Integrative Medicine and Family Practice

[IntegrativeMed]

I am trying to decide between the best path into Integrative/Holistic Medicine. I am basically trying to decide between PM&R and FP. Internal medicine with subsequent specialization into a field like Endo is also a possibility. Basically, my personal interests are very diverse and I feel that FP's approach is what feels the most right for me. If I choose FP, I am wondering how realistic it would be for me to work 9-5 M-F, with no call and to be able to spend longer times with the patients. I plan to get training in accupuncture and other holistic modalities during residency and possibly to complete the Integrative Fellowship. I worry that being in the primary care setting, I will be overwhelmed with the volume of patients, paperwork and other administrative things that take a lot of time and energy and are not compensated for...

Also, I am wondering what the salaries are for FP faculty and what their lifestyle is. I know that some people have become Medical Directors at the Integrative Medicine Centers but I have no idea what their job entails... Any feedback would be greatly appreciated. Feel free to PM me 🙂

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[oxytocin]

This is exactly where I stand right now. Please give insight on this topic. Thank you.

 

[lowbudget]

I worry that being in the primary care setting, I will be overwhelmed with the volume of patients, paperwork and other administrative things that take a lot of time and energy and are not compensated for...

Don't worry, you'll be compensated. What you'll find is that people are willing to pay cash for these things. When your practice picks up, you can start dropping insurance and/or spacing out your patient visits.

You'll be fine. Chase your passion; the business will follow.

 

[IntegrativeMed]

I was actually hoping to see if there are any practitioners here who do Integrative Medicine and how their practice is set up. I have been really discouraged from going into FP by my own family and multiple FMG family practice residents 🙁 So disappointing. Everyone is telling me to just do PM&R and to have a nice time... I feel like I could also practice Integrative Medicine through Internal Medicine if I wanted to expect it seems that Internal Medicine is much more rigid in terms of sticking to traditional methods... and there is much less emphasis on preventive and outpatient care... And my rank is list is due on Feb 24th. Fun times.

 

[oxytocin]

I don't think IM is very open to integrated medicine...although I am sure it is possible to do. However, if you are looking at outpatient for long run, I've heard FM residencies are best at training their residents for that.

Why did they suggest PMR over FM? That seems be a growing field now.

 

[FMstudent]

We have an integrated medicine center at Duke.

http://www.dukeintegrativemedicine.org/

They just came to give us a lecture the other day.

Kind of interesting, expensive though...all cash..but they said that Medicare does have some coverage...I am going to try to do an elective over there if I can...

Every FM program is different...wouldn't write them all off ...or listen to your family ...it's not their career.

I got a lot of grief about going FM , but I wouldn't change it...

FMintern

 

[IntegrativeMed]

There are many reasons why PM&R is great. First of all, it is very open to alternative modalities - a lot of docs I know use accupuncture and OMM. Second of all, it's pretty comprehensive- you get to address a lot of different issues for the patients. Third of all- the hours are pretty amazing, no night call and weekends mostly off, non-urgent low stress environment and very nice people. For those who are into musculoskeletal medicine/sports medicine this is pure heaven. 🙂 However, even though I do think PM&R is a wonderful field and I think I would be happy if I do match into it, I feel like it would limit my outlook on life. There is not much primary prevention going on and the focus is mainly on making the disabled patients most functional. Also, I feel that I would really miss out on learning about other organ systems in greater depth. Then again, maybe if I have more free time on the weekends, I will be able to learn all about integrative modalities. 😱

 

[lowbudget]

I honestly don't know much (of anything for that matter) but would be interested to hear how this all flushes out. I'm gonna throw out a few observations.

How integrated can you truly be if you only focus on the (neuro)musculoskeletal system?... one.

Two, if you're going to run a cash practice, which is basically what integratative medicine is, you really need to figure out how you will be getting your patients. If you stick your head into the PM&R forum from time to time, you will realize that PM&R, while an awesome field, has an identity crisis. Good or bad, at least with FM, people know what FM is... and I'm going to go with Good because FM is at least at the center of a national debate about health care reform, one that really is being pushed by patients out there, rather than doctors causing all this ruckus. Tell people you're a family doc & people know what that is. Tell people you're a physiatrist & you'll need to do some 'splaining. Few people know what PM&R is, few doctors know what PM&R docs do. It's not a knock on physiatry, that's just reality. So if few patients know what PM&R is & few doctors know what PM&R is, you have a marketing challenge in terms of pulling in patients.

I don't think it's impossible. But what you will need is an angle. And maybe physiatry is that angle. Dr. Oz has that whole I'm a heart surgeon thing going on. Are Andrew Weill & Deepak Chopra general doctors? I dunno. Anyways, my point is that you will be spending enough time explaining to the public (both medical & lay) what integrated med is. Really consider if you want to also explain what physiatry is. You should spend some time in the PM&R forum reading about some of their concerns. Every field's got theirs & I don't think PM&R's are minor.

 

[oxytocin]

That's a good point about PMR. I think it is incorporated into the wellbeing of a patient, but probably not as easy to promote integrative med over a FP. In addition, I noticed that santa rosa has an integrated med program. Anyone know much about their fm or integ med fellowship? It seems flexible but I read that they take calls too? That's a bit odd to me.

On a side note, has anyone done an integ med rotation anywhere? I'm curious to if anyone met drs who are starting off the practice and how much of what they learn in their fellowship gets implemented.

 

[Doctor Grim]

It is exciting to see health care providers interested in Integrative Medicine, especially medical students.

Many Americans are willing to pay out of pocket to seek CAM therapies because they realize that their needs are not being met by conventional treatment modalities. In reality, more money have spent on CAM therapies per year by Americans out of pocket than all health care dollars in primary care.

What is health? WHO defines it as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." How many times have a patient complains that he or she isn't feeling right and we tell them they're fine (and it's in his/her head) just because all the labs come back normal? By definition, we are practicing euboxic medicine.

I'm a board certified family physician and a fellowship trained geriatrician. While practicing allopathic medicine, I realized that conventional medicine is excellent for acute and life-threatening conditions. But low cost, less invasive, and scientifically sound alternative modalities, with or without combining with mainstream medicine may be better for certain chronic illness. And chronic pain being one of them. So my experience inspired me to pursue further training in Integrative Medicine.

I'm a current fellow in Integrative Medicine at the University of Arizona, a program directed by Andrew Weil, MD. There are 2 classes per year and there are 65 primary care physicians in my class, with about 1/3 of them coming from academic institutions such as UCSF, Oregon Health Sciences, Mayo Clinic, University of Maryland, Duke, Emory, University of Cincinati, a couple from osteopathic medical schools, etc. The majority of my classmates are family physicians, a couple are cardiologists, a few pain specialists, a few rheum, a few ID docs, a few gyn, 2 psychiatrists, and one surgeon. The pain docs enrolled because they want to widen their practice but also they felt like additional training can help them deal with some primary care issues.

So IM is getting popular among academic institutions. There are -40-50 academic center in N. America with an Academic Center for Integrative Medicine and these are very reputable institutions.

There are I think at least 9 FM programs in the US now that are piloted to provide integrative medicine in residency training. It might be 4 yrs as opposed to the traditional 3. So you won't have to go through an additional 2 yrs like I do after I've completed my FM residency.

I think in the next 10-15 yrs, if primary docs don't do something integrative, they will be pretty hard to compete with those who do and might be out of business. And integrative medicine is NOT complementary and alternative medicine but rather the combination of evidence based mainstream and CAM therapies to treat the whole person taking into the account the patient's body, mind, spirits, lifestyle, and community. IM docts neither discount mainstream medicine nor accept CAM uncritically (unlike naturalpaths). You don't impose IM on your pt's unless it fits their beliefs. You pretty much cherry picks what's best in mainstream and what's best in CAM and apply them to your patients based on their beliefs. I have no problem giving my patients a 3-5 day course of antibiotics for their UTI, for example, but it is how you integrate their care that is the most importnat so that they don't develop another episode in the future.

Opportunities are out there. Many hospitals are looking to develop integrative medicine clinics or programs. They are looking to improve care quality, patient satisfaction, and perhaps decrease ER visits and hospitals stays. An inpatient consultation service may decrease the length of stay esp on the surgical ward or oncology ward.

Also many family medicine residency programs are looking for fellowship trained IM docs to help them develop IM curriculum and perhaps creating an IM fellowship in the long run. I see some residency programs already have IM month blocks built in to their training curriculum. And an IM elective is also available for medical students in some institutions.

