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Wednesday, July 24, 2013

Considering the differences between alternative, holistic and integrative medicine

Recently a patient of mine brought in a bottle given to her by her acupuncturist. She had turned to acupuncture with my encouragement after traditional medicine fell short at addressing her chronic pain. Indeed, there is data to support the efficacy of acupuncture in the management of chronic pain. I was encouraged to hear that this treatment, often labeled as "alternative," seemed to be helping her substantially.

However, my patient's questions had to do with the ingredients of the herbal medication she was given to help with weight loss and phlegm--a potpourri of botanicals translated from Chinese to English. She asked for my assessment and blessing, reminding me that I was a self-proclaimed "holistic" doctor.

Quickly I scanned the product's label. It contained, among other things, Raphanus Semen, something I immediately felt that I personally would not care to ingest. Despite my initial concern, I promised to research the herbal supplement to the best of my ability. Later, I discovered that Raphanus Semen was radish seed, which at least seemed less disgusting than what I had imagined.

This patient interaction brought to light two topics worth discussing:
1. What is meant by "Holistic Medicine?"
2. How does one assess the safety of complementary and alternative therapy, and more specifically, of botanicals and natural supplements?

I am fairly certain that "holistic" