1. The document provides an overview of integrative medicine, discussing definitions of primary care, healthcare trends, evidence-based treatments, and the role of complementary and alternative medicine. 2. It describes a typical day in the life of a physician, including patient cases, medical education and certification requirements, and professional positions held. 3. The future of healthcare is discussed, focusing on healthcare reform, accountable care organizations, and rewriting medical education through programs like the MS ACP at National University of Health Sciences.

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
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– Stress management
• Pap smear
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– Parenting classes
• PSA
– Cooking classes
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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
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– 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.
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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.
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(Graduate Hospital) • Commitment to Patient Confidentiality.
• Chief of Integrative Medicine • Commitment to maintaining Appropriate Relations
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(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
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4. ‘HONDA’
HONDA Evidence Based Medicine
• #1 problem we face
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• 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
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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
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– 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.
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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
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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
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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
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• 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
Women's & Men's Health / Geriatrics
Ethics & Risk Management
Clinical Competencies
Capstone Defense
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