Years ago when I was interviewing for residency and I had no problems disclosing my interests in IM. The key word is IM, not CAM. I wasn't interested in practicing CAM but rather how to draw the best treatment modalities from different therapeutic systems. Some programs told me that I didn't know what I wanted to do with my career and I said thank you and moved on. Some programs were very interested so I ranked them. And I was glad I matched to my first choice where they were open minded and were very interested. As a matter of fact, the program director and associate program director are now certified to do acupuncture and they have an acupuncture clinic now. They've also instututed the month block for all 2nd yr FM residents.

I don't think of it as a subspecialty and I don't want IM as a subspecialty. It should really be the foundation of routine medical care. Yes, you might make a lot of money with it after you complete your training and there is nothing wrong with it, but I think even the underserved and indigent patients deserve it. And it might lessen the burdern on our current dysfunctional health care system just because IM docs are trained to use low-cost interventions when appropriate.

As you can see, it's early and my thoughts are not that coherent. But I can go on and on about it after experiencing first hand the limitations of conventional medicine in treating most chronic illnesses. All we're doing is giving patients meds and more meds. After all, this is a pharm driven industry. I think Osler once said the first duty of a physician is to educate the masses not to take meds or something like that.....and I think doctor in latin means teacher. But we're not teaching people how to be healthy. And I think medicine in latin originally means an art, it was never meant to be drugs....

Feel free to pm me.

 

[deleted87716]

There are only two kinds of therapies: those that work, and those that don't. Utilize the former, and don't kid yourself (or your patients) about the latter.

Call it whatever you want, but it's all "medicine."

 

[Doctor Grim]

There are only two kinds of therapies: those that work, and those that don't. Utilize the former, and don't kid yourself (or your patients) about the latter.

Call it whatever you want, but it's all "medicine."

I agree with you. This is the beauty of Integrative Medicine where you could draw and use any safe and yet effective treatment modalities from all healing systems.

This is a very interesting article about Milk Thistle. Also alpha-lipoic acid (more so in the IV form) has been approved in Germany for treatment of DM neuropathy. I wonder why we just keep on prescribing narcotics.

http://www.santacruzsentinel.com/ci_11432584

 

[GoodmanBrown]

If I choose FP, I am wondering how realistic it would be for me to work 9-5 M-F, with no call and to be able to spend longer times with the patients. I worry that being in the primary care setting, I will be overwhelmed with the volume of patients, paperwork and other administrative things that take a lot of time and energy and are not compensated for...

Also, I am wondering what the salaries are for FP faculty and what their lifestyle is. I know that some people have become Medical Directors at the Integrative Medicine Centers but I have no idea what their job entails...

I can't at all speak about FP faculty positions, but I do wonder if you'd necessarily see much difference between PM&R and FP in private practice if you're considering IM.

I mean, in both, you would probably have fairly large amounts of cash only business (from acupuncture, perhaps from manipulation, etc.). And with cash only, comes the freedom to schedule patients as desired and worry about fewer administration hassles. The caveat being you still have to pay the bills regardless of specialty, payment method, etc.

So, FP or PM&R both seem like they could accommodate your desire to have fewer patients per day and fewer administration tasks.

 

[deleted87716]

PM&R isn't going to give you the broad-based generalist training that you'll get in FM or internal medicine. If you only want to focus on pain management (e.g., acupuncture, etc.) then you could go either way.

 

[deleted87716]

This is a very interesting article about Milk Thistle.

Not exactly CAM, though...just unapproved in the US. Lots of drugs used in other countries ("natural" as well as synthetic) aren't approved in the US.

Also alpha-lipoic acid (more so in the IV form) has been approved in Germany for treatment of DM neuropathy. I wonder why we just keep on prescribing narcotics.

Aside from the fact that IV therapies are costly and unappealing to most patients, there are a variety of other effective therapies available. I rarely use opioids (the preferable term to "narcotics") for neuropathic pain.

 

[Doctor Grim]

CAM is any treatment modalities not routinely used in mainstream medicine i.e. in hospitals or taught in medical schools. Some modalties have sort of become "mainstream" in the past decade(s).

I wasn't taught about milk thistle in medical school or residency. Then one day a new pt who came in for cholesterol check told me that he's been taking milk thistle as recommended by his previous internist when he was started on a statin for liver protection. Nor was I taught about red yeast rice in training for its potential in lowering cholesterol.

Massage therapy has kind of become mainstream. Maybe acupuncture for certain types of pain.

The fact of the matter is, I ask patients what they want and individualize treatment plans to meet their needs within the scope of evidence-based practice by doing no harm. I would never recommend against chemo for instance if an oncologist recommends it but would work with the patient seeking CAM to minimize the side effects.

Also my patient population plays a role in what I do for them. I care for a lot of frail elderly people and some are on palliative care. So they've exhausted their options and are looking for alternatives to improve their quality of life.

I also tend to work with a "sliding scale" of evidence based medicine in CAM modalities. Those that are proven safe and effective, I will recommend, those that are proven safe but ineffective, I will tolerate if the patient still wants to use it, those that are proven unsafe but effective, I would discourage it, and those that are unsafe and ineffective, I would strongly recommend against it.

Just my 0.02.

 

[deleted87716]

Nor was I taught about red yeast rice in training for its potential in lowering cholesterol.

Red yeast rice is a classic example of how natural therapies are frequently misrepresented as safer or more effective than conventional therapy.

Red yeast rice is a naturally-derived statin, roughly equivalent in potency (in usual doses) to around 2.5mg of lovastatin (the weakest statin). It has the same potential side effect profile as the statins, but with an unpredictable effect due to the lack of regulation of purity and potency in the supplement industry.

If you're going to use red yeast rice, you'd be better off taking low-dose lovastatin. At least its effect is predictable. Lovastatin is typically cheaper, too. The only advantage red yeast rice has is the notion that it's "natural."

 

[lowbudget]

I have been really discouraged from going into FP by my own family and multiple FMG family practice residents 🙁 So disappointing.

Losers.




The field most open to even discussing or considering CAM is FM. Physical medicine (and included in there physical therapy, modalities, chiropracter, OMM) is only a subset of integrative medicine. You ignore all the other alternatives that affect the brain, heart, lungs, prostate, hormones, etc.

Hell, even our review journal, American Family Physician, will throw in articles about Complementary Alternative Medicine (just search those terms) and they make up a regular series of articles that's published in AFP.

How about this... CAM topics like primose, ginseng, milk thistle actually appear in your in-training exam and our board exam. How's that for an open minded field that is at least willing to study, review evidence, and debate the topic? I'm not aware of any other medical fields that go to that extent to educate their residents on integrative medicine than FM.

What the hell is there to discourage? One, and two, why do you care what those people think? So what if you pick FM? If validation and social acceptance is what you are looking for, you're unlikely going to find it in FM... but you sure hell won't find it in integrative medicine.

Have the courage to stand alone. Who knows, you may be right all along.

 

[oxytocin]

I'm a current fellow in Integrative Medicine at the University of Arizona, a program directed by Andrew Weil, MD. There are 2 classes per year and there are 65 primary care physicians in my class, with about 1/3 of them coming from academic institutions such as UCSF, Oregon Health Sciences, Mayo Clinic, University of Maryland, Duke, Emory, University of Cincinati, a couple from osteopathic medical schools, etc. The majority of my classmates are family physicians, a couple are cardiologists, a few pain specialists, a few rheum, a few ID docs, a few gyn, 2 psychiatrists, and one surgeon. The pain docs enrolled because they want to widen their practice but also they felt like additional training can help them deal with some primary care issues.

I was actually reading about that fellowship last night! It states that tuition is 30k for the fellowship. I'm surprised at the cost since most of it is conducted online and there's 1-2 sessions where you actually meet in person in AZ. When I was first reading it, I wasn't sure how much I would get out of it. What's your personal experience of the program? Did they ever followed up on other graduating fellows to see what they ended up doing with their careers?


In addition, is it possible to skip a fellowship all together and still do integrative medicine? I was considering practicing after my residency and using seminars to adjunct my practice. I'm not sure if patients look strongly at that 1-2 year of fellowship or if they just appreciate the concept of integrative medicine in a family practice setting. Any thoughts on this?

