OVERVIEW                                                    1. Definition of ‘primary care’         INTEGRATIVE MEDICINE  ...
Tertiary Prevention                                                       Healthcare 2014 and Beyond• Locking the barn aft...
Medical Professionalism in the                        Positions Held                                                      ...
‘HONDA’                             HONDA                                                  Evidence Based Medicine•   #1 p...
Evidence Based Medicine                                            UpToDate.com                                           ...
Brave New World                                              MS ACP Program & NUHS                                        ...
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Integrative Medicine - Eric J. Deppert


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Integrative Medicine by Eric J. Deppert, MD, FACP

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Integrative Medicine - Eric J. Deppert

  1. 1. OVERVIEW 1. Definition of ‘primary care’ INTEGRATIVE MEDICINE y 2. Healthcare 2014 and beyond Eric J. Deppert, MD, FACP 3. A day in the life of …………. Me Clinical Assistant Professor of Medicine, 4. Evidence based pharmacopoeia & herbal 4 E id b d h i h b l Drexel University College of Medicine treatment Postprofessional Faculty, 5. Role of CAM & integrative practices in the future National University of Health Sciences y of healthcare 6. MS ACP program and NUHS rewriting the book Primary Prevention Secondary Prevention• Protect against disease and disability • Identify and detect disease at its earliest d f dd d l• Immunizations stage, before noticeable • Prevent the spread of communicable diseases• Safe drinking water • BP screening• Seatbelts and airbags • Colorectal screening• Health promotion & wellness • IFG/DM & lipids / – Stress management • Pap smear p – Parenting classes • PSA – Cooking classes 1
  2. 2. Tertiary Prevention Healthcare 2014 and Beyond• Locking the barn after the horse is out • 50,000,000 i 50 000 000 uninsured d • 30,000,000 covered (Affordable Care Act)• 95% of my world • 20,000,000 left out? • “Cost containment” Chiro opportunity • Rationing of health care (Arizona MA xplants) • Evidence based medicine • My experience before Affordable Care Act • CASE: Betsy Headache y – MRA dissection – Couldn’t get approved Accreditation Council for Education Graduate Medical Education (ACGME)• Bachelor of Science (BS) degree (4 years) Responsible for the accreditation of post MD medical training• Doctor of Medicine (MD) degree (4 years) Core Competencies – Years 1 & 2: Basic & Clinical Sciences (classroom) – Years 3 & 4: Clinical Rotations / Clerkships • Patient care • Average GPA entering program 3.80/4.00*• Postgraduate Residency (3+ years) Medical knowledge – – PGY PGY 1 2 Internship Resident (Internal Medicine) • Practice based learning & improvement – – PGY PGY 3 4 Resident (Internal Medicine) Chief Medical Resident (Internal Medicine) • Systems based practice• USMLE Parts 1, 2, Clinical Skills, 3 • Interpersonal skills and communication• A American Board of I t i B d f Internal M di i C tifi ti E l Medicine Certification Exam – Recertification (every 10 years) • Professionalism• Upon successful completion of the residency program, one is able to practice medicine independently (pursue licensure) and sit for certification examinations. 2
  3. 3. Medical Professionalism in the Positions Held New Millennium• Clinical Assistant, Chairman of Education Assistant • A physician charter: professionalism i th b i of h i i h t f i li is the basis f (Presbyterian/UPenn) medicine’s contract with society.• Director of Ambulatory Care y • Principle of Primacy of Patient Welfare Welfare. (Presbyterian/UPenn) • Principle of Patient Autonomy.• Director Podiatric Medical Consults (Presbyterian/UPenn) • Principle of Social Justice.• Internal Medicine Residency Director (Presbyterian/UPenn and • Commitment to Professional Competence. Graduate Hospital)• Vice Chairman of Medicine • Commitment to Honesty with Patients. y (Graduate Hospital) • Commitment to Patient Confidentiality.• Chief of Integrative Medicine • Commitment to maintaining Appropriate Relations g pp p (Mercy Fitzgerald Hospital) with Patients.• Physician Advisor Case Management ( (Mercy Fitzgerald Hospital) y g p ) • Commitment to Improving Quality of Care. Medical Professionalism in the A Day in the Life of ……… ME New Millennium (cont’d)• Commitment to Improving Access to Care. • A day in the office – clinical cases• Commitment to Just Distribution of finite • My H & P forms and screening Resources. • Chiropractic physician – Home Inspector• C Commitment to Scientific Knowledge. i S i ifi K l d • ME – 3rd Engine at 5 Alarm Fire• Commitment to Maintaining Trust by g y Managing Conflicts of Interest.• C Commitment to Professional R it tt P f i l Responsibilities. ibiliti 3
