Adding Wings to the Pepper Tree: Integrative Medicine

adding wings to the pepper tree:lessons from integrative medicine on patient-centered careSuzana Makowski, MD MMM

No ﬁnancial disclosures

The Japanese Master Basho inresponse to Kikakou’s Poem We shouldn’t abuse God’s creaturesYou must reverse the haiku,not:a dragonﬂy;remove its wings-pepper tree.but:a pepper tree;Add wings to it-Dragonﬂy.

Overview• Deﬁnitions & background• From Alternative to Integrative - CAM to CIM• Adding art to our science• Can healing occur at all stages of life?

deﬁnitions & background

Deﬁnitions• Patient-centered care: (a) explores the patients main reason for the visit, concerns, and need for information; (b) seeks an integrated understanding of the patients world—that is, their whole person, emotional needs, and life issues; (c) ﬁnds common ground on what the problem is and mutually agrees on management; (d) enhances prevention and health promotion; and e) enhances the continuing relationship between the patient and the doctor. Stewart, M. Towards a global definition of patient centred care BMJ. 2001 February 24; 322(7284): 444–445.

ON PATIENT-CENTERED CAREDON BERWICK

Deﬁnitions• CAM: A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. ✦ Complementary medicine is used together with conventional medicine. ✦ Alternative medicine is used in place of conventional medicine. ✦ Integrative medicine combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness.

Utilization trends Many Americans use complementary and alternative medicine (CAM) in pursuit of health and well-being. The 2007 National Health Interview Survey (NHIS) ~ 38 percent of adults use CAM CAM use was more prevalent among people with a prior diagnosis of cancer ✦40-80% of cancer survivors reported using CAM ✦18 % had used multiple CAM therapies ✦Herbal and other natural products 20% ✦Deep breathing (14 percent), and meditation (9 percent). Between 40 and 70% of CAM users do not disclose their use to their physician. Over $40 billion spent out of pocket on CAM. http://nccam.nih.gov/health/whatiscam/

Must it beeither / or ?

“They don’t ask me, so I don’t tell them” Patients CliniciansNeed to perceive openness Need to demonstrate opennessNeed to perceive respect Need to demonstrate respectNeed to perceive interest Need to demonstrate interestUse driven by cultural identity Need to initiate discussionUse driven by family history Can ask about TM/CAM in acute settingUse driven by proximity to home Can still be clinical and evidence-basedDo not have outward characteristics Need not be content experts Shelley BM et al. Ann Fam Med 2009 7: 139-147; doi:10.1370/afm.947

Dangerous alternative medicine: Exercise after a heart attack

History of Integrative Medicine

What is health?

health = absence of illness

Problem-based care• Identify the complaint• Develop a problem list ✦Eliminate acute disease through medicine prescribed ✦Manage the chronic condition by medicines and therapies

Moving from the problem list to thepatient’s narrative

ReﬂectSound familiar?

"All physicians need a strong foundation on which to base the art and heart of [medicine]. They need the heart to care and the art to communicate," said Carol Aschenbrener, executive vice president at AAMC.Read more: http://www.insidehighered.com/news/2009/06/05/medical#ixzz1qxS6dUNJInside Higher Ed

On Curiosity

Problem-based model Sore, stiff neck

Problem-based care• Identify the complaint• Develop a problem list ✦Eliminate acute disease through medicine prescribed ✦Manage the chronic condition by medicines and therapiesThe integrated approach expands the notion of the interdisciplinaryteam from doc-nurse-social worker-chaplain to include massagetherapist-acupuncturist-nutritionist...

On Beauty

Lessons from integrative medicine• Ms Johes is a 63 yo with ovarian cancer, who has recently experienced increased difficulty with insomnia. Her current medications include: morphine SR 45mg bid, morphine IR 15mg q2 hours prn, dexamethasone 4mg qam, and a good bowel regimen. She shares that her mind is busy with worry, and once she falls asleep, she stays asleep. The chaplain has been working with her. Which of the following should you recommend next? a)  Lorazepam before bed b)  Chamomile before bed c)  Sleep hygiene d)  Lavender footbath before bed e)  Kava kava before bed f)  Metatonin before bed

Insomnia and the art of medicine• Lorazepam (and other benzos) – may have a “hangover” effect. Not ﬁrst line. Behavorial approaches are•Chamonile is a mild hypnotic tea. Research is poor, limited. But it is generally safe and may be added as part of “sleep hygeine”•Lavendar foot bath – is essentially a means of sleep hygiene, with an added “twist”. Behavioral interventions – including sleep hygiene, CBT, are ﬁrst line treatment with strongest evidence of support. Lavender aromatherapy has been shown to decrease delirium in the elderly.•Kava Kava and Valerian are two of the strongest hypnotics of the herbal-kind. Kava has been banned in EU due to risk of liver failure. Valerian has the strongest evidence as herbal treatment for insomnia.•Melatonin is a hormone that normalizes the sleep-wake cycle. It won’t help her “busy-mind,” but may be helpful if she had a sleep-wake cycle shift, or if on SSRI. (2- 7 mg

health = well-being

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.Preamble to the Constitution of the World Health Organization as adopted by theInternational Health Conference, New York, 19 June - 22 July 1946; signed on 22 July1946 by the representatives of 61 States (Official Records of the World HealthOrganization, no. 2, p. 100) and entered into force on 7 April 1948. The definition hasnot been amended since 1948.

Health is a “resource for life,not the objective of living.”- World Health Organization (WHO) 1986

curing and healing

Healing can happen at any stage of illness Healing - from hælan - to make whole If we turn back to the concept that health is not the goal, but rather a means to live fully - a challenge to all of us is how to heal when curing is no longer possible.

Adding wings to thepepper treeIt is emotional laborBut - leaning in, being presentdecreases compassion fatigueand burnoutSo listen...

Listen

Balfour Mount, MD “So I think healing has to do with slowing down, coming into the present, listening, accepting, forgiving, entering into community with, and healing is prevented by the opposites of those things.”

In the end...maintain curiosity to what we might notknowhold onto the wonder at the resilience ofhumanitysee and create beautyinstilling kindness

The Japanese Master Basho inresponse to Kikakou’s Poem We shouldn’t abuse God’s creaturesYou must reverse the haiku,not:a dragonﬂy;remove its wings-pepper tree.but:a pepper tree;Add wings to it-Dragonﬂy.

Adding Wings to the Pepper Tree: Integrative Medicine

by Suzana Makowski on Apr 21, 2012

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