 

[IntegrativeMed]

Thank you all so much for your input! I really really appreciate, especially since the rank list deadline is nearing!!! The reason why FP is more appealing to me than PM&R is that FP is more general. I like most of the organ systems and cannot say that I'm only interested in MSK. The problem during med school, if you can call it a problem, that I liked most of my rotations, with the exception of some Gyne Surgery, Emergency Medicine and some aspects of Internal Medicine. I really love some of the medicine subspecialties, such as Cardiology and Endocrinogy...and there is so much room there for integrative modalities...However, the thought of going through the traditional Internal Medicine makes me want to turn inside out...I feel like that would set me back a lot in my journey towards integrative medicine, but at the same time it would earn me some respect as an expert... I guess I could always switch into Internal Medicine, if FP really does not work out. A lot of people also argue that if I am so indecisive about the best field and not particularly interested in pediatrics and obstetrics (and I don't mind those aspects, but can do without them),I should just do internal medicine, because from there I can either specialize or stay in primary care and do integrative medicine if I wanted to.

Since I have a strong interest in the Endocrine system, I wonder how much I can focus my practice on that as an FP or would I have to ship my best cases off to a specialist...
Also, is there any word out there about how much Integrative Med Faculty make?? I love to teach.

Please feel free to PM me! Thank you all so much!

Oh and by the way, the fact that people do not know what PM&R is, is not really a big concern to me. A lot of people still don't know what DO doctors do. For me, it's not about the name 🙂 and I don't mind explaining. I think rehab is a wonderful field and I would be happy doing it, but I see myself as more dedicated to caring for the whole person... I guess it also comes down to whether or not I want to view being a doctor as a job that pays bills vs. something that I'm really excited about and cannot wait to get to work every day. However, I also know that I will not be very excited if I am working crazy hours, not sleeping through the nights because of calls, and not being able to see my family and friends...Plus, when you're somebody's primary care doctor, they call you for every little thing...and you have to fill out a ton of different forms and to follow up on every little test result.

 

[Doctor Grim]

I was actually reading about that fellowship last night! It states that tuition is 30k for the fellowship. I'm surprised at the cost since most of it is conducted online and there's 1-2 sessions where you actually meet in person in AZ. When I was first reading it, I wasn't sure how much I would get out of it. What's your personal experience of the program? Did they ever followed up on other graduating fellows to see what they ended up doing with their careers?


In addition, is it possible to skip a fellowship all together and still do integrative medicine? I was considering practicing after my residency and using seminars to adjunct my practice. I'm not sure if patients look strongly at that 1-2 year of fellowship or if they just appreciate the concept of integrative medicine in a family practice setting. Any thoughts on this?

The IM fellowship at UA is the best IM fellowship there is. The faculty members, led by Dr. Weil, are top notch. These are experts in their fields who are nationally well known and respected. You're not going to get anything better than this.

The training is 1000 hours. You can learn to play piano really well if you put in 1000 hours. A lot of it is online but the educational experience is very innovative. You have to take a final exam at the end of each quarter, usually every 2-3 months. It is highly interactive, with faculty members as well as your classmates. The diversity in your class is definitely a plus as you'd always learn something new from one another.

The residential weeks are amazing. I was there at the end of Jan and it was very fruitful. Your schedule is tight, usually your day begins at 6:30 where you have the option of doing yoga, tai chi, or heart meditation. Then classes will begin and they're very hands on. You will get to experience all sorts of evidence based CAM modalities.

Once you begin your fellowship, you have access to the campus website. You will have contact information for all of the fellowship's previous alumni. There are a lot of influential physicians who head their academic departments. You could join special interests groups as well, ask questions as curbside consult, and you will get responses from integrative experts in the field.

Check out the Bravewell scholarship. Many of my academic colleagues are funded through it, including two GPs from the UK. Some FM residency programs or fellowships will also fund this education. There are 2 residents in my class who started out in their PGY2 year and there is one cardiology fellow from Scripps in San Diego. Some classmates had their hospital or group fund their education and in return they will help develop a program at their work.

Is it worth $30K if you were to pay out of pocket, like a lot of my private practice classmates? I think so. My colleagues say it's the best investment they've ever done. One colleague physician, who's a 60+ family physician/geriatrician said he now feels like his medical education has been completed.

Another classmate of mine who is a FM faculty at UCSF and attends to the IM clinic at the Osher Center is already an expert in IM through personal experience. However, he joined because he wants to do what he does better.

The Az Center for IM at UA leads the Consortia of Academic Center for IM in North America. These centers are located in top medical schools i.e ucla, ucsf, harvard, duke, hopkins...you get the point. There are approx 50 centers in N. America. In order to have a center, sr. leadership of the medical school must pledge to support IM and also the center must fulfill its responsibility in research, education, and provide clinical services (I think at least 2 out of the 3 above). So your fellowship experience and certificate will be valued. If you're in private practice, you can advertise however you want to attract patients. However, in academia or hospital systems, they want you to demonstrate expertise by having trained in a fellowship. I've come across a lot of ads looking for fellowship trained IM docs to join their concierge practice. So I guess it will not hurt you to have a legitimate certificate.

You can learn all sorts of CAM or IM on your own. But you may not get the whole systems approach thoroughly. You will also be missing out in terms of the network and the friendship with people who are like-minded like you.

There will always be people who are dubious of IM or CAM in general. But again, your job is to do what is right for your patients and patients WANT this. Otherwise Americans wouldn't spend billions out of pocket per year to use CAM. Your job as a IM doc will be to lead them away from unproven therapies and charlatans.

I'm a faculty at a huge academic center, within the dpt of medicine. My colleagues are interested and supportive of what I do, including my division chief. So I don't really think it matters whether your in fm or im for that matter.

 

[Doctor Grim]

Red yeast rice is a classic example of how natural therapies are frequently misrepresented as safer or more effective than conventional therapy.

Red yeast rice is a naturally-derived statin, roughly equivalent in potency (in usual doses) to around 2.5mg of lovastatin (the weakest statin). It has the same potential side effect profile as the statins, but with an unpredictable effect due to the lack of regulation of purity and potency in the supplement industry.

If you're going to use red yeast rice, you'd be better off taking low-dose lovastatin. At least its effect is predictable. Lovastatin is typically cheaper, too. The only advantage red yeast rice has is the notion that it's "natural."

I totally agree with you. But what are your options when your patients refuse to take prescription medications and only want something "natural?" Meds are only effective when people take them.

I may be wrong, but I think the FDA banned OTC RYR that contain statin like properties in early 2000s. And I have patients who take OTC RYR now whose lipids are now normalized. Could there be anything else in RYR that are responsible for this? I don't know.

 

[oxytocin]

Thank you all for your input. Very helpful to read it all and hear first hand from someone who has gone through the process of fellowship. Does anyone have feedback about the Santa Rosa fellowship too?

 

[deleted87716]

I totally agree with you. But what are your options when your patients refuse to take prescription medications and only want something "natural?"

I document their refusal to follow my recommendations and attempt to talk some sense into them. Whether or not I support whatever option they prefer depends on the situation.

We're in the business of giving people what they need, not necessarily what they want. If people just want feel-good "medicine," they can go get a massage.

I think the FDA banned OTC RYR that contain statin like properties in early 2000s.

No. Naturally-occurring red yeast rice contains a substance called monocolin-K, which inhibits HMG-CoA reductase. For this reason, there have been squabbles with the FDA over the years as to whether or not RYR should be regulated as a pharmaceutical, but it's still out there.

your job is to do what is right for your patients ... Your job as a IM doc will be to lead them away from unproven therapies and charlatans.

I agree. However, there's a fine line between doing this correctly and becoming part of the problem. It's a slippery slope.

 

[Doctor Grim]

Thank you all for your input. Very helpful to read it all and hear first hand from someone who has gone through the process of fellowship. Does anyone have feedback about the Santa Rosa fellowship too?

http://www.srfmr.org/fellowship.php

This program is pretty new but the fact that you get paid to do a fellowship is wonderful. The CME allowance is very attractive, it may allow you to attend some of the conferences hosted by the Consortia of Academic Centers for IM or attend some workshops in Tucson, Az at UA.

One of the program directors, Dr. Wendy Kohatsu is an alumni of my IM fellowship. So if you decide to join, you're in good hands. I'm sure the didactics would be great.

The fact that the program is affiliated with UCSF and you actually get an appointment from UCSF is great. I guess during the fellowship you will also pick up some leadership and administrative skills.

I don't know how far Santa Rosa is from SF but you might be able to arrange some time away to see how the Osher Center functions at UCSF and what their IM attendings are doing as a fellow.

90 minutes for each patient encounter is excellent 👍 You will get ample amount of time to do whatever you would need to do with the patients.

Normally people think IM is available to the elitists because only they could afford it. It is wonderful to see that it is now available for the underserved as well.

That's about all I'm going to say.

 

[oxytocin]

Thank you for your feedback. I think the IM field is growing fast and it's great to hear that it's not seen as complete "voodoo" by the general public.

 

[Doctor Grim]

Lots of medical schools and FM residency are now incorporating some sort of CAM/IM curriulum into their educational programs. AFP also has periodic evidence-based articles dedicated to CAM. So yes, IM is becoming more popular.

The IM fellowship at UA trains approximate 140 physicians per year. These physicians will then teach or train others either formally or informally.

Like I said before, in about 10-15 years, most primary care physicians will have some personal experiences with CAM/IM. One of the goals of the Consortia of Academic Centers for Integrative Medicine is to put IM into every FM residency programs in the next decade.

Here is a list of all the centers in North America.

http://www.imconsortium.org/members/home.html

You can also google David Eisenberg, MD at Harvard or go to pubmed and read some of his publications. Patients oftentimes don't disclose CAM use to their physicians not because they are afraid of disapproval by their docs but rather they're afraid that their docs won't know what to do with their CAM use and integrate these modalities into their care.

So I think in 10-15 years, if you have two board certified primary care physicians, one with training in IM and the other not, most patients will probably pick the former in general unless he or she is a total jerk.

 

[digitlnoize]

I vote that we start calling it IGM. IM is too easily confused with IM. See?

 

[jl lin]

Lots of medical schools and FM residency are now incorporating some sort of CAM/IM curriulum into their educational programs. AFP also has periodic evidence-based articles dedicated to CAM. So yes, IM is becoming more popular.

The IM fellowship at UA trains approximate 140 physicians per year. These physicians will then teach or train others either formally or informally.

Like I said before, in about 10-15 years, most primary care physicians will have some personal experiences with CAM/IM. One of the goals of the Consortia of Academic Centers for Integrative Medicine is to put IM into every FM residency programs in the next decade.

Here is a list of all the centers in North America.

http://www.imconsortium.org/members/home.html

You can also google David Eisenberg, MD at Harvard or go to pubmed and read some of his publications. Patients oftentimes don't disclose CAM use to their physicians not because they are afraid of disapproval by their docs but rather they're afraid that their docs won't know what to do with their CAM use and integrate these modalities into their care.

So I think in 10-15 years, if you have two board certified primary care physicians, one with training in IM and the other not, most patients will probably pick the former in general unless he or she is a total jerk.

Or they don't b/c they fear their physicians will poo poo them, even when in Europe and other areas, CAM and naturopathics have been used well for years. Of course there are many aspects of this to consider; but we can't ignore the cost of meds and the FDA requirements and costs to get them to the point of use.

There is a legitimate tug of war between using certain naturopathic substances versus those that have had to go through the expense and long-term pluses and minuses of FDA approval. There are no easy answers here in terms of effectively finding ways to validate safety across the board. If money can't be made after approval studies, things that could be of great value in terms of both safety and efficacy, overall are SOOL as treatments. So then it comes down to politicoeconomical issues. It's sad.

If, as a physician, a person is hard set against CAM and naturopathic approaches,etc, I say openly let your patients know about it; but then be kind and not dismissive of them so that they will openly share what they are using. There are safety issues all the way around that need to be considered. As a RN I can say without a doubt that patients are often fearful of physicians opinions--what they will think of them--to the point that they get intimidated, and when you encourage them to write down their questions for the physicians, they still get all tripped up. Half the time, they only come out understanding a small portion of what the physician has said to them. *sigh*

I'm sorry. I can't get all negative with CAM and the like and neither can I be all , one-way, positive about it.
What I can get on board with is incorporating more wellness teaching into medical practice. People will get information and make their own decisions. Practitioners need to know what is going on in these areas, and IMHO, they need to be more opennminded in learning about CAM.

And there is one thing that most can't ignore, and that is that wise, regular exercise can kick the butt out of taking certain prescription meds and alternative meds many times. Regular exercise is a "wonder 'drug'" in itself. Sure there is an issue of compliance; but to me, part of that has to do with what is presented to the patient and how it is done by the attitude and example--that is, the approach and philosophy of the practice. I mean you are not going to see Dr. Oz take a wishy-washy view on these kinds of things--especially in promotion of wellness as it pertains to exercise. He's not standing up there out of shape, unable to climb stairs, espousing health and wellness principles while having a dangerous BMI.

OK, so, as an example of the benefits of sound wellness practices I share this. I've never been lactose intolerant, and I've loved cow's milk my whole life. However, I followed one naturopath's recommendations regarding limiting bovine in my diet--cow's milk--caseine. When I do this I unquestionably have less problems with my sinuses and joints and muscles. Now I love to cook, and I love cheese. But when I stick to harder cheese or 9mo. aged Manchengo sheep cheese, I have less h/a s and less arthalgias and myalgias. Same thing with beef. If I limit that, I actually do feel better.

Now I have been allergy & imm. tested up the whazoo by renowned allopathic specialists in the Al & Imm. field. They end up telling me, LOL, "I'm sensitive but not allergic." OK. Whatever. Nothing, however, that they ever did for me helped me. Eliminating bovine protein, as directed by a reputable naturopath (that has worked with patients in this regard and with good success for decades), helped me enormously--as in seriously different quality of life enormous.
Also, the great thing about this particular naturopath is that she practices what she preaches and in that is a great example to her patients. They take wellness seriously b/c she takes it seriously.

Much of wellness and even CAM is about making the patient take ownership of their own health and wellbeing. I applaud that, seeing that there can be so many pts that are just generally noncompliant and need to see that much of getting well is up to them. Yet there they are. They take the doctor's time making them repeat things, and they doctors are frustrated by these patients not following through. It's not any one physician's responsibility to write a magic script or perform a procedure and make a person truly well. Wellness is a lifestyle choice.

I've often said as an open heart recovery ICU RN when I worked with adults, that CABG, for example may absolutely be necessary. It does NOT, however, cure the coronary artery disease process--the things that caused damage to occur in the first place. One surgeon was tempororaily annoyed with me for presenting this view, until he stopped and reconsidered what I was saying.

Yes, hell yes. If a patient needs the surgery they had better get it. But the things that are controllable that brought them to that point must be addressed. Graft occlusions and such are not unheard of for God's sake.


