Tuesday, June 2, 2015
Integrative Medicine is Good Medicine
It was time for a yearly physical. I walked into the waiting room of my internist's office and checked in at the window. The receptionist politely asked me to have a seat. Anxious to get this over with, I turned and scanned the room for a seat. If it were an office with windows, I would normally opt for a seat with a view, but this one has four walls and my only interest is to make eye contact with the nurse that calls my name. It's not that I abhor going to see the doctor; it's just that usually it seems to be a waste of time. I don't mean to sound cynical and am in fact thankful for typical appointments with nothing to report. My symptoms or complaints tend to be related to Multiple Sclerosis, and for the most part they are a bit illusive. How do you evaluate fatigue? Fatigue for one person may be very different than another. Otherwise my test results are usually within normal range. The appointment usually ends with an obvious reminder, "Your symptoms are most likely related to MS."Today I sat down, picked up a magazine, and read half heartedly about the latest debacle in government. For what ever reason, waiting rooms are stocked with sports or news related magazines and the occasional home décor. A better choice would be to have subject matter that would lower one's blood pressure, not increase it. As I'm flipping through the pages, I am aware of how apathetic I've become towards the issues of the world. "Is my lack of interest a reflection of a disregard for social concerns or am I just saturated with constant negative reporting?" Suddenly, I am startled by a woman sitting to my right; she excuses herself and puts her magazine down, as she walks into the examining room. Silly, but I felt a bit of jubilation; she had left me a Better Homes and Garden to look through. I quickly returned the news magazine to the table and began flipping through BHG for an article that would take my mind off serious issues. One sounded intriguing; a discussion about the pros and cons of eclectic design. I wondered why I'm so drawn to an eclectic design. Undoubtedly the affinity I have for old world décor is a result of living with my grandparents in Portugal for a few years. My tendency is to recall these childhood memories with a palpable perfection. Traveling also influences the atmosphere of my home. It engages my emotions, bringing me closer to the local customs; making me feel alive. I enjoy learning first hand about different cultures and exposing my son to these cultures as well. Whether we choose to fly to Europe, take a train to Canada, drive over the border to Mexico or walk to our local home goods store, it is probable that we will encounter an item from another country, an item reflecting a particular tradition. That is why eclectic design is so appealing to me; it incorporates beautiful and at times meaningful items from many cultures around the world. These artifacts not only serve as reminders of my experiences abroad, but also represent the idea that our world is diverse and full of wonder. When I think about it, every aspect of my life is affected by an eclectic philosophy. I use what works for me and leave what doesn't.According to this article in BHG, there are a few guidelines to follow in order to achieve a successful eclectic design. Rule number one; it's essential to identify a common thread and continue it throughout the room. Rule number two; keep it organized and uncluttered; present your items with respect for the individual piece and its origins. Just as I was beginning to read rule number three, my name was called out. I quickly put the magazine down and followed the nurse down the hall and into the examining room. She asked me to remove my clothes and put a gown on. I could wrap myself three times in this one. I tied the strings, but it was pointless really, it fell off my shoulders and inevitably opened from behind. This didn't bother me; I was never very bashful in front of physicians. It felt like a business transaction in many ways. You go in, take care of business, and you leave; hopefully with a healthy evaluation.However, today was a little different. Fatigue comes and goes, but lately it had lingered longer than usual. Lately it had been affecting my ability to function at work and home. Usually I just assume it is MS related and muddle through it. But lately it's been bothering me more so. I decided to discuss my symptoms with the doctor and ask her to check other non-routine lab work. Maybe I had hypothyroidism or perhaps I was anemic. Both conditions could be easily treated. In essence I was hoping the doctor would find a benign condition or cause; identify it, treat it and resolve it. She agreed these conditions were plausible in lieu of all my symptoms. She agreed to do a full work-up, including thyroid tests and iron levels. I was to see her again once the results of the lab work came back.A week later I was back in the examining room. While I was waiting I remembered that article that I had read in the previous visit. It occurred to me that health care providers would benefit from an eclectic approach to medicine. Today I was hoping for something more. I had been experimenting with alternative health practitioners on my own from time to time, and I wondered if she was knowledgeable about alternative medicine. I decided to ask her how she felt about it, willing to take the risk of being ridiculed. I wanted my doctor to work with me and respect my beliefs. I wanted to take these visits and change them from a business transaction to a healing experience and felt that maybe it was up to me to open the door. . She entered the room with a pleasant smile on her face; explaining that the lab work was normal and although this was ultimately good news she could at the same time understand my frustration. She