2016 Public Health Grand Rounds 12/02

PUBLIC HEALTH GRAND ROUNDS Linking Research to Community Health Improvement Jointly sponsored by the Department of Public Health Sciences & URMC Center for Community Health

- They'll be done after today,
and we'll see you again in the beginning of February,
so watch your emails for notifications from that.
Public Health Grand Rounds is brought to you
as a combination of efforts between
Public Health Sciences Department,
and the Center for Community Health,
who work hard at finding issues and speakers that link
the community, or clinical enterprise
with the community and community-based research.
Integrative medicine is an example of that.
This particular topic is a big one for the HRSA Grant,
that the Public Health Sciences Department
recently acquired to discuss integrative medicine,
and to talk about that with,
especially with our prevention medicine residents.
We're very happy to have Dr. Kless,
who's a expert in the field and will be
giving us an introduction to the field today.
(audience member claps) So I will read you his--
Oh, yes, thank you, (laughs) very good.
(laughing) (audience claps)
They love you, and you haven't even said anything yet.
So I'll just read you his brief bio,
and then we'll get started.
So Dr. Kless is a family medicine physician
at Highland Family Medicine,
involved both with the residency and in the clinic.
He graduated from medical school at Boston University,
and then trained in Seattle at Swedish
Cherry Hill Family Medicine Residency,
for both residency and a fellowship.
He completed his fellowship in integrative medicine in 2013.
In his role as assistant professor,
he continues to practice full spectrum family medicine,
including obstetrics and inpatient medicine,
as well as prescribing for opiod dependence.
He is passionate about teaching
medical students and residents
about primary care in integrative medicine,
which is why we invited him here today,
so thank you for your attention,
and please don't forget to fill out your evaluations,
both for feedback to the speaker,
but also to give us ideas on future topics
for Public Health Grand Rounds.
So thank you very much.
Dr. Kless.
Now you may. (laughs)
(audience clapping)
- All right.
Let me just turn on the mic,
which may or may not be easy.
Great, turned it off.
Well, we'll just go with this mic.
Let me just pull up my slides here.
- [Engineer] Want me to set the mic up?
- Sure.
Great, perfect.
All right, can everybody hear me okay?
- Yep. - Wonderful.
Thanks for your patience.
So thank you for the very kind introduction, Theresa.
Today we're gonna talk about
an introduction to integrative medicine
and its application in a primary care setting.
Good news, University of Rochester
is the only people that pay me a paycheck,
so I have nothing to disclose.
Today we're gonna start by defining integrative medicine,
and going through a whirlwind tour of what it is,
because it can mean so many things
in so many different ways.
And first I wanna just define a couple of terms.
Complimentary approaches or complimentary modalities,
are those kind of alternative modalities
used in conjunction with conventional medicine,
and when we are using those complimentary modalities
in conjunction with conventional or allopathic medicine,
that it is truly integrative medicine.
So after reviewing a few of those different approaches,
we'll talk about the public health relevance,
and why I'm here today, to talk about integrative health.
And then we'll talk about
a few case studies from my practice
to illustrate how I use it in my practice.
So to start, integrative medicine is really
an approach which emphasizes the relationship
between the practitioner and the patient.
It focuses on the whole person,
trying to put their symptoms and their problems in context,
informed by evidence, and making use of
all the approaches that we can possible.
It's really about getting to know your patients
and getting to know what's gonna work for them.
It is not simply using things like
nutritional medicine or herbal medicine,
it's using all of these modalities together,
and sometimes not all of them, sometimes just a handful,
and that handful might be different for each patient.
But it's really patient-centered medicine,
taking a holistic approach and trying to use
all these modalities that may be helpful
for our patients sitting across from us.
When I think about integrative medicine,
my mind is called back to this figure,
which is from an article on evidence-based medicine
in primary care, way back in 1998.
In my medical school training,
and I'm not sure how many other doctors
we have in the audience today,
I was taught to focus on the research evidence.
If I was gonna suggest an intervention for a patient,
I had to have a research study that proved
that this would be effective and helpful for that patient.
And if I did not, then I was immediately questioned.
But I think it's interesting that when
evidence-based medicine was first introduced,
it wasn't just about the research.
It's also about our clinical expertise.
It's about our intuition.
It's about the feeling that we have about patients.
And as much it's about the patient preference,
and what that patient wants,
what fits into their worldview,
what fits into their biopsychosocial patterns.
So I try and practice in here,
and that's really what integrative medicine means to me.
It doesn't mean just one of these modalities,
and not focusing on the other.
It means finding the right combination of things
that will work for each patient.
For instance,
when we talk about blood pressure,
we have these randomized controlled trials
that bring together tons of evidence
to try and normalize our treatment protocols
for all patients no matter what they look like.
But the truth is, if I was talking about
a blood pressure medication for this gentleman,
it's probably gonna be different from this woman,
especially if she's of childbearing age
and planning to get pregnant in the next year.
I might avoid an ACE inhibitor and an ARB,
and I might look for a different medication like Labetalol.
Additionally, this woman may have
a different cause for her hypertension,
or may not be interested in medication at all.
So integrative medicine allows me to have
more tools to interact with my patients,
and to find something that works for them.
And probably most important is to address those
kind of complimentary approaches in a nonjudgmental way,
and not pushing the patient away
when they suggest something,
or when they ask about something.
I'm gonna talk about some of those tools
that we have in integrative medicine,
but I just wanna emphasize that anything
I talk about today, is just the tip of the iceberg.
There is enough that I could about things for
hours and hours when it comes to mindfulness meditation.
My wife and I gave a presentation
earlier, last month now,
and we focus purely on mindful eating.
Not just mindfulness,
not mind-body medicine, but mindful eating.
And we gave an hour-long talk on it.
These modalities are pretty in depth,
and some have more evidence than others,
and sometimes a lack of evidence
does not necessarily mean that something is not helpful.
But let's start by talking about some of these modalities.
Probably the biggest one for me is just
talking about nutrition with patients,
and in my medical school training,
I didn't get a whole lot of tools to do that.
And so in my integrative training I've learned
a lot more about talking about a rainbow of vegetables
and fruits that I can offer to my patients.
This is an antiinflammatory diet pyramid from Andrew Weil.
Or even just talking about the sugar,
the sugar content of sugar-sweetened beverages,
and trying to help patients make
better decisions for themselves.
And this is just talking about nutrition and food,
not even the microbiome, which is,
a whole nother series of talks.
Another modality that we use in integrative medicine,
is mind-body medicine.
Some of you may be familiar with the work of
Mick Krasner and Ron Epstein here,
in terms of mindfulness training for physicians,
and that's one type of mind-body medicine,
but there are many others including yoga,
which a lot of people use for back pain,
as well as a full list.
I have the Center for Mind-Body Medicine here
because that's how I got my entree
into a lot of these modalities to use for myself.
It's a organization, I'm just gonna give a quick shout-out,
started by Jim Gordon, who's a professor
of Psychiatry at Georgetown University.
And what they've done is is set a structure
around groups in which patients,
medical students, residents, physicians themselves,
get together, learn about one of these modalities,
practice it, and then debrief about
what that experience was like for all of them.
It's a really powerful way to experience these,
and to encourage anyone to use it in their own lives.
So as an example of where mindfulness techniques
and mind-body medicine have been studied
and shown to be helpful in patients,
just to keep this not just a fluff piece
about what integrative medicine is,
there was a really interesting study in 1999,
looking at (audio cuts out) in patients for asthma.
They took 61 patients,
they divided them up, randomized,
and half, well, a little bit more than half
were randomized to the treatment group,
where they were instructed to journal about
the most stressful experience they've had.
They journaled I believe just 20 minutes
on three consecutive days.
The other half were randomized to just write about
what their plans were for the day.
And using spirometry, there's some pretty impressive results
that journaling led to a decrease in FEV1 by,
or an increase in FEV1 by 10%,
and that that persisted over many months.
So the power that our mind has to affect our body
is really, really, really strong,
and we wanna try and support our patients.
And going back to this list,
there may be something that works for you,
but it may not work for me.
Again, this is the individualized-medicine approach.
So really being able to guide your patients through
each of these approaches to try and help them
find the right one for them is important.
Another really, really intriguing cross-sectional study,
another randomized controlled trial, was performed,
looking at the genetic expression
of genes involved in cellular damage and death.
And so basically they took 20 people
who practice a relaxation response method,
some sort of meditation,
and had been long-term practitioners,
and then they took 20 people
who were not experienced with this,
and they looked at their gene and gene's expression,
and there was significant differences
in the gene expression related to oxidation,
or oxidative species and oxidative phosphorylation.
And that alone is interesting,
but then they took the 20 people who had
no experience with relaxation response,
put them through an eight-week course
to learn relaxation response,
and then reevaluated their genes,
and found that those changes that they had seen
in the long-term practitioners were also observed
in the ones that had just been taught over eight weeks.
So these techniques have wonderful,
wonderful effect on our bodies.
So this is the first time I've talked about
herbs and supplements,
which I don't know if any of you thought that's what
I was gonna start out with or talk mostly about,
but if anyone is like me, I was very naive.
When I went into integrative medicine I thought,
let's try and find an herb or a supplement
for me to offer every patient before I offer a medication.
And it turns out, couple things,
first you can get into polypharmacy
with herbs and supplements just as fast,
if not faster than you can with medications.
And secondly in addition to integrative medicine
as one of my passions, working for the underserved
is another one of my passions.
And the bummer about herbs and supplements
is they're not covered by insurance,
so it has to be an out-of-pocket charge.
To go back to my body medicine,
can you tell that I love it?
It's free to go back to nutrition.
Everybody eats, so these are tools that are
really translatable across populations.
These can also be helpful, don't get me wrong.
In the right setting, in the right course.
Eating turmeric alone in your diet can increase,
or decrease the inflammatory activity throughout your body.
It can be really powerful.
Other complimentary modalities
are many types of manual medicine.
Are there any osteopaths in the house?
All right.
Well, osteopathic manipulation is something that
osteopathic doctors learn while they're in school,
and it's really focusing on the
structure and function of the body,
and helping the bones and the fascia align,
and can be really powerful.
Massage, I think we all know.
I'm not gonna go through all of these,
but they can be helpful, used in conjunction
with conventional therapies for patients.
And it makes it different for the patients if they ask,
"What do you think about Rolfing for my low back pain?"
If we say, well, I don't know.
I need to look this up.
It might be helpful, I can't say.
But as long as it's not gonna cause harm,
I support you giving it a try.
And that's really what integrative medicine is all about.
Knowing where to find the evidence,
where to find those things,
and supporting your patients to
be engaged in their health and healing.
Other complimentary modalities include things like,
energy medicine, like acupuncture and reiki.
Reiki is used on,
well, there's a few major oncology centers.
I know Columbia Presbyterian has trained
the nurses on the oncology floor in reiki,
so that they're able to deliver a hands-on healing,
actually hands-off, but energetic healing,
for patients that might be interested.
It can be a powerful, powerful thing to offer to patients.
With regards to acupuncture,
there's many studies looking at its use and utility,
and I just wanna point out one randomized controlled trial
for acupuncture in the treatment of fibromyalgia.
And what I really love about this study,
is that it randomized 25 patients
to the treatment in the sham acupuncture.
Traditionally, sham acupuncture has been used
by just poking needles randomly in people's bodies.
But as you can see from the meridians here on this diagram,
there are energetic pathways in our bodies
that could be affected when needles
are just haphazardly poked in our bodies,
so it's tough to say that it's really
a nonintervention in that case.
In this case what they did is they either
put the needles in the correct points,
or they used a dull surgical probe
to press in that area and then stuck a piece of tape
with what looked like the end of a needle.
So to someone walking by, both patients would look
to have needles in the exact same places,
and you couldn't even tell.
Regardless, in this trial they used
the fibromyalgia impact questionnaire,
a measure of patients' symptoms of pain, and saw,
between the baseline and one month, a huge difference.
People were treated two to three times a week
for three weeks, and that benefit was
not as great at seven months, but it was still present.
So energy medicines can be helpful.
Other types of complimentary modalities
are just traditional approaches.
This is a representation of the doshas
and the elements that make them up in Ayurvedic medicine.
These are many of the herbs that are used
in Chinese medicine, Ayurveda and Tibetan medicine.
And these can be helpful for patients.
There are also complete systemic
approaches to patients' health.
Functional medicine is very interesting,
and looking at the functioning of
the patient's body and the organs.
Trying to take a whole patient into account,
and looking often at a kind of biocellular level
to find hints at where we can improve function.
Though I don't know much or practice
homeopathy or naturopathy,
again, my goal is to support my patients
if they decide to pursue those treatments,
and to let them know when I have concerns
about their safety or efficacy,
and when they might be wasting money
on things that would not be helpful.
Osteopathy, this is Andrew still,
looking at the bone again, for those osteopaths out there,
if you've ever seen a lecture about osteopathy,
this gentleman pops up many, many times.
One thing I did wanna mention about osteopathy is
when you talk to osteopathic physicians,
they are taught to look for the health in a patient,
and to support that health.
And we who have had allopathic training,
are taught to look for the symptoms of disease,
to try and find that disease.
And so one thing I really appreciate about osteopathy,
and that's carried into integrative medicine,
is really trying to help support
the health and vitality of our patients.
So what is integrative medicine?
I'm gonna ask that question again.
The National Center for Complimentary
and Integrative Health defines it as,
incorporating complimentary approaches
into mainstream medical care,
which I think is a good start.
But I also think it's the natural progression
of the biopsychosocial model,
which was kind of first written about
and defined by George Engel here
at University of Rochester back in the 1970s.
And that looks at health
as a combination of these three factors.
As one of my mentors has taught me,
integrative medicine is really just good family medicine.
It's listening to your patients.
It's trying to find a comprehensive plan
that can help them and help their health.
Where is integrative medicine practiced?
Well, it's practiced at integrative medicine centers,
of which there are many, in fact some big names.
Cleveland Clinic has a functional medical center
that they started in the past two years, I believe.
And not only because of patient demand,
but also the profitability that they demonstrated.
They had to expand their staff.
They had to double it.
So these are really popular things.
I'll talk more about the Academic
Consortium for Integrative Medicine.
There are integrative medical centers at Duke,
at Columbia Presbyterian, out at Scripps.
They're all over, University of Washington.
But that's not the only places where
integrative medicine is practiced,
but that's just to demonstrate how
widely accepted it is throughout our country,
And I hope that we can eventually have an integrative
medicine center here at University of Rochester,
and I'll talk more about that later.
It's all practiced in specialty offices,
in FQHCs and hospital-based clinic, and private practice,
and it's also practiced inpatient at the hospital.
And in a survey of hospitals that offer
integrative medicine to their patients,
85% report that the reason for inclusion
of those integrative therapies,
is because of patient demand.
70% is for clinical effectiveness.
So the two messages,
these modalities are effective for patients,
and patients want them.
Where else is integrative medicine practiced?
On the internet.
For anyone who sees patients, they can be rest assured
that they're gonna face questions from their patients
that they've gleaned from the internet.
Sometimes from questionable sources,
but there are good sources out here.
This is, Tanmeet Sethi is the doctor that taught me
out in Seattle, and she has a Twitter account,
where she blasts her followers
a few times a day, a few times a week,
with little tidbits to try and help them live a better life,
and achieve that optimal health and vitality.
Tieraona Low Dog is someone who's involved
with the University of Arizona
Center for Integrative Medicine,
where they have fellowships,
and training in residency as well.
And she also has a very active
Facebook page and Facebook followers.
So knowing where to point your patients
to good internet resources, as well as helping them glean
what is helpful or not helpful, can be really helpful tools.
All right, so let's talk about the public health relevance.
I'm at Public Health Grand Rounds,
and I should probably talk about this.
So the National Health Interview Survey
is something that's done annually by the CDC,
and every five years, they include questions about
complimentary and alternative medicines,
and complimentary and alternative care for patients.
So the most recent data I have is from 2012.
And a third of U.S. adults use some sort of
complimentary health approach in their life.
And if you're one of those U.S. adults
in the audience who uses those things,
you know this to be very true.
If you're a practitioner, you may not realize
that your patients are using this because
if you don't ask, sometimes they won't tell you.
And sometimes even if you ask, they won't tell you,
because they're worried you're gonna judge them.
So again, building that relationship
with your patient is really how we
find an integrative health path.
A significant number of children
often use complimentary health approaches.
The majority of these things are used
for chronic pain as one of the top things,
as well as anxiety and depression.
And the spending approaches $30 billion a year.
That's a huge amount.
It turns out that's about 10% of the out-of-pocket cost
that Americans are paying for their healthcare,
which is pretty impressive.
So it behooves us to talk about this with patients.
What are they doing?
The majority of folks are using natural products,
which are non-vitamin, non-mineral supplements.
So things like magnesium oxide
that a cardiologist might prescribe to a patient,
is not included in this.
Or vitamin D that your doctor may prescribe for you,
because you live in Rochester, New York, also not included.
So why do we care?
Because our patients are using this.
We need to know about this.
I love this picture of Montana football players
doing some yoga on their field.
It's a little bit of a shout-out,
my wife's family is from Montana,
so it just makes me happy.
This is a community acupuncture.
We have a wonderful one over at the village gate,
if anyone is interested in experiencing
acupuncture at a very affordable price.
It's basically a big room where people
get treated mostly on their extremities,
and sometimes their head and face as well,
depending on the condition.
If anyone is an athlete, they probably know Tiger Balm,
or something like it, something that contains menthol
and used for sore muscles and joints.
And if you walk into almost any pharmacy,
I think this is a Walmart actually,
there's a huge wall of supplements,
and vitamins and minerals and herbs,
that may or may not be helpful for patients.
So we need to know how to navigate these things.
And more importantly, we need to have the attitude
that just because we didn't learn about it
in medical school, doesn't mean that it doesn't
have some efficacy or utility in our patients' lives.
This is a homeopathic product with belladonna in it,
which I don't suggest that anyone take belladonna,
but homeopathy is basically trying
to get that product to such a place
that there is no actually belladonna within it,
and the structural changes that are in the tablets
will have a profound effect on people's body.
So how do we help our patients go through these supplements?
Well the truth is, it's tough,
because the FDA doesn't regulate things.
What they do is respond to supplements
that have been found to be adulterated
or cause abnormal effects for patients.
So these are a couple of the recent,
recent recalls that have been issued.
This was actually for the homeopathic teething tablets
that contained a much amount of belladonna.
This was just a few months ago in September.
Red yeast rice is a little controversial,
that I won't go into too much depth,
but basically, it contains a small amount of statin,
which is why it can help with cholesterol,
but the FDA doesn't approve of non-drug marketing
for things that contain drugs.
So how can we help our patients now to get this?
We can look for two things.
We can look for a USP label, which is U.S. Pharmacopeia,
or a GMP, a Good Manufacturing label.
Those labels are independently distributed
for producers that tend to have
exactly what they say on the label,
that don't make claims about health that are not warranted,
and basically a product that your patients can trust.
So this is very helpful.
Another reason for public health.
Diabetes is on the rise, this is not a surprise.
These chronic conditions like diabetes and obesity
have been on the rise for a while.
And the solution is not gonna come in one pill.
It's gonna come in preventive medicine,
and population health, and changing people's attitudes,
and correctly informing them about
how to get engaged in their health.
Because if we don't have an ally
in each of our patient's health,
then we can't make any changes for them.
Additionally, in 2010, 70% of the top causes of death,
were due to chronic diseases, and the underlying causes
of these chronic diseases are mostly biopsychosocial,
so we wanna be prepared to help shepherd our patients
through these difficult times,
to support their health and vitality.
All right.
I intended to pull these up beforehand, but I did not,
so I'm gonna try and just show you
two resources that can be very helpful.
Natural Medicine's database is something that
the University of Rochester had
when I first got here two years ago,
and then decided not to invest in a second year,
which caused me a lot of frustration,
but I wrote in support of it,
I spoke with some of the librarians,
and apparently I was not the only one to do so,
because now it's back, and we have access to it,
so please use it.
