms of osteopathic
manipulation
25. Purdue Univ,
etc Health
effects of polyphenols
26. Univ
of Illinois Botanical
supplements and women’s health
27. Pennington, etc Botanicals
and metabolic syndrome
28. Sloan-Kettering, etc Botanical
immunomodulators
29. Wake Forest U, etc Botanical
lipids
30. Univ
of Maryland Arthritis
and Traditional Medicine
31. Mt Sinai Chinese
Herbal Therapy
32. Temple U Mechanism
Underlying Millimeter Wave Therapy
33. Univ
Maryland, etc (International) Functional
Bowel Disorders in Chinese Medicine
34. Univ
Missouri, etc (International) Indigenous
Phytotherapy Studies
35. Univ
of Wisconsin Center
for the Neuroscience and
Psychophysiology of Meditation
36. Montana
State Univ CAM as Countermeasures against Infectious and
Inflammatory Disease
37. Univ
of CA, San Fran Metabolic
and Immunologic Effects of Meditation
38. Univ
of Chicago Center
for Herbal Research on Colorectal Cancer
o Office
of Dietary Supplements (ODS)
- This
office, which is within the NIH, was established as a result of the 1994
DSHEA legislation on dietary supplements.
- ODS
collaborates with multiple other NIH Institutes and Centers, including
NCCAM.
- The ODS budget has increased
from $1 million in 1996 to $25 million in 2004.
- The ODS IBIDS database
currently contains over 690,000 unique scientific citations and
abstracts.
- The ODS exhibits at national
meetings such as the Annual Session of the ACP.
- Education
- Courses
in CAM were a requirement in
approximately 90% of US medical schools in 2007-2008, compared with 30%
in 2001-2002, according to the AAMC (NCCAM 11/09 newsletter)
- In
a study of 53 medical schools in 2000, 66% taught relaxation and
meditation, 37% taught guided imagery, and 34% taught biofeedback (Acad Med. 2002. 77. 876-881).
- NCCAM
in 2000 offers grants of up to 1.5 million dollars per school for
innovative programs which integrate complementary and alternative
medicine into the medical school curriculum.
- Quality
CME programs for practicing physicians (Center for Mind Body Medicine, Columbia, Harvard, Scripps, and University of Arizona).
- Fellowships
in Integrative Medicine
- University of Arizona two year fellowship
started 1997 and discontinued in approximately 2006 due to inadequate
funding.
- University of Arizona distance-learning
Associate Fellowship started in approximately 2000, and is ongoing.
- University of Wisconsin
- Beth Israel Hospital
in NYC
- Integrative
medicine 4 year residencies – University
of Arizona, OHSU, Connecticut, Portland
Maine
- A Consortium of Academic Health Centers
for Integrative Medicine (CAHCIM) was formed in 2001, following
initial meetings in 1999 and 2000.
- The
initial 8 members were Duke University, Harvard
University, Stanford University,
University
of California at San Francisco, University
of Arizona, University of Maryland,
University of Massachusetts, and the University of Minnesota.
- The
consortium has grown steadily, with 42 member medical schools as of 2009
(38 in US and 4 in Canada).
- Initially
3 working groups (clinical care, education, and research), with a fourth
working group (policy) added in 2005.
- The
mission is to help transform medicine and healthcare through rigorous
scientific studies, new models of clinical care, and innovative
educational programs that integrate biomedicine, the complexity of human
beings, the intrinsic nature of healing and the rich diversity of
therapeutic systems.
- Consortium
is funded primarily by the Bravewell Collaborative, an organization of
philanthropists whose goad is transforming medicine. Philanthropists and
foundations participating in the Bravewell Collaborative must pay
$50,000 annual dues. In 2003, there were 16 foundations/philanthropists
participating in Bravewell; this number decreased to 8
foundations/philanthropists at the end of 2007.
- In
2006, the Consortium decided to require annual dues from member medical
schools, $2500/year. www.imconsortium.org.
- An
Academic Consortium for
Complementary and Alternative Health Care (ACCHAC) was formed in
2004, following initial meetings dating back to May, 2000 (Integrative
Medicine Leadership Summit)
- Principally represents leading educators
in disciplines such as chiropractic, massage therapy, naturopathy, and
Oriental medicine. Founding executive director is Pamela Snider, ND.
- Consortium
got started based on a philanthropic grant; in 2006 decided to require
annual dues from member organizations, on a sliding scale ranging from
$1000 to $5000.
- Integrative
Family Medicine Residency – in 2004 the Family Medicine RRC
approved an experimental 4 year program at six institutions; several of
the lead faculty are graduates of the University of Arizona fellowship program.