It is clear there will always be a need for allopathic medicine. I think integrative medicine can be a postive thing as well. People may well be able to benefit in having their practitioner draw from more than one sensible arsenal. Safety is the key there. But also, efficacy matters as well.

````

 

[Doctor Grim]

Or they don't b/c they fear their physicians will poo poo them, even when in Europe and other areas, CAM and naturopathics have been used well for years. Of course there are many aspects of this to consider; but we can't ignore the cost of meds and the FDA requirements and costs to get them to the point of use.

There is a legitimate tug of war between using certain naturopathic substances versus those that have had to go through the expense and long-term pluses and minuses of FDA approval. There are no easy answers here in terms of effectively finding ways to validate safety across the board. If money can't be made after approval studies, things that could be of great value in terms of both safety and efficacy, overall are SOOL as treatments. So then it comes down to politicoeconomical issues. It's sad.

If, as a physician, a person is hard set against CAM and naturopathic approaches,etc, I say openly let your patients know about it; but then be kind and not dismissive of them so that they will openly share what they are using. There are safety issues all the way around that need to be considered. As a RN I can say without a doubt that patients are often fearful of physicians opinions--what they will think of them--to the point that they get intimidated, and when you encourage them to write down their questions for the physicians, they still get all tripped up. Half the time, they only come out understanding a small portion of what the physician has said to them. *sigh*

I'm sorry. I can't get all negative with CAM and the like and neither can I be all , one-way, positive about it.
What I can get on board with is incorporating more wellness teaching into medical practice. People will get information and make their own decisions. Practitioners need to know what is going on in these areas, and IMHO, they need to be more opennminded in learning about CAM.

And there is one thing that most can't ignore, and that is that wise, regular exercise can kick the butt out of taking certain prescription meds and alternative meds many times. Regular exercise is a "wonder 'drug'" in itself. Sure there is an issue of compliance; but to me, part of that has to do with what is presented to the patient and how it is done through, by and large, with the practice--it's approach and philosophy. I mean clearly you are not going to see Dr. Oz take a wishy-washy view on these kinds of things--especially in promotion of wellness as it pertains to exercise.

OK, I've never been lactose intolerant. However, I follow one naturopath's recommendations regarding limiting bovine in my diet--cow's milk--caseine. When I do this I have less problems with my sinuses and joints and muscles. Now I love to cook, and I love cheese. But when I stick to harder cheese or 9mo. aged Manchengo sheep cheese, I have less h/as and less arthalgias and myalgias. Same thing with beef. If I limit that, I actually do feel better. Now I have been allergy & imm. tested up the whazoo by renowned allopathic specialists in that field. They end up telling me, LOL, "I'm sensitive but not allergic." OK. Whatever. Nothing, however, that they ever did for me helped me. Eliminating stuff as directed by someone (reputable naturopath) that has worked with patients in this regard and with good success for decades, did a lot more to help me. The great thing about this particular naturopath is that she practices what she preaches, and in that is a great example to her patients.

Much of wellness and even CAM is about making the patient take ownership of their own health and wellbeing. I applaud that, seeing that there can be so many pts that are just generally noncompliant--yet they take the doctor's time making them repeat things and not following through. It's not any one physician's responsibility to write a magic script or perform a procedure and make a person truly well. Wellness is a lifestyle choice.

I've often said as an open heart recovery ICU RN when I worked with adults, that CABG, for example may absolutely be necessary, BUT it does NOT cure the coronary artery disease process--the things that caused damage to occur in the first place. One surgeon was tempororaily annoyed with me for presenting this view, until stopped and reconsidered what I was saying. Yes, hell yes. If you need the surgery you better get it. But the things that are controllable that brought you to that point must be addressed. Graft occlusions and such are not unheard of for God's sake.

It is clear there will always be a need for allopathic medicine. I think integrative medicine can be a postive thing as well. People may well be able to benefit in having their practitioner draw from more than one sensible arsenal. Safety is the key there. But also, efficacy matters as well.

Great post.

Again, Integrative Medicine is NOT CAM. I'm not a proponent of CAM but I advocate for IM where you'd cherry pick the safe and effective treatments from all healing systems to recommend to patients based on his or her personal beliefs taking into account the well-being of his or her mind, body, and spirit. If a mild-moderate depressive patient wants a SSRI, I will prescribe a SSRI. If he or she wants to explore more natural therapies, I may recommend St. John's Worts (studies have shown that it is better than placebo and as good as sertraline for mild-moderate depression) + mind-body approaches.

Yes, there will always be a need for allopathic medicine. That's why I went to an allopathic medical school and not oriental medical schools or naturalpathic medical schools. But allopathic medicine is mostly effective for acute and life-threatening conditions. If I were involved in a severe car accident or had a MI, I would want to be treated at the best ER with all the high tech equipment.

Herbs and botanicals are NOT major components of IM. Other modalities include acupuncture/acupuressure, massage, OMM, aromatherapy..etc. These are essentially safe. I would never recommend substituting conventional treatment with CAM if the former is appropriate and necessary. But I would work with the patient in integrating effective and safe CAM into his or her care to ensure that the patient is well in terms of his or her mind-body condition and not merely because he or she looks good on labs (euboxic medicine).

The major component of IM is a healthy lifestyle promotion which includes proper nutrition and exercise. Other components also include allopathy, osteopathy..etc. We as physicians are not doing a good job in educating our patients about it. If fact, I wasn't taught what a healthy diet is when I was in training. And I soon realized that the more I tried to talk to my patients, the more I didn't know what I was talking about.

Diets are important. I advocate for whole foods. And everyone should be on an anti-inflammatory diet such as the Mediterranean diet. All disease processes are due to 1) inflammation, 2) oxidative stress, 3) cryptic infection, and 4) impaired repair or regeneration. So if you eat right, you pretty much lessen the risks of 1 and 2. But we have to admit, sometimes regardless of what we need, some of us would still need supplements--Vit D for one.

And by eliminating some things in the diets as you mentioned, you can alleviate some dis-ease in patients. I have had some great success in helping children with asthma and eczema by having them eliminating caseine and glutun and soy and by adding omega-3s (DHA>EPA) into their diets and now they wouldn't have to rely on synthetic meds such as steroids.

Prevention is really the key. I wish we have a health care system rather than a disease care system where we are reactive to bad things once they have occurred due to poor lifestyle decisions.

 

[deleted87716]

All disease processes are due to 1) inflammation, 2) oxidative stress, 3) cryptic infection, and 4) impaired repair or regeneration.

Not to be argumentative, but...evidence, please?

Anytime someone says "all" (as in "all disease processes") my B.S. detector goes off. Yours should, too.

I advocate for whole foods.

Based on what? What's a "whole food?*" As in, "I can't believe I ate the whole thing?" That's sorta the problem with most Americans, now, isn't it? 😉

I wish we have a health care system rather than a disease care system where we are reactive to bad things once they have occurred due to poor lifestyle decisions.

And I wish I had a million dollars.

"Hot dog!"

*Edit: I do know what a whole food is, BTW...I'm just being a smartass. 😉

 

[jl lin]

Not to be argumentative, but...evidence, please?

Anytime someone says "all" (as in "all disease processes") my B.S. detector goes off. Yours should, too.



Based on what? What's a "whole food?*" As in, "I can't believe I ate the whole thing?" That's sorta the problem with most Americans, now, isn't it? 😉



And I wish I had a million dollars.

"Hot dog!"


*Edit: I do know what a whole food is, BTW...I'm just being a smartass. 😉

It is true. "All" is like "always." One of those alarm words. While there are congenital disorder that may have something to do with preventable, wellness, types of issues, there are those, genetically speaking, that do not--at least not yet. Mom and even dad can come from good stock (that they knows of). They can live clean, healthy lives, have had good healthcare their whole lives, do everything right, and boom. There is the child that I am preparing to stage for cardiac surgery or treatment for some unusual genetic disorder. No one really knows why.

But I think the point is well taken that inflammatory states are associated with many kinds of illness, both acute and chronic. I have an autoimmune disorder that been complex--inflammation can be a chronic state. I have to do all that I can to maximize balance in my immune system--part of that involves, yes, once again, exercise. Of course I can't push it too far on the other end either. You eventually find out what works for you. I say just stay open to things that may be helpful or relevant. Judicious uses of Mg++ has helped me reduce pain. Yet, though I have to be careful, mostly good ole ASA works best at reducing pain and inflammation. I tend to hyperclot at times, so it's not so much of a problem--except watching what I take it with and how often; d/t GI reasons. In fact if there weren't time delays in clotting when taking ASA and the GI bleed factor, I'd say this is a pretty good agent to me; but it still has many associated risks. I am careful in how I take it, period. But acetaminophen and ibuprophen and even naproxen don't give me the same inflammatory relief bang for the dosage or buck.


[I personally believe that physicians like Dr's Oz and Roizen are on the right track. I find the other "doctors" (whatever network) miss things. Perhaps it is that they don't clarify things as well as Oz or Roizen. But I also sense a fear from "The Doctors" in terms of straying too far off the allopathic reservation, so to speak. Quality Stevia, for example, is NOT the same as aspartame or sucralose. They recently contended that people will get used to a higher sweetness factor as they take these things. and they didn't mention Stevia or bioflavinoid sweeteners. I can't speak for aspartame or sucralose, b/c I don't use them in terms of getting used to more of a sense of sweetnesss. I will say that other like-minded consumers and I have not found that we need something to taste sweeter b/c of using things like Stevia or Agave Nectar.

In fact, as much as I love maple syrup, I use agave nectar instead, b/c of it's lover glycemic index factor. I used the same small amounts and have done so for years. If anything, I crave less "sweetness," not more. I don't add any sweetners to my fruit for example. Fructose is pletny sweet enough. You can actually get used to less of a sweetness demand by using things like Stevia or Agave Nectar as well as my reducing exposure to high sugar contents in general. So when you are exposed to highly sweetned things, regardless of the source of sweetness, you are actually taken back. Personally I'm an herb and spice user anyway. I believe in dimensions of various flavors--so if something is either salty or sweet and that's it, I'll probably be bored with it anyway. My real point about the Stevia or Agave Nectar and "The Doctors" is that a little does go a long way. So no, we don't find we are using more and more greater amounts of stevia or agave nectar. By ignoring judicious use of stevia, "The Doctors" ignored that what they were hoping to achieve--overall less use of sugar or artifical sweetners (The ones I believe are more on the toxic side of things--Monsanto corp. nothwithstanding) could be avoided. But I do agree that people need to use restraint and just use less things, even sugar in general. I don't use two packets of stevia for my coffee in the morning--lucky if I use a whole one. (OK, my naturopath would be on the side against even the one cup of coffee, lol--even that which is organically grown--she admits its her bias and that she finds that too many folks can't stop at one or two cups.) I don't use stevia with green tea b/c I don't find that it helps the flavor. Perhaps Agave Nectar works better; but now I'm used to drinking my organic green tea w/o sweetners.]





I only wish some mega-wealthy persons would put up money for more extensive research into CAM, naturopathy, etc. But see, how would they make that money back? Thus the pharmaceuticals dilemma. Of course all you have to do also is to look at Monsanto and how they fought to keep their art. sweetner on the market while increasing resistance in the procurement of stevia. Hmmm. I'm all for capitalism, but fair is fair.



But so much of this gets run over b/c of the lack of EBM. The problem with EBM is that there will never be enough money and studies to be helpful enough for people for enough kinds of scenarios or disorders. How many lose out or have lost out b/c of financial-backing when it comes to studies?

Also how will there ever be the opportunity to produce enough incontroversible research for all that would need to be considered in terms of medicine and the individual--or even many variant groups of individuals. I don't know why folks are so quick to utterly dismiss the art side of practicing medicine. People aren't freaking widgets. The holistic approach has its place, b/c people are so unique in terms of responses to things. If anything there are more spectrums of things with individuals and various disorders and responses. I thought the whole point of Integrative Medicine was to try to use the best from both worlds, so to speak.

When it comes to using more wellness practices, and the like, truth is, the money-making potential is not there to afford the studies on a larger scale. So, things that have real potential and may be shown as such over time are SOOL. To me this is problematic.

 

[JaggerPlate]

Interesting thread. I didn't know there was such an interest in integrative medicine. I'm wondering, for those who are doing integrated med work (I think Grim said he was in the Weil fellowship in AZ), what are you guys thoughts on the bioidentical hormone replacement and or the HGH injections (or IV err whatever). I've just heard some bad things about HGH, but I don't know if this is more on the anti-aging (A4M) front, or if integrative med uses them too.

 

[deleted87716]

The Skeptic's Dictionary sums things up nicely:

http://www.skepdic.com/integratmed.html

Integrative medicine is a synonym for "alternative" medicine that integrates sense with nonsense. It integrates the scientific with the untested and the discredited. ... Someday we may look back at this period in our history and see the "alternative" science movement as a well-engineered social movement that created a very popular mass delusion on par with the tulip mania of 17th century Holland.

 

[jl lin]

Hmmm, well guess that sums it up for you.

Philosophy of approach does matter, just as, many times the 'art of medicine' matters.

People could argue this to the cows come home. When safety isn't an issue and there is a demonstrated improvement in the quality of life for someone, it should matter. Not everything is some placebo effect.

I guess I don't understand people digging their heals in too much in one direction over the other. Even in allopathic medicine there are different opinions and approaches, a lot. Also, I feel that some may not have bought into sound wellness practices, b/c for some reason, they don't consider consistently incorporating them into their own lives as something they want to do. So it can be easy to take the path of least resistance--even a skeptic's view. And yes skepticism certainly can have its place.

But it's like people are damned no matter what they do. If they just follow along to allopathic referral after referral, take a plethora of "wonderful" FDA approved meds, but only are marginally better and not really well if you will--or perhaps there isn't an improvement at all--and then they get sick of the whole game, and stop complying, they are screw-up, non-compliant patients. OTOH, if they find safe practices that do show them, in their own bodies, on a regular basis that their quality of life is improved, they are whacko pts that were just looking for some effect that they get on board with and be in control over-and so they really do not have all that much wrong with them anyway. *sigh* Now forget that their labs panels show marked improvement when they go to say, their rheumatologist. Forget that they are actually sleeping better and things like the BP and other numbers are much improved. Forget about the fact that they are not getting nearly as many cold bugs and such, and should they get them, they shake them A LOT faster. Forget that they are able to run, exercise, or walk more, work harder, and enjoy an overall better quality of life. Ah what the hell. These people are just wackos trying to control things for themselves. The labs and other data, well, it's all a fluke. It's unfreaking believable. It's predetermined by some that it is all BS. People often know about their own bodies--and this I find is often true for women. They've become adept at sensing regular and significant changes in their bodies from puberty on. Yet they get labeled the most as "wackos" by certain practitioners.


WOW. Until a person is seriously and chronically ill, they don't know what a major burden it is. It's not some fun passtime for which they can play at being their own doctors. Most people don't want to do this. They just want to live their lives with some decent quality of life. Yep. They'd much rather be golfing or fishing or scuba diving too! And they want to enjoy their own work as much as possible. They want get the hell up and live without being sucked dry and pulled down by their particular pain in the azz disorders. Often when it looks like people are going this alternative medicine route, it is b/c they do so out of desperation and necessity. They don't want to be sick and sickness and pain has sucked up a considerable part of their lives and quality of lives.


Oz and Roizen are right. Genetics may load the gun, but lifestyle choices often pull the trigger.



Oh and there is nothing wrong with wise use of natural analogs or bioidentical hormones, if all things are considered in balance, if people are monitored correctly by reputable people, and if the pt meets the safety zone criteria for such things in the first place.

My naturopath comes from a long line of folks with chronic disease that died young. She wised up, educated herself, began employing sound wellness, and she is 78 years old and can run circles around any 20 year old that comes into her office that I've seen. She works full-time Monday thru Friday and every other weekend included. Sure she knows that she, like others are not going to live forever. But she is determined to be as healthy and live as much in a state of wellness as she possibly can, and it shows. She is a person of great integrity and high ethics. She also understands the importance of 'physician, heal thyself.'

Now, if she is in a car accident, she certainly does want to go to a good trauma center, if that is necessary. And she attempts by no means to take anyone off of their allopathic medical regimes. If, for example, their BP goes down significantly and consistently b/c of wellness practices, weight loss, diet, taking in good omegas and other nutrients, etc, it's up to the patients to discuss what they want to do with those pharm agents with their allopaths.


Now as far as testing and research is concerned, I'd put more faith in it if there wasn't this huge, glaring issue of cost recovery. I'm not against it. Don't get me wrong. And I am not saying that pharms shouldn't recover their investment. But it is sad from a purely scientific standpoint that other things of a more natural state, which in some cases may be equal to or even better in terms of being supeior in overall safety and efficacy profiles, are NOT tested as well b/c no one can really make decent bank $$$ recovery by doing so. Please don't assume incorrectly. I'm a capitalist. But there is a glaring problem with limiting fair investigation and research based on what bank recovery you can get out of it. And even when some of those pharms from major pharm companies have gone through the whole costly processes for approval, there have been several pharm agents that have had to be pulled or are causing concern for folks.

Western allopathic medicine is good at diagnostics and use of surgical and innovative interventions, but in terms of helping to increase quality of life in terms of wellness for folks, especially those that have chronic diseases, well it knows darn well that it falls short. This is no revelation to anyone in 2010.

And we'll never have enough money to test everything perfectly well or even close to it. Thus if you use sound safety to efficacy and monitoring practices, it isn't necessary to deprive patients of other approaches that may significantly increase their wellness, if they are consistent and followed correctly.