knew I was looking for the answer. Regrettably she had nothing else to offer. At that point I asked her how she felt about alternative approaches and if she had any personal knowledge of such therapies. To her credit she compassionately listened to me and proceeded to explain that she had no professional knowledge of alternative therapies, but that she could relay an experience one of her secretaries recently had. Apparently she had been experiencing sharp pain in her right arm for years. She went to several physicians including specialists. Her efforts led to no avail. She was so desperate that she decided to try an acupuncturist as a last resort. After a few sessions the pain resolved and the use of her arm was back to normal. Dr. Jones had to admit that based on her personal knowledge of the case, the outcome was phenomenal. Choosing her words carefully she acknowledged my belief in the benefits of certain alternative therapies but cautioned me as well. I saw the apprehension in her face. Alternative therapies were foreign to her and have often been admonished and ridiculed by western medicine. Traditional western medicine has no place for alternative therapies; it's not part of the construct.There is a level of comfort one enjoys, albeit illusory, in believing that science, especially the western medical model, is the only model we can truly trust. Anything outside of the parameters is unwelcome, considered dangerous, archaic, and pointless to investigate. For example, why would we use herbs if we have drugs? Isn't the use of whole herbs a symbol of an archaic medical system? Hasn't modern medicine developed drugs as a result of the less effective use of herbs? Haven't we transcended the need for herbal preparations altogether? Many western practitioners would answer yes to these questions. And if this is their premise, than it becomes clear as to why good solid research on the use of botanicals and other alternative therapies has lagged behind. If your perspective is one of transcending the ancient medical models, than there is no room for exploring what they have had to offer for millennia. Dr. Jones had at least allowed for the possibility that acupuncture may have helped in a very real observable way. In contrast, there have been other physician encounters where I had been admonished for using supplements such as; CoQ and Primrose oil. There is reason to take comfort; it is an easier way to practice medicine. It may not however be ultimately in the best interest of the patient. Doctors are taught to offer all potentially helpful options and to educate the patient with regards to the risks and benefits of such options. At the very least the health care provider should be aware in a general sense of alternative options and have connections with reputable alternative practitioners who are licensed and respected within their field of expertise.Being a patient who has a pharmacy background has been at times a struggle for me. On the on hand it has been helpful in guiding me through decisions with respect tom own health. On the other hand having a chronic disease like Multiple Sclerosis, I am painfully aware of conventional medicine's shortcomings. There are not many options available and the ones that I have tried have brought with them side effects that I wasn't willing to live with. Having no other option I turned to acupuncture in desperation. To my surprise it not only helped, the effect was significant. There were no side effects--only improvement.Professionally I was trained to disregard alternative therapies and to caution patients against them, but here I am with a personal experience that proves to me and me alone that there are effective alternatives that are being overlooked or ignored. As a pharmacist I walk a thin line. Morally I feel obligated to offer information to patients about alternative therapies when appropriate. At the same time I feel I hold back for fear of being reprimanded by the board of pharmacy or worse still by disgruntled physicians who may not appreciate my suggestions. First do no harm has at times become; first protect yourself legally; and that's unfortunate.We have been forced to practice defensive medicine. Our medical system, as technologically advanced as it is, is in disarray. Thousands of MRI's, CAT scans, X-rays, blood work are being performed every day; many needlessly. Prescriptions are being handed out like candy; at times just to pacify the patient. Unfortunately these patients soon realize just how expensive the piece of paper they hold in their hands really is.At the pharmacy I'm approached by patients all the time with various questions. In an attempt to more effectively provide them with helpful information, I usually ask brief questions about their conditions and if they had discussed their concerns with their physicians. Often time the answer is no. Excuses may range from, "I could see that he was busy, so I didn't want to bother him" or "We did discuss it, but I'm not sure I understand" or "I'm concerned about any side effects or drug interactions" or "Isn't there anything else I could take that's over the counter" or "This is too expensive, I can't afford it". In addition, many patients are seeing several doctors and often times each doctor is unaware of what the others are prescribing. In an attempt to save money the patient frequents several pharmacies in order to get the best price. All of this leads to a disorganized medical system which leaves the patient in a vulnerable position as well as their health care providers. If Dr. X isn't aware that Mrs. Smith is taking diazepam, he may write for another sedative, alprazolam. If her primary care physician prescribed the diazepam for muscle spasms and her psychiatrist prescribed alprazolam for anxiety, the patient may believe that these two drugs have nothing in common and it