Integrative Medicine by Eric J. Deppert, MD, FACP

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