- Duke University
Medical School
opened in January 2007 an Integrative
Medicine Center
in a free standing building.
- Integrative
Pediatrics (Explore. 2007. 3.
91-92)
- Between
1997-2007, 17 academic medical centers created pediatric integrative
medicine programs.
- Integrative
Pediatrics Council formed in 2004 – consists of individuals in
leadership positions in pediatric integrative medicine in the U.S. and Canada, and offers an annual
Pediatric Integrative Medicine Conference.
- American
Association of Pediatrics in 2005 established the Provisional Section on
Complementary, Holistic, and Integrative Medicine.
- Integrative
Medicine in Residency – in 2008, family medicine residencies at 8
major medical centers have embraced a 250-hour integrative medicine
training curriculum developed at the University of Arizona Center for
Integrative Medicine, and aimed at developing core competencies in
integrative medical practice. The program makes extensive use of online
learning tools and web-based course work.
- Hospitals
- New York Beth Israel
Medical Center
in 2006 became the first general services hospital in the nation to add a
formal department of integrative medicine. The first chair of the
department is Woodson Merrell,
MD. The department will
coordinate diverse services, including acupuncture, Alexander technique,
art therapy, healing touch, massage, meditation, music therapy, and reiki.
- 40%
of hospitals surveyed by the American Hospital Association in a 2007
national poll offered at least one CAM
therapy (NCCAM 11/09 newsletter)
- Peer
reviewed journals and newsletters:
- Alternative Medicine Review -
quarterly
- Alternative Therapies in Health and
Medicine – every other month
- Alternative and Complementary
Therapies
- Explore – every other month
- HerbalGram
– American Botanical Council
- Integrative Cancer Therapies
- Integrative Medicine - A Clinician's
Journal – every other month
- Journal of Orthomolecular Medicine
– quarterly (since 1970)
- Journal of the Society for Integrative
Oncology
- Seminars in Integrative Medicine
– quarterly review journal
- Seminars in Preventive and Alternative
Medicine – quarterly
- The Journal of Alternative and
Complementary Medicine
- The International Journal of
Integrative Medicine
- Alternative Medicine Alert –
every month
- Centers
of excellence:
- Center
for Mind Body Medicine at Georgetown
University (James
Gordon, MD)
- Mind
Body Clinic at the New
England Deaconess
Hospital (Herbert
Benson, MD)
- Mindfulness
Based Stress Reduction Program at the University of Massachusetts.
Established in 1979 (Jon Kabat-Zinn, PhD)
- Rosenthal Center
at Columbia
University (Fredi
Kronenberg, PhD)
- Textbooks
- Essentials of Complementary and
Alternative Medicine edited by Wayne Jonas and Jeffrey Levin. 1999.
584 pages.
- Integrative Medicine edited by
David Rakel MD. 2003. 793 pages. Second edition 2006.
- Integrative Medicine: Principles for
Practice edited by Benjamin Kligler MD and
Roberta Lee MD. 2004. 184 pages.
- Integrative Oncology: Principles and
Practice by Taylor & Francis. 2006.
- Nutritional Medicine. Alan R Gaby. 2011.
- Textbook of Functional Medicine
edited by David Jones MD. 2005. 790 pages.
- Textbook of Natural Medicine
edited by Joseph Pizzorno ND and Michael Murray ND. 1993, 1999. 1620
pages (2nd edition).
- The American College of Physicians
(ACP) Evidence-Based Guide to Complementary and Alternative Medicine. Edited
by BP Jacobs and K Gundling. 2009.
- Other
resources
- Integrative Medicine Consortium (IMC) – a
cooperative organization formed in 2006, composed of the American
Association of Environmental Medicine (AAEM), American Association of
Naturopathic Physicians (AANP), American College for Advancement in
Medicine (ACAM), American Holistic Medical Association (AHMA), Institute
for Functional Medicine (IFM), and International College for Integrative
Medicine (ICIM).
- Integrative
Oncology – the Society for Integrative Oncology (SIO), an
international organization of oncology professionals researching and
integrating effective complementary therapies in cancer care, held its
first international conference in 2004. President in 2005 is David S.
Rosenthal, Professor of Medicine at Harvard Medical
School and Medical
Director of the Center for Integrative Therapies at the Dana-Farber
Cancer Institute.
- Bravewell
Collaborative www.bravewell.org
– includes a clinical network which is comprised
of eight leading integrative medicine centers that are developing
successful models of integrative medicine care and delivery.
- Cochrane Collaboration CAM Field. As of issue 4,
2009, 396 reviews related to CAM
categorized at www.cochrane.org/reviews/en/topics/22_reviews.html.