doesn't even occur to her to mention it to either doctor.Physicians will routinely ask if you are taking any other medication. Time and again I see that physicians are not aware of their patient's complete drug history and even less aware of what they take over the counter. It is our responsibility as pharmacists to bring this to the doctor's awareness, but we are hindered by not having access to the patient's complete medical history, which includes other pharmacies that they go to. In these cases it seems obvious that the person most capable of resolving these issues is the patient herself, by being forth coming with the information. I'm all for patient responsibility, but what do you do with an elderly population that has a difficult time remembering and understanding medical jargon?And what of individuals whose English is their second language and have difficulty understanding as well? By no means are these the only patients that we have to be concerned with. The population at large still sees the physician as a patriarchal figure, an expert when it comes to their health. They mistakenly assume that practitioners have an ongoing dialogue amongst one another in which they routinely partake in conversations regarding their patients.This naive understanding of the medical system, contributes to a patient's vulnerability and less than optimal medical care. I am a strong supporter of patient responsibility--to a certain extent. They are responsible for communicating openly with all their health care practitioners and asking questions, until they are satisfied that they understand all options regarding therapy they are receiving. However how is it possible for someone outside the medical field, to understand completely what is best for them? It seems that every nightly news show is full of contradictory research conclusions. Part of the problem is sensational headlines, whose only purpose it to captivate the audience's attention. Viewers are left with the misleading headline in their minds and aren't aware of the details in the research, which offers a more comprehensive analysis. Of course we are taking for granted that the study itself was well designed and accurate. Patients are bombarded with contradicting information on a regular basis. Even if they want to take an active role in their healing process, they are overwhelmed with questions that seem to have no end. To make matters worse, according to Dr. John Abramson of Harvard Medical School, many popular studies that have been done in the recent past have had significant flaws at best and outright fraudulent at worst. How are patients to know the difference if practitioners themselves have a hard time deciphering the good ones from the bad?What I once thought to be research that was done impeccably, with the highest scientific standards, published in trustworthy peer reviewed journals, is no longer true. I went to college in the eighties, a time in which I was made to believe that scientific research was almost sacred in nature. Scientists were seen as objective individuals who would above all else do everything within their power to avoid any bias toward a particular outcome. Dr. Abramson explains in his book Overdosed America that we are standing on shaky ground. Research that once was done by nonprofit organizations, such as universities and hospitals, is now being done by drug companies. Our regulatory agencies which once were forbidden to take money from drug companies are now being subsidies by them. The journals that once had my full confidence, are now receiving millions of dollars from drug companies in exchange for advertisements. Physician's prescribing habits are not only being monitored by insurance companies but also by drug companies and their sales people, in order to more efficiently target marketing. In addition, practicing physicians have routinely been recruited to participate in clinical studies. They were modestly reimbursed for their time if at all; now participating in clinical research means big dollars. Not only are the drug companies doing their own research, but they are hiring their own doctors to do the follow-up clinical studies. This does not mean that all results are unreliable, but one has to question the validity of studies financed through private companies. Where are the safeguards against bias?Practitioners that are hesitant to recommend or even tolerate the idea of alternative medicine should consider the issues that have arisen over the last few decades within our own medical system. Healthy skepticism is necessary when evaluating any therapy now more than ever before. Fortunately many physicians have the capacity and aptitude to thoroughly evaluate a study. Statistical analysis is now taught at most medical schools. Unfortunately, evaluating alternative therapies is a bit more complex, only because their knowledge base in these therapies is negligible. Most medical schools don't have these courses available.There are some medical school curriculums which offer courses on alternative and complimentary approaches. These are few and are most often offered as electives within the required curriculum. Some schools are on the cutting edge of training their physicians in a more comprehensive fashion. Often these opportunities are available to medical school graduates when they finish their standard training. These already established physicians chose to do a fellowship in integrative medicine. One such school is the University of Arizona Integrative Medicine Program. This program was founded by Dr. Andrew Weil a foremost expert in the field. In an attempt to educate the practitioner at large, the program also offers continuing education courses on various therapies in complimentary and alternative medicine (CAM). Educational institutions such as this one are at the forefront of a changing paradigm