And also a lesson that if you are frustrated
with something that has changed, speak up.
The reason I like this database,
you can search by supplements,
and we're gonna go through supplements real quick.
You can look at the effectiveness,
and they have a really nice database
of what's likely effective, with all of the references
to the studies which have been involved.
And then it goes through and says things that
we can't really say, we don't know if it works.
But not just the supplements themselves,
you can also say, well,
I have this patient in front of me with diabetes,
and I wanna know what things I can use.
So you can go to integrative therapies,
and see which have a good evidence, strong evidence,
unclear or conflicting scientific evidence.
So this is just an incredible resource for us here,
and is really, really helpful.
Okay, so,
Consumer Lab is another way, in addition to
the GMP or the USP logo, Consumer Lab is,
it's a cost I think, 30, 35, or $39 now per year.
You might get a little bit cheaper
if you do a two-year subscription.
But what they actually do is a level beyond
the GMP or the USP label.
They test all of those products
to make sure that they contain what they have,
and you can look and find the specific brand
that you have in your hand and make sure that
what you're buying has what it should contain.
So those are very helpful resources.
Where can I find information for patients,
or to educate yourself?
I strongly support the University of Washington
Integrative Medicine Department's webpage.
David Rakel, who literally wrote the book
on integrative medicine, if you wanna read the book
on integrative medicine, you will buy his book,
was the head there and set up a really fantastic program,
with two different fellows, just expanding the knowledge.
They have a wonderful website,
and they recently partnered with
the Veteran Health Administration
to set a national database of resources
for practitioners in the veterans health system,
and to really expand integrative medicine
in the veterans health system.
So this is big.
We're doing great things and we wanna be involved.
Again, one of my passions is for the underserved,
and Integrative Medicine for the Underserved
is also a great resource that has
patient handouts in both English and Spanish
as well as Powerpoints from I think
their last few conferences as well.
So it can be really powerful and really helpful.
Okay, so we talked about what integrative medicine is,
and all of the complimentary modalities that can be used.
We talked about the public health relevance
and why we should care about integrative medicine.
What does it look like in practice?
It depends on the patient, right?
We talked about that at the beginning,
because we're making patient-centered plans
for all of our patients,
so let's look at a few patients.
I don't need to read this, I think you guys can.
But once you've read it, what does this person have?
And I think I planned to talk to more doctors,
so if you guys don't know, it's okay.
Depression, perfect, all right.
So we're gonna prescribe an SSRI and counseling.
Perfect, evidence-supported therapies.
But then he says, you know, I'm not gonna take that.
I don't have time for counseling.
What else can I do?
Isn't there anything else I can do?
And this is where integrative medicine can be helpful.
It can start with just meditative breathing.
I breathe with my patients, I sit there,
and I take some deep breaths with them, so frequently.
Sometimes I do that because someone's anxiety
is making me feel anxious in the room.
And sometimes I do it because I wanna demonstrate
what tools people can have to improve their health at home.
Vitamin D?
Again, it's Rochester.
No one is gonna be hurt by an extra thousand
or 2,000 international units of vitamin D.
B-complex vitamins support the formation of serotonin.
Fish oil is anti-inflammatory,
and is shown to be helpful in depression.
You wanna look for a ratio of EPA to DHA,
the important Omega-3s of about seven to one if you can.
And exercise, exercise, exercise, exercise.
The important thing about this is when I,
I give patients this option all the time,
for depression or for anxiety,
and if they go home and they use these for a few months,
but don't have positive results,
they're much more likely to partner with me
to see a counselor, or to take a prescription drug,
if that's appropriate.
So again, making that partnership is just so important
and integral to this integrative approach.
Another case, 50-year-old woman,
history of a traumatic brain injury,
she lives with chronic back pain,
doesn't want opiod medications,
really doesn't want medications at all if she can.
She can't afford massages.
She went to a chiropractor and the last time she was there,
she left feeling more hurt than helped.
So I do some hands-on treatment with cranial osteopathy.
So even though I'm not an osteopath,
I didn't go to a DO school, I'm an MD,
I was connected with an MD physiatrist in my fellowship,
and learned, basically apprenticed,
some hands-on techniques, and since then I've done
80 hours of training in cranial osteopathy,
and use it frequently with my patient.
The point of my history there is just to let you know
that even if you take different routes,
there are ways to learn about these methods,
and to put them into practice for yourself,
and it can be really profound and helpful.
And, again, I went to medical school,
and I didn't really touch patients that much.
So finding a manual technique that I could
reinforce that connection with my patients,
and do some physical exam in a different way,
has been really helpful for me.
All right, 51-year-old woman,
irregular bleeding, hot flashes,
headaches, insomnia.
She's heard bad things about estrogen,
doesn't really want hormones.
What does it sound like?
Menopause, perfect.
So how do we treat that?
Well, we first we do meditative breathing.
Because when those hot flashes hit,
they're not gonna last forever.
And the more we can try and decrease our sympathetic tone
and increase our parasympathetic tone,
the better those flashes are gonna resolve.
