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 “Integrative 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 presents 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 all 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 physicians 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, Practices, 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.”
 Definitions

“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
Alternative Ayurveda, Chinese, Native American, Aboriginal, African,
Medical Middle Eastern, Tibetan, Central and South American cultures,
Systems Homeopathy, Naturopathy

Mind-Body cognitive-behavioral approaches, meditation, hypnosis, dance,

Interventions music, art therapy, prayer, mental healing
Biological dietary supplements, herbs, orthomolecular (varying
Based concentrations of chemicals, such as, magnesium, melatonin, and
Therapies mega-doses of vitamins), individual biological therapies (use of
laetrile, shark cartilage, bee pollen).
Manipulative chiropractic, osteopathic manipulation, massage
And Body-
Based Methods
Energy Therapies Qi gong, Reiki, therapeutic touch, bioelectromagnetic-based
therapies (pulsed fields, magnetic fields, or alternating current
or direct current fields)

As Defined by NCCAM
 Why Should We Care?
• 30,000 herbs on the market currently
• Estimates of $30-40 billion dollars 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 bottles 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 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” products
• Patient feels empowered
• Focus on spirituality and emotional well-
being
• Health Care Provider provides the 3 T’s:
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 do patients not tell their physician
about their CAM use?
• 60% - “My doctor never asked.”
• 60% - “It wasn’t important for my doctor to
know.”
• 20% - “My doctor wouldn’t understand.”
• 14% - “My doctor would disapprove.”
•
70% of patients see their Physician before or concurrent
with their visits to a CAM provider

Eisenberg 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
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 estimate 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 Us?
• DSHEA 1994
– www.consumerlabs.com
• 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 Formulations
– Difficult to Blind Patients and Practitioners
– Treatments Very Individualized – Difficult to
Formulate Protocols
 RCCT
• Gleevec
• Albuterol
• Acupuncture
• Chinese Herbal Therapies

• How Can This Stand the Test of Time?

 Comparison
• Mainstream Medicine
– Large Double Blind Placebo Controlled Trials
• Many Exclusions 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
CAM MODALITY LICENSURE
Chiropractors All states
Massage ther. 27 states
Naturopaths 13 states
Homeopaths 3 states
Acupuncturists 32 states
• Patients are choosing
integrative and
alternative medicine,
but what about
physicians?
 Where Are We Today?
• Clinical Fellowships: • Academic Fellowships
– University of Arizona (Research)
(Founding Program) – Harvard University
– University of Michigan – Tufts
– University of Maryland – Boston University
– University of Wisconsin – Stanford
– Maine Medical Center – Duke
– Cooper Health System (NJ) • Residencies in Integrative
– Lawrence MA Medicine
– Beth Israel Medical Center – Oregon Health Sciences
– UCLA University
– Montefiore Medical Center
(NY)
Where Are We Today?
 CAHCIM Members
• Albert Einstein/Beth Israel
• Columbia University
• Duke University
• George Washington
• Georgetown
• Harvard
• 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 California/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
• University 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, 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 Providers
• 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 Medicine Curriculum Demanded
by Students
• Integrative Medicine Interest Group
• “Integrate Chicago” http://www.integratechicago.com/index.html
 The 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 and 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
– Training 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 Empathy 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 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.

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 patients 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
conventional 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
Alternative Ayurveda, Chinese, Native American, Aboriginal, African,
Medical Middle Eastern, Tibetan, Central and South American cultures,
Systems Homeopathy, Naturopathy

Mind-Body cognitive-behavioral approaches, meditation, hypnosis, dance,

Interventions music, art therapy, prayer, mental healing
Biological dietary supplements, herbs, orthomolecular (varying
Based concentrations of chemicals, such as, magnesium, melatonin, and
Therapies mega-doses of vitamins), individual biological therapies (use of
laetrile, shark cartilage, bee pollen).
Manipulative chiropractic, osteopathic, manipulation, massage
And Body-
Based Methods
Energy Therapies Qi gong, Reiki, therapeutic touch, bioelectromagnetic-based
therapies (pulsed fields, magnetic fields, or alternating current
or direct current fields)

As Defined by NCCAM
 Unsafe/Proven Safe/Proven

Unsafe/Unproven Safe/Unproven
 The Future of Integrative Medicine
• Nutrition
• Exercise

• Lycopene
• Glucosamine
• Peppermint Oil
• Fish Oil
• Soy
 The Future of Integrative Medicine

• Epocrates Rx Pro
• Micromedex
• Commission E

• Plus Many Other Databases

http://nccam.nih.gov/
 Resources

• Commission E
– Germany
– Ranks Quality of
Evidence
– Evaluates Benefits 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

Alternative 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.org

• Online Resource
– http://www.altmedicine.com
 Where Should We Go for
Information?
• Product claims
– www.quackwatch.com
– www.snopes.com
• Product quality assurance
– www.consumerlab.com
• Product ingredients
– Natural Medicines Database www.naturaldatabase.com
• Product safety and efficacy
– www.cfsan.fda.gov/~dms/ds-ind.html
– www.naturaldatabase.com
– The Natural Pharmacist www.iherb.com or www.consumerlab.com
 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!