in medicine. They are doing much to dispel the negative stereotype that CAM approaches have received over the last forty years or so. They have taken a hard look at CAM therapies and identified those that are efficacious and beneficial.Although the number of clinical trials being conducted on CAM therapies are growing in number, there is an undercurrent of disapproval in order to show that most of these therapies are ineffective at best and harmful at worst. It is logical that given the number of therapies available to the consumer, some will be shown not to work and some may prove to be unsafe, but the amount of negative reports in the media suggest a negative bias. There was a news report a few years ago whose headline read "Study proves that St. John's Wort is no better than placebo". In that same study they also compared the efficacy of a popular antidepressant medication. What the media didn't convey was that this antidepressant, which was widely used, was shown to be less effective than placebo. What would it mean to the drug companies if an herb was found to be effective in mild depression? Millions of dollars would be lost.It is difficult to discern credible reporting from what amounts to be agenda driven advertisement. It is essential that we understand the obstacles that we are faced with and take it upon ourselves to unscrupulously assess the reliability and credibility of the report, whether it be conventional or alternative. We need the support and guidance of respected institutions to help us lead the way to a more holistic model of medicine. At the same time we need comprehensive resources to be easily accessible. Having these support systems in place would not only afford us the ability of providing quality care, but would simultaneously reduce our exposure to liability. According to the University of Arizona Program in Integrative Medicine (PIM), the legal issues that health care providers face when recommending or discussing complementary and alternative medicine modalities in their office are as follows: •Malpractice liability for inadequate informed consent •Licensure and credentialing •Scope of practice (the legally authorized practice boundaries for providers) •Professional discipline (discipline for professional misconduct) These concerns are valid and one can understand the hesitancy that many practitioners have. From their perspective they would be jumping in a fire hoping to avoid getting burned. In the midst of these obstacles there are seeds of hope. We as patients and as healthcare providers must not capitulate to this challenge. We must avoid complacency and strive for a healthcare environment that is open to new thought and offers more options. PIM offers suggestions and guidelines to follow which will help in traversing these murky waters. When a patient asks about alternative therapies the following should be considered: What is the curability rate with conventional care? Weigh quality of evidence, invasiveness, and toxicities of each therapy. Patient clearly understands the risks and benefits of each option and accepts those risks.It is also important to familiarize yourself with organizations that have been established, in order to demystify CAM therapies. The Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) is an organization responsible for performing rigorous studies on various medical therapies in order to create new models of clinical care, these models would integrate biomedicine, the complexity of human beings, the innate nature of healing, with the diversity of therapeutic systems from all over the world. It understands that the western medical model, although superb at treating many diseases and conditions, also has limitations. At the same time it acknowledges that for millennia there have been effective medical models from around the world. Some of the academic medical centers that are members of CAHCIM include: University of Arizona, Harvard, Georgetown, Duke, and Columbia University to name a few. The following is a list of resources that are also a good place to start: American Botanical Council American Herbal Pharmacopoeia Consumer Labs: Randomly test dietary supplements and release their finding to the public http://www.drweil.com/: Extensive website with information pertaining to both conventional and CAM treatments. FDA Food Manufacturing Practices (GMP): Sporadically monitors products off the shelf Independent Drug Information Service (iDiS) National Center for Complimentary and Alternative Medicine (NCCAM) National Institute of Health National Sanitation Foundation (NSF): Dietary supplement quality verification, they use GMP compliance standards Overdosed America, Dr. John Abramson Powerful Medicines, Dr. Jeffrey Avron The Association of Official Analytical Chemists (AOAC) The Compendium of Asian Patent Medicines University of Arizona Integrative Medicine Program United States Pharmacopoeia (USP): Dietary supplement quality verification they use GMP compliance standards World Health Organization Given the available resources and I'm sure there will be more to come, a practitioner who has a sincere interest in offering his patients more options, can feel more comfortable with the use of credible complimentary medicine. It saddens me to think how the western medical community has so often disparaged and looked upon other medical models with disdain and total disregard. We don't have all the answers, far from it. All medical traditions have blind spots, strengths and weaknesses. Western medicine would benefit from a visit to the therapist, there it would hopefully have a revelation, and it would realize that it is not omnipotent. Could it be projecting onto other medical models what it is afraid to accept of itself? We bare and share the same responsibility, which is to provide the best medical care available to our patients.