Additionally, vitamin E in those doses and flax seed,
I found fantastic results with my patients.
And there is some evidence there to support it.
Case four.
This gentleman was a lovely, but kind of
interesting man, kind of interesting mannerisms,
and he came to me, and initially,
he was pretty well controlled with his diabetes,
and then that increased even higher.
And so I had a talk with him
about adding another medication,
or potentially even going to insulin,
and he was incredibly resistant.
No, that doesn't work for my life.
I have no interest in doing that.
I just won't take it.
So I said all right, let's talk about what you're eating.
Let's talk about everything you do.
And it turns out he was having a soda a couple times a day.
Let's try and change that.
And how do we try and change that?
Well, I actually had him just do a diet diary.
And he impressed me.
He came back and he had everything written down
that he wrote, he put in his body every day,
between the last time I saw him and when I saw him again.
And I said this looks good.
You're drinking sugar-free Kool-Aid,
which I don't even wanna know what's in that.
(audience laughs)
Water and coffee, and that's okay,
you've cut back on your sugar,
you're thinking about what you're eating,
and lo and behold, his A1C came down to 7.5.
We didn't change medications at all,
we didn't add insulin, he just made the changes
in his life and his lifestyle himself, and it was profound.
So coming back to try and sum it all up.
Wow, I flew through this.
So integrative medicine in practice.
We're trying to develop a treatment plan right there,
balancing our patients' preferences
and the things that make them them, and uniquely them,
balancing our clinical judgment, and what may or may not
have worked in the past for similar patients,
as well as the research evidence that supports or refutes.
There's actually, I'm gonna look at my notes,
'cause I remember, there's an acronym
that can be helpful when trying to assess this,
when talking about a potential
integrative therapy for patients.
And that is ECHO.
When you're looking at the efficacy and evidence,
the cost, the question of harm, and the opinions,
what are the opinions of the patient.
Are they interested in the proposed intervention or not?
And if not, then it may be something we should change.
But you're always trying to build that
therapeutic partnership with your patient,
trying to look at individualized medicine
and find the right thing for them.
This is the Integrative Wheel of Health
from Duke Integrative Medicine,
who also have a really diverse website,
with actually some online trainings for both
medical professionals and laypeople, if you are interested.
And so at the center is the focus of
the Wheel of Health, it's you.
And being mindful and aware of yourself and your needs
are gonna help to strengthen your health and vitality.
This green section is all about self care.
What are your habits that you do
to try and help support health in your body?
What can we change for that?
And only outside of that really important center,
are conventional and complimentary approaches
when we're talking about preventing disease.
You're trying to respond to disease and disease symptoms.
So I find that a very helpful thing.
Let's get Rochester on the map.
This is from the Bravewell collaboration,
which is focusing on bringing
integrative health and integrative healthcare
to the healthcare centers across the nation.
Those are the 29 freestanding
integrative medical centers that exist.
The Academics Consortium for Integrative Health & Medicine,
is an organization of now I think 70 some institutions,
largely universities, but also some healthcare systems,
like Sutter Health and the Cleveland Clinic itself.
But things like, places like Yale, Duke, Columbia,
Mount Sinai School of Medicine, they are the members,
and I'm not sure why Rochester isn't yet,
but I'm hoping to change that.
So our patients want this, it's important to them,
to try and find a multi-pronged approach
to best fit each of their lives.
It's not all herbs and supplements.
It's not all finger waving and saying
this may or may not work.
It's about collaborating with your patients,
building that relationship, and really finding
the treatment that works for each patient at the moment,
in the office, in their life at that time.
So thank you for letting me take you
on a journey of integrative medicine,
and talk about some of the uses in my office,
and talk about the public health relevance.
Let me know if you have any questions, please.
- [Guest] You mentioned mindfulness and shamanic medicine,
but I'm curious to know why there's no mention
of religious practices in people's lives,
since it's a fairly common--
- Yeah.
Yeah, I--
- [Guest] And I have a feeling that there's a history
or something, where all of our hospitals have chaplains,
and some people have religious practices
that are more conventional than shamanic or mindfulness,
and I'm a little surprised that there's
no acknowledgement of that sphere.
- Sure, that was not meant to be exclusionary,
because I think of prayer as a
very powerful form of meditation.
In fact, Father Thomas Keating in the Catholic tradition,
has pioneered centering prayer
and sharing that with patients,
and I use that with patients all the time.
I'm not sure why I didn't.
That's an oversight on my part, and I apologize for that.
Interestingly enough though,
I think part of it is that
the survey, the National Health Survey,
when it includes prayer as part of its
complimentary and alternative measures,
the numbers go from a third of the population
to two-thirds of the population.
So you're exactly right that it's included.
Part of it is for the statistics
of keeping and talking about this,
but spirituality is absolutely one of
the pillars of an integrative approach,
and understanding where a patient is coming from,
and understanding a patient's life.
And spirituality can mean organized religion of any sort,
but it can also just be a connection
with something greater than ourselves,
and so I hope you understand that
that wasn't meant to not acknowledge,
or purposely exclude chaplainship
and the power of a belief in something
more powerful than ourselves,
and how it can affect our healing,
because I think that is important,
and I would include it in kind of a spirituality practice.
- [Guest] I would also look for the negatives.
I mean, it can be harmful.
- How so? Tell me about that.
- [Guest] Well, I think people's fear
of punishment and their guilt,
can be reinforced by their religion in negative ways.
- Absolutely, and I think,
in having an honest discussion,
you can help whomever you're talking to,
whether it's as a patient provider,
or whether it's a friend and mentor,
or even a family member, you might hope
to try and navigate that difficulty.
When I think of spirituality, I try and think
of an open arms enclosing us all,
so I think you're right that there can be
(audio cuts out) there, but it's a delicate line.
- [Guest] You had mentioned cost.
What do you suggest to your patients
if they're interested in one of the,
like if they're interested in vitamins,
or chiropractic or massage or something,
and they don't have the resources for it?
Have you found any help for them?
- I haven't found help for the supplements and herbs.
I mean often depending on the herb,
I might tell the patient to try and go find it,
so that they can eat it, because often
that's cheaper than taking a supplement itself.
With chiropractic,
I started practicing in the area about two years ago
and I'm still learning the resources here.
I believe there are some offices
that work on a sliding scale of some sort,
but I'm not entirely sure where they are.
The majority of my patients, truth be told,
have access to chiropractic when they want it,
either it's because of a motor vehicle accident,
and that insurance is paying for it,
or actually a lot of insurances
do cover chiropractic itself.
Occasionally with massage, we need to do a little bit of
letter writing to advocate for our patients,
but often we can insurance to cover that too.
Rochester Community Acupuncture
is also a great place that does sliding scale,
and there are a lot of affordable
acupuncturists out there as well.
So part of it is me trying to
get to know this community better,
to be able to tell you more resources,
but often you'd be surprised at what
patients can find for themselves.
- [Guest] I agree that it would be great
if we had a (muffled speech)
and it's so parallel with the bias
of the psychosocial problem, which is
so ingrained in who you are.
So what do you think would be the next steps,
and what are some of the challenges?
- [Dr. Kless] Sure.
One thing that I think I included in my notes,
but since I'm not looking at them, I forgot to mention
is that the neuroscience, or Neurorestorative Institute
is going to have a section for integrative health.
I don't know what that means, but in my mind,
integrative medicine is something that applies
across the board to any patient that's out there,
and doesn't need to be prioritized
for just neurorestorative medicine.
Often you'll see integrative, and I actually think
that the cancer center, the Wilmot Cancer Center,
has a few integrative practitioners as well.
But I'm not sure that they have
a dedicated integrative space.
But often you see that in cancer care as one of the
first entrees for integrative medicine in a system.
But the truth is, the more people get exposed to it,
the more interest there is.
I think the next step is probably to apply for the academic,
the Consortium of Academic Medical Centers,
which myself and a few other providers,
throughout the URMC system are trying to
put together an application for the spring.
I think that will allow us to increase
some of the resources that we have here.
But as far as getting a center itself,
I think that's a little bit above my paygrade unfortunately,
because I think we need either a donor
who's very interested in specifically that,
or finding the budgetary wherewithal
to be able to put a freestanding center,
or to be able to find the space
and preexisting spaces to have a center.
But we're not giving up.
- [Guest] I'm wondering about a community of colleagues
for yourself here in Rochester,
because my impression is that at the primary care level,
there's a lack of integrative
primary care practitioners in this area.
- [Dr. Kless] Well, I'm here.
And I have some colleagues as well.
I'm working at the residency to try
and educate family medicine residents
as they're practicing now,
so Highland Family Medicine might be a great place
to find some integrative practitioners.
I know there are, well, unfortunately,
a number of the practitioners recently
retired or moved on, that I was aware of.
But again, I don't think it needs to be a separate thing.
I think it's important to increase all of our toolkit,
so that we all have the ability to work with our patients.
And the truth is, that would allow you to find the best
relationship with a provider that you work best with.
Yeah, please, go ahead.
- [Guest] I have one other followup question,
which is a question of collaboration
with other practitioners,
and could you comment on that,
because you've mentioned a lot of alternative practitioners,
and I'm wondering if it's just simply
a supportive process on your part,
or whether there's more active exchange of information.
Could you comment on the collaborative notion?
- [Dr. Kless] Sure, sure.
Well, to pick up on a little bit
of your language that you used.
So alternative practitioners, I would think of
in place of conventional medicine.
And so I really like to focus on complimentary approaches,
and complimentary practitioners, which we work in concert.
For instance, next month, a little over a month from now,
for an educational day at the residency,
we're gonna be inviting a few other faculty member
in other departments who practice integrative medicine,
as well as an acupuncturist to allow us
to interface directly with the acupuncturist.
A lot of this is done on your own,
trying to get out there, and there's not
a big system of collaboration unfortunately.
It's something that you have to explore on your own,
and get to know the people and the practices.
But when I'm practicing, my goal is to work in connection,
and to respect the other practitioners a patient works with.
So if they're seeing someone for chiropractic work,
or they're seeing someone for acupuncture,
then I try and respect the care that
they're getting there, without questioning it.