  4. 4. ‘HONDA’ HONDA Evidence Based Medicine• #1 problem we face p • Vit i D Insufficiency Vitamin I ffi i• ‘Stupidity is a god given right’ i.e. unaccountable patient – NEJM 364:3 Jan 20, 2011 p 248 254• e.g. ‘Tony Soprano (endothelial dysfunction) Tony Soprano’ – “…despite the recent focus in the media on the potential role of p p vitamin D in reducing the risk of various chronic diseases, this• Mediterranean diet study – Metabolic Syndrome hypothesis requires testing in large, randomized, controlled trials, and vitamin D cannot currently be recommended for the Findings: ½ of the study group did not improve – purpose of reducing the risk of heart disease or cancer.” went on to diabetes mellitus • Vitamin D Insufficiency• Galaxy Trial, Jupiter etc Trial etc… – Mayo Clinic Proceedings Jan 2011; 86 (1) p 50 60 Jan, – “…in adults, vitamin D supplementation reduces the risk of• Prevention fractures and falls. The evidence for other purported beneficial• Treatment T t t effects of vitamin D is primarily based on observational studies…”• Regression Evidence Based Medicine Evidence Based Medicine • Vit i D PTH and CV Mortality in Older Adults – Th Vitamin D, d M t lit i Old Ad lt The • Transpalmitoleic acid Metabolic Risk Factors and New Onset Diabetes in acid, Factors, Rancho Bernardo Study U.S. Adults – Ann Int Med 2010; 153: p 790 799 – AMJMED 2010, 07, 13 – Good fats vs bad fats. Decreased incidence of atherogenic dyslipidemia, insulin fats dyslipidemia – “…serum levels of 25(OH)D, 1,25(OH)D, and intact PTH were not resistance and new onset diabetes. independently associated with cardiovascular mortality…” • Effects of Lowering HC Levels with B Vitamins in CV Disease, CA and Case • On the Epidemiology of Influenza Specific Mortality p y – Arch Int Med 170 (18) Oct, 2010 p 1622 1633 – Virology Journal 2008, 5:29 – Dietary supplementation with folic acid to lower homocysteine levels had no – Seasonal outbreaks? Increased expression of cathelicidin? effects within 5 years on cv events or on overall cancer or mortality in the populations studied studied. • Vitamin D and the Heart: Why We Need Large Scale Clinical • Should Healthy People Take a Multivitamin? (Oliver Wendell Holmes, Sr.) Trials – Cleveland Clinic Journal Med 77 (10) Oct, 2010 p 658 – Cleveland Clinic Journal of Med 77:12 p 903 910 – “ at least it won t hurt me may not be true “ won’ – VITAL trial (vitamin D and omega 3) – Vitamin E: increased rate of all cause mortality. – SELECT trial: vitamin E increased prostate cancer / selenium increased diabetes. 4
  5. 5. Evidence Based Medicine UpToDate.com UpToDate com – good site to review• M k d V i bilit of M Marked Variability f Monacolin L l i C li Levels in Commercial R d i l Red • C CAM Rx Yeast Rice Products – Arch Int Med 170 (9) Oct 2010, p 1722 1727 – For cancer – Marked variability in monacolin content and potential nephro – Rheumatoid disorders toxic citrinin. – St. John’s Wort• Potential for Interactions Between Dietary Supplements and Rx Medications – Depression – J Am Med 2007.21.014 p 207 211 – Saw Palmetto – Mainly anticoagulants and diabetes Rx – Echinacea• Mercy Medical News – Ginko Biloba General Urology: Enzyte and prolonged QTc interval. interval General Infectious Disease: Indian coleus (forskolin) potential Rx – LBP for UTI. – Probiotics Role of CAM & Integrative Practices Common Ground in the Future of Healthcare • Countdown to Reform C td t R f• Gone is the “dumbluxation” • 2011 stage 1 meaningful use.• Gone are the silos Chiros/PCP h l h / • 2012 Accountable Care Organization program • 2012 Independent Payment Advisory Board (IPAB)• Need to integrate and educate • 2013 stage 2 meaningful use g g Ourselves & public • 2014 first set of IPAB recommendations due to improve• Share strengths & resources quality and cut costs • St Stage 3 meaningful use i f l• Age old struggle against the Antivaccinationists –NEJM 364:2 Jan 11 –Pertussis epidemic & measles back in the news • 12 Things Doctors Want to Tell Patients –Quality indicator for Medicare and other insurance carriers – Physician Practice 10/10 5
  6. 6. Brave New World MS ACP Program & NUHS • R Rewriting the paradigm iti th di• Affordable Care Act and the Future of Clinical Medicine: The Opportunities & Challenges • African American Barber Shops?• ACO’s: The End of Independent Practice? – Not a bad idea i.e. education – But did we really fail that badly?• Patient Centered Medical Neighborhood • Broadening the Scope of Nursing, Psychology and• Hi h V l Cost Conscious Health Care: Concepts f Cli i i High Value, C t C i H lth C C t for Clinicians t to Optometry Practices Evaluate the Benefits, Harms and Costs of Medical interventions • The Philadelphia Project p j• Can Congress make you buy Broccoli? And why that’s a hard • Doctor of Chiropractic Medicine and Post Graduate Clinical question. Residency• The challenges of a (growing) medical assistance population • MS ACP PProgram MS ACP Courses Course Titles Clinical Neurophysiology I & II Clinical Skills for the Primary Care Physician Clinical Problem Solving Biostatistics & Research Methodology Mechanisms of Pain Psychological Issues of Illness Clinical Nutrition I, II, III , , Advanced Clinical Laboratory Medicine I & II Independent Research I & II Advanced Diagnostic Imaging Internal Medicine Clinical Rotation Clinical Neurology I & II Clinical Pharmacology I, II, III Pediatrics Womens & Mens Health / Geriatrics Ethics & Risk Management Clinical Competencies Capstone Defense 6