And have you spoken to some patients lately???? They are tired of running around, circling their lives around physician visits, juggling how they can afford to pay for certain pharmaceuticals, and fighting with their insurance carriers for promised coverage.

Don't misread me for someone that is behind the Obamacare agenda. I am so not. I have a problem with expanding government to far into people's lives, etc. Also, I know what it is like to have to go back and forth again and again with insurance companies. As much as a MAJOR pain in the BEhind as that is, I still know that I was able to negotiate out with the PI and still get what is needed, as contrasted with being told hands down, "tough, you will get what we 'give' you" by some government controlled system that sees me more as a drain than anything else. I understand what a gov't system, especially in a country like ours will mean in reality.

But people must get over their rigidity and explore things more openly. I wouldn't call Drs Oz and Roizen 'alternative movement tooty-fruities" for the love of God.


We are getting backward though if we don't start to look at things that we can change to promote wellness. People don't want to live their lives always going back and forth to doctors. It's not even like the days when a person could see a physician have a lot of their labs drawn in the office, or limit all the goofy hoops in order to meet the diagnostic work-ups. Everything is farmed out to somewhere. And then one group of specialists don't like the labs from another place that physicians have used. It gets to be all-consuming and ridiculous. People don't want to live this way if they can help it.

 

[deleted87716]

I'm not here to debate you, and I'm not about to respond to you point-by-point. I don't have that kind of time.

I'm a family physician. I "get" the whole "wellness thing." I prescribe lifestyle modification on a daily basis. I don't believe there's a pill for every ill. I use conservative (non-drug) therapies whenever possible. I even recommend (judiciously) certain vitamins and supplements, when it's appropriate.

However, I'm not about to buy into the "integrative medicine" movement hook, line, and sinker. The term "movement" suggests motion in some direction, and in the case of integrative medicine, that direction is away from science and towards what essentially amounts to religion (belief without evidence).

That, my friends, is a slippery slope to quackery.

 

[digitlnoize]

I'm not here to debate you, and I'm not about to respond to you point-by-point. I don't have that kind of time.

I'm a family physician. I "get" the whole "wellness thing." I prescribe lifestyle modification on a daily basis. I don't believe there's a pill for every ill. I use conservative (non-drug) therapies whenever possible. I even recommend (judiciously) certain vitamins and supplements, when it's appropriate.

However, I'm not about to buy into the "integrative medicine" movement hook, line, and sinker. The term "movement" suggests motion in some direction, and in the case of integrative medicine, that direction is away from science and towards what essentially amounts to religion (belief without evidence).

That, my friends, is a slippery slope to quackery.

I agree with Blue Dog. I will just say this: I am willing to accept that Hippie Plant X is just as valid a chemical compound as Drug Y. That being said, I don't think the research on Hippie Plant X has caught up to drug research yet.

I think we do need people in IM, in order to do further studies. The field is in its infant stages, and until more research is done showing true benefit, I think we could be doing patients a disservice by prescribing the Hippie Plant over the Drug.

I understand that there are people out there who are jaded with the medical system and with drugs and their side effects. I understand that they are a gullible, open market. But I also understand that natural does not equal safe. The natural compounds, if effective, are likely to have similar side effect profiles to the drugs. If, for example, you inhibit HMG-CoA Reductase...it doesn't really matter what did the inhibiting...the effects are likely to be the same.

I do like the idea of people being able to "grow" their own medicine. But I don't think the evidence is there just yet...in most cases. I also think that we're approving drugs too fast and without enough evidence of their efficacy and side effects, but that's another discussion.

 

[deleted87716]

A Short History of Medicine

2000 B.C. - Here, eat this root.
1000 A.D. - That root is heathen. Here, say this prayer.
1850 A.D. - That prayer is superstition. Here, drink this potion.
1940 A.D. - That potion is snake oil. Here, swallow this pill.
1985 A.D. - That pill is ineffective. Here, take this antibiotic.
2000 A.D. - That antibiotic is artificial. Here, eat this root.

😉

 

[Doctor Grim]

Interesting thread. I didn't know there was such an interest in integrative medicine. I'm wondering, for those who are doing integrated med work (I think Grim said he was in the Weil fellowship in AZ), what are you guys thoughts on the bioidentical hormone replacement and or the HGH injections (or IV err whatever). I've just heard some bad things about HGH, but I don't know if this is more on the anti-aging (A4M) front, or if integrative med uses them too.

Bioidentical hormones have been claimed to be "natural" and chemically identical to those made by huamns. But I think it is more of a marketing strategy.

The FDA also has warned several pharmacies that have sold these bioidentical hormones over the internet not to make misleading claims about safety and efficacy. The FDA also said that these bioidentical hormones are no safer than conventional HRT which are synthetic.

The maker of Premarin also asked the FDA to restrict the availability of bioidentical hormones because its sales dropped by approx 50% after huge government-sponsored studies showed that HRT raises risks of breast ca, stroke, and mi.

I have only used HRT judiciously for a very short period of time for peri and post-menopausal women who had very severe symptoms. I like estrace and oral micronized progesterone. Both are FDA approved.

Bioidentical hormones essentially have the same risks as synthetic ones. But perhaps the side effect profiles are better (?). More research is needed.

 

[Doctor Grim]

I believe in the care of the whole person, taking into account the patient's physical body, mind, spirit, lifestyle, and community. And yes, I will consider their religous beliefs too.

I believe in a patient-centered care, pretty similar to the medical home model where a PCP acts like a quarter back and coordinate and integrate appropriate care. I still prescribe hctz and metformin for htn and dm just like every other docs do who practice within the standard of care but with every intention to get them off as soon as possible. In addition to conventional medicine (I don't substitute it), I use a sliding scale of evidence on other complementary modalities. Those that are safe and effective, I will recommend, along with their conventional treatment if there are no adverse interactions, those that are safe but ineffective, depending on the patient's beliefs, I would tolerate it. Those that are unsafe but effective, I would recommend pt to avoid it, and those that are unsafe and ineffective, I will strongly recommend against it. So how am I or other appropriately trained IM docs unscientific?

In IM training, it's not like we were told ok, you can use acupuncture for this, you can use aroma therapy for that and accept it uncritically. We were exposed to research studies and evidence facts. There are 60+ licensed US physicians in my class with 1/3 of them being academians. Do you think we're all gullible and idiotic? I don't think so.

The reality is that the American people are spending billions of dollars annually on CAM. These are out of pocket expenses, unreimbursable. So there got to be some regulations on this because most of these CAM modalities are ineffective and maybe harmful to patients.

The scary thing is that 1/3 of Americans are using CAM and they are not telling their docs that they are using CAM and I'm sure there are adverse drug-herb interactions. And I think this is where IM docs come in.

I won't debate on conventional medicine vs. IM anymore. It's just two different belief systems. I'll leave it to the Americans. This is a great country we live in because people can have their own beliefs and decide.

 

[deleted87716]

I won't debate on conventional medicine vs. IM anymore. It's just two different belief systems. I'll leave it to the Americans. This is a great country we live in because people can have their own beliefs and decide.

See, that's the problem.

Science isn't a "belief system." And most Americans are idiots. Why do you think we're in the shape we're in today (literally as well as figuratively?) Giving them more of what they want is most definitely not the right answer.

To make needed lifestyle changes, most Americans need tough love and a swift kick in the butt, not coddling and indulgence.

 

[Doctor Grim]

See, that's the problem.

Science isn't a "belief system." And most Americans are idiots. Why do you think we're in the shape we're in today (literally as well as figuratively?) Giving them more of what they want is most definitely not the right answer.

To make needed lifestyle changes, most Americans need tough love and a swift kick in the butt, not coddling and indulgence.

So most osteopaths believe in their own system (except some of those who couldn't get into allopathic schools and decided to go that route). Are they less of a physician or unscientific?

 

[Doctor Grim]

To make needed lifestyle changes, most Americans need tough love and a swift kick in the butt, not coddling and indulgence.

You sound exactly like one of my attendings in residency, who was a military officer 😀

 

[deleted87716]

You sound exactly like one of my attendings in residency, who was a military officer 😀

Drop and give me twenty! 😉

So most osteopaths believe in their own system (except some of those who couldn't get into allopathic schools and decided to go that route). Are they less of a physician or unscientific?

Most DOs don't practice OMT once they're finished training, so that should tell you something.

 

[digitlnoize]

So most osteopaths believe in their own system (except some of those who couldn't get into allopathic schools and decided to go that route). Are they less of a physician or unscientific?

I wouldn't call it a belief system. Like Blue said, most DO's don't use OMM anyways, but even amongst those who do, it's mostly limited to techniques that: a) are similar to techniques used in physiatry/physical therapy, b) make sense, and c) are backed up by research and data.

I know cranial is still taught (for some reason) but hardly anyone actually uses it. Many teachers won't even teach it anymore and schools have to ship in "experts" to teach it. It will be gone soon.

OMM techniques in use today are no more than MSK/soft tissue techniques. Would you reduce a dislocated shoulder? That's OMM. I don't call that a "belief system."