- See also Appendix below.
- Insurance
- increasing health insurance coverage for complementary modalities of
treatment (Oxford,
Mutual of Omaha).
- Public
Health - natural medicine program established through the Public Health
Service in King County (Seattle,
WA and population 1.8
million)
- Integrative
medical clinics in which ND’s and MD’s work side by side, and patients get to choose who they see (if
patient is uncertain, scheduler decides whether the initial appointment
is with a MD or ND).
- In
2008 the network consists of 7 integrative medical clinics (six include
acupuncture, naturopathic medicine, and nutrition, seventh for now with
just nutrition services), 4 dental clinics, and one school based center.
- This
program in the community health centers is administered by HealthPoint, a nonprofit entity.
- Public
Policy:
- President
Clinton in 2000 established a White House Commission on Complementary and
Alternative Medicine Policy, which issued a report on legislative and
administrative recommendations.
- In
2003 the Policy Institute for Integrative Medicine was founded by Marc Micozzi, MD, PhD, in affiliation with Thomas Jefferson University,
based on a grant from the Ira and Myrna Brind
Foundation. The mission of this Institute is the gathering,
analysis, and presentation of best practices that can help policymakers,
health professionals, and consumers re-shape the health care
system. Website for the institute is www.piimed.org
- On
1/12/05 the IOM released a report on a study by an expert committee on
many aspects of the use of CAM in the U.S. This study had been
requested by NCCAM amongst others, to assist in developing research
methods and setting priorities for evaluating CAM
therapies. Complementary and Alternative Medicine in the United States
is available free at www.nap.edu/catalog/11182.html
or at a charge by contacting 1-888-624-8373.
- Publicity
- Dr.
Weil on the cover of Time -
symbolic of increasing coverage of this topic by the press.
- PBS
2 hour special 3/29/06 – The New Medicine, focusing on initiatives
at leading academic integrative medicine centers.
What are the barriers to more widespread use and
acceptance of Integrative Medicine?
- Knowledge
barrier - there is currently a "conspiracy of silence" between
physicians who do not ask their patients about the use of complementary
modalities of treatment and patients who are afraid to tell their
physicians.
- Cost
barrier - due to lack of insurance coverage, much is available only to the
wealthy.
- Lack
of research - most practitioners are clinicians, and not researchers.
Research that does exist is often not in English, and cannot be found by a
Medline search.
- Lack
of licensure for some complementary practitioners, such as naturopaths.
- Health
insurance reimbursement schedules for physicians which financially reward
shorter visits.
- Medicolegal system.
- Biases:
- Stereotype
that practitioners are uneducated or physicians with "weak
minds" who are simply out to "make a fortune."
- Belief
of safety in the status quo.
- Confidence
in high technology which exceeds the evidence for effectiveness (COTA
study in 1978 which concluded that only 10-20% of conventional medicine
practices are based on data derived from controlled clinical trials).
Four step approach to the evaluation of complementary
modalities:
- Is it
safe?
- Is
there evidence for efficacy?
- Prospective
trials?
- Retrospective
trials?
- Anecdotal
evidence?
- Is it
expensive?
- Is
there a theoretic rationale for its use in a given situation?
Pneumonic: I ASK
(inexpensive, available, safe, knowledge)
Evaluation guidelines as per Dr.
Wayne Jonas:
- Get
a three part education:
- Understand
the concepts thoroughly.
- Evaluate
the data critically.
- Experience
the practice openly.
- Do a
two part look:
- Scientific
- strength/likelihood of attribution.
- Pragmatic
- benefit/magnitude of effect.
- Take
a SEC approach:
- Systematic/explicit/comprehensive
(SEC).
- Use
good methods of evaluation.
- Define
the detail, do not just label the system.
- Distinguish
under-evaluated from ineffective.
Physician responsibilities as per Dr. Wayne Jonas:
- Protect:
- Toxic
therapies (i.e. megavitamins).
- Ineffective
therapies, especially if substituted for effective therapies.
- Permit:
- Safe,
inexpensive therapies (i.e. homeopathy).
- Chronic
disease management.
- Promote:
- Safe
and effective therapies (i.e. relaxation techniques for pain management).
- Therapies
for which the mechanism is understood (i.e. acupuncture for pain and endogenous
opiates).
- Partner:
- Communicate
with the patient.
- Co-manage
illness - provide input on the evidence.
The future:
- Integrative
Medicine as a river, ever changing.
- The
consumer is awash in the ocean amidst many islands of treatment modalities
- practitioners must build bridges.
- Centers
for Integrative Medicine.
Appendix - web sites:
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