- [Guest] But the patient themselves
has to do the integration across practitioners.
- [Dr. Kless] I'm not sure I follow that question.
- [Guest] Okay, so say I'm a patient,
and I say I have my primary care provider,
I'm also using massage, I might do some shamanic work,
I might do something else.
It's up to me to integrate all of that,
rather than to have those people
talking to each other about the effect on me.
- [Dr. Kless] I see what you're saying.
- [Guest] Being able to count on my primary care provider
to be looking at me in that larger way,
and then simply having the conversation
from a medical point of view,
and then having separate conversations with everybody else.
- [Dr. Kless] So it's difficult to get
all those people in the same room.
And unfortunately, in our current system,
there's not a whole lot of accommodation for providers
to reach out to other providers and discuss.
When necessary, I think that all of us
are willing to talk to those other providers
involved in a patient's care.
But it may not be necessary,
because if you have a good relationship with your patients,
if you listen to where they're coming from,
then you probably understand what that
shamanic work is accommodating for each patient,
or what they're working on with the acupuncturist.
And sometimes all it takes is to ask the patient,
because what's more important than me talking
with the acupuncturist that's placing the needles
in the patient that's sitting across from me,
is my patient's perspective on how
that treatment is helping her or him.
Does that answer your question a little bit?
- [Guest] At some type of level,
if it's not face-to-face conversation,
but exchange of information we now have,
in a lot of electronic health records.
If you're looking at that and you
wanna get a sense of the whole person,
you're not getting that from the electronic health record.
- [Dr. Kless] I agree with you entirely.
I think you need to talk with your patients
to try and develop that relationship.
And I think if you're doing that well then you have
an understanding where the patient's coming from.
I occasionally get records from a chiropractic practitioner.
I occasionally get records from an acupuncturist.
And I'm happy to review them and try and understand them,
but often, it's Greek to me because
that's not the paradigm in which I practice.
- [Theresa] I just wanted to hear more about the
intersection with the underserved in integrative medicine.
Biopsychosocial, I get the biopsycho but,
where is the social part addressed by integrative medicine?
Is it all a stress-relief technique,
or is there more to it than that?
- Well, stress and anxiety, depression,
are prevalent across all socioeconomic groups,
so certainly, the benefit of the meditative work
is that it doesn't cost a thing.
You can pay $25 for a yoga class, but you don't have to.
And breathing, everybody breathes.
For food, everybody eats.
So trying to meet your patients where they're at.
One of the tough things with the underserved especially
is the fact that they're living on food stamps quite often,
or a very limited budget, so one of the great things
about the Rochester Public Market
is that food stamps can be doubled,
for tokens at the booths there,
and there's very affordable,
we're blessed with wonderful farms around here
that bring wonderful vegetables and fruits,
so I often am educating my patient on that.
There's Foodlink, which can be a support
for patients who want access to
fresh fruits and vegetables as well.
But you know,
did I answer your question?
- [Theresa] Yeah, stress relief is the big one.
I think that's the emphasis, where you're going there.
But it's certainly food and--
- Yeah, I mean, stress relief is important,
and how to cope with loss and change,
but ultimately, if we're not attacking the factors
that lead to those losses and changes
in lower socioeconomic classes,
then we're not doing our job.
So as a family medicine practitioner,
with a love for the underserved,
yes, I am looking for every opportunity I can
to try and improve the overall status
of those in the lower socioeconomic classes.
From an integrative medicine perspective,
a lot of these things like I said are free and useful,
and I try and focus on the things that are free and useful.
I don't recommend a $60 probiotic to my patient
who's homeless and living on food stamps.
That doesn't make sense.
- [Theresa] And I think getting back to what you
originally said about a degree in medicine
is center around the patients,
so thinking about their needs and,
- Exactly. - prescribing accordingly.
- Exactly, yeah.
- [Guest] Going back to your point of how
we might be able to get more integrative,
combine settings of the education process here.
Just for history, for 20 years I've been
a chiropractor in the community,
and that's what a medical record would tell us.
In our practice for the I think 15 years,
your R2 family practice residents came into our practice,
and I think the more exposure you have early on
to all these different practitioners,
the more it is easy to have those conversations
and to really understand what's going on.
- Absolutely, I'm in 100% agreement.
And will never forget the time,
when I was in my training and rotated at Bastyr University
and got to see, work right alongside naturopaths,
and learn how their approach differs from mine,
but what I could learn from them.
To go back to the mind-body groups,
in Jim Gordon's paradigm from
the Center for Mind-Body Medicine,
in Duke and Georgetown, and a few other schools,
all of the medical students have to go through that.
They're required to do those groups,
to learn those skills and get exposed to those skills.
What they do with it after that, that's up to them.
But at least getting them exposed is big.
I would love to work with the medical students here.
I actually work with our residents
in their R2 rotation as well,
doing a very abbreviated mind-body group with them as well.
So I'm trying to make changes slowly,
but it happens slowly.
Any other questions?
Well, thank you all for your time.
(applause) I really appreciate it.
- [Theresa] Dr. Kless will linger a minute.