Modern medicine works like this (as I understand it): If a technique (be it medical, musculoskeletal, herbal, etc) is shown, using studies of acceptable quality, to benefit a patient with a certain condition, then the technique can be used (or should at least be considered as an option) to treat the patient. If there is no evidence of benefit, then it's probably not ready for the "big time" yet.

 

[sirscrubsalot]

Hey everyone! Well... I figured that I'll come here to "briefly" participate in this discussion 🙂 Now I'm only a mere FMG-MS3 fresh into clerkships right now, so I'm not trying to demarcate lines or take sides or... create a "family feud" for that matter! Over the years, I myself personally have been interested in how I might bring the best of both worlds into future practice - that being in family medicine. I've been fortunate to be surrounded by many people's viewpoints on these topics, and I just couldn't turn my cheek away. That said, for me along with the many interested would probably feel the same way on how and why something "alternative" might or might not work.

I'll hold off on quoting for now because there were many thought provoking replies from both the pros and cons re: to "Integrative Medicine" I'm just here to possibly reiterate and share some of my thoughts, most of which have been touched from the great replies here so far.

So I wouldn't say that CAM or IM is or should be a total replacement for traditional medicine. I'll just use IM for now as these terms shift loosely and are often misunderstood amongst the two at times and to further emphasize, are quite different as Doctor Grim noted. There are always going to be problems where patients are going to require most often, traditionally prescribed medication. However, I feel that there are certain modifications in diet/treatments/methods that can be coupled to or possibly used on its own... provided that there is sound evidence behind to support. That later statement is the kicker though! There just aren't enough quality studies being done or reported to justify. There are many past and emerging IM + CAM-related textbooks & journals published or supported by well known traditional authorities. Some of these texts and journals have references to cite different treatment options to use standalone or in conjunction with regular pharama. One problem though with many of these references to other journal articles and "studies," is to actually weigh how good of a study it was - basically, being able to sift through a "good vs bad" paper to go by. It's tough to get funding with good studies when you have big pharma riding on FDA's back, sometimes preventing such things from ever happening though! Money still talks - 🙄


I wouldn't necessarily go on just by "word on the street" and tell my future patient that this or that will work for them - I'd definitely like to see the true or at least the best of "the how's and why's" trying to back up a claim. It's also important to have that also because it's very difficult trying to introduce and share the material to other physicians who haven't been exposed to the slightest in all things "integrative medicine." I think this is one of the reasons why such things are usually shunned or frowned upon from many in the medical community.

Another thing is, it seems that there are a million and one "guru's" out there - who are they? Are they legit? Very difficult to find the real "go to" sources. It makes it much more difficult when now CAM or IM topics are being shifted to the mainstream - the media has caught on this now, thanks to people like Oprah/ big news health consultants, etc. Big $$$ now to make - supplement industries are thriving more than ever now, making millions of dollars in profit/month - there definitely needs to be some sort of way to educate people better on what they are buying and if it ill work for whatever it is they are trying to "treat or alleviate."

It ticks me off whenever I do go to one of these "natural food/supplement" stores and overhear the conversations of employees (at times, really in good will) giving their take on what they must do - what works for Bob isn't going to work for Nancy. To make it worse, what Bob thinks might work for him might make Bob even worse off in the end - alas the good and bad of the internet - some youtube videos for example, add more fuel to the fire - when I see patients now during my ambulatory month and even at these types of stores - people will look up a problem via the internet and find the first supporting thing they feel best suited for them and usually buy and try it first. So many of these customer reviews are shady, misleading and giving false hope at times.Most often at times, these customer reviews are written so well that anyone can be fooled. There are good companies out there, but it's hard in general to begin sorting through the masses.

It seems from my observations that many patients that come down this road have just been so dissatisfied with their current or past doctors - we need to be able to listen to them and understand why such things have happened and address/discuss these concerns for better solutions. Heh, I witnessed the other day a customer coming in and complaining about their doctor saying they need X medication for their condition. They ended up going on the internet and reading up that X causes this and that side effects - the shop keeper along with a group of nearby listeners all started shaking their heads in disapproval. Poor doc hehe. The shop keeper then said they need this and that - some recommendations possibly being ok, whereas others I couldn't believe my ears - ah what could I do at the time. I probably would have been "tarred and feathered" in the shop if I said I was going to agree with that doctor. 😛

On a positive note, I have shared and discussed my situation with people in similar places and have been welcomed well with warm arms in agreement with my future hopes and views in joining the two together.

I do feel that there are some well used approaches to diet, treatments and methods out there - there are quite of a few integrative family medicine docs sprouting up that genuinely give good care to their patients, and most importantly - the patients themselves are satisfied and really happy with results.

Aside from some universities having small programs within the hospital, I'm aware of Dr. Weil's pilot programs and have always been interested in trying to bridge a route between the two scopes - what we have to learn traditionally through medical school and residency... definitely doesn't always agree or mesh will with the counterpart of it all. It definitely adds another layer to the thought process and really, one has to be seriously interested to take on that challenge too! Still, it's great that these pilot programs are around, and I hope they will take on more emphasis by the time I apply for family. Dr. Weil is making some big $$$ (his restaurants, books and supplement lines) though like Dr. Oz/Dr. Phil and all the other TV health consultants - I just wish at times things wouldn't be so commercialized - but then again, we do have big pharma commercials going on round the clock for how many years now? 😉

I appreciate the comments from both ends of this. Blue Dog definitely has some excellent points that are not to be ignored - and that's great, because we need to look at the big picture without going into "impulse mode" and accepting everything. Jl lin put some well added perspective with which I'll nod with approval on. I can also agree on many of Doctor Grim's approaches on combating some of the mentioned problems because I've been tracking such things for a few years now, especially in terms of diet and when needed, proper added nutrition. A lot of these adjustments can be simply done by modifying what and how we eat. I deal a bit in functional strength and conditioning and have seen the great benefits of this when incorporating just that alone. When used right, IM and even CAM, can be a powerful ally to have. I know that it'll have a place with me in the times to come but will need to proceed with attentive caution. Bottom line, we're all here and strive for the same ultimate purpose - the well being of the individual. Right? 😎

Ah, so much for being "brief."

 

[facetguy]

I agree with Blue Dog. I will just say this: I am willing to accept that Hippie Plant X is just as valid a chemical compound as Drug Y. That being said, I don't think the research on Hippie Plant X has caught up to drug research yet.

I think we do need people in IM, in order to do further studies. The field is in its infant stages, and until more research is done showing true benefit, I think we could be doing patients a disservice by prescribing the Hippie Plant over the Drug.

I understand that there are people out there who are jaded with the medical system and with drugs and their side effects. I understand that they are a gullible, open market. But I also understand that natural does not equal safe. The natural compounds, if effective, are likely to have similar side effect profiles to the drugs. If, for example, you inhibit HMG-CoA Reductase...it doesn't really matter what did the inhibiting...the effects are likely to be the same.

I do like the idea of people being able to "grow" their own medicine. But I don't think the evidence is there just yet...in most cases. I also think that we're approving drugs too fast and without enough evidence of their efficacy and side effects, but that's another discussion.

Substituting a 'green drug' for a conventional drug is not the idea here. Truly integrative practice should involve much more than this.

 

[facetguy]

But it's like people are damned no matter what they do. If they just follow along to allopathic referral after referral, take a plethora of "wonderful" FDA approved meds, but only are marginally better and not really well if you will--or perhaps there isn't an improvement at all--and then they get sick of the whole game, and stop complying, they are screw-up, non-compliant patients...

This is where the breakdown occurs. To most in medicine, there simply is no other way, so a patient seeking anything outside of medicine is a whacko and the person treating that patient is a whacko and a charlatan. Understand that no one outside of medicine can help anyone, or so the thought goes. It's been interesting to watch the evolution of 'Integrative Medicine' over the years. First, these were crazy MDs throwing their careers away. Now, with increasing evidence and increasing credentials of those practicing Integrative Medicine (as Doctor Grim alluded to), there's quasi-acceptance among peers. Give it time; these practices will become more and more standard.

 

[Doctor Grim]

Integrative Medicine (Cardiology) at its best.

http://www.nmh.org/nm/prevention+is+key+in+the+fight+against+heart+disease

 

[deleted87716]

Integrative Medicine (Cardiology) at its best.

http://www.nmh.org/nm/prevention+is+key+in+the+fight+against+heart+disease

Geez, if that's all we're talking about, I guess that makes me an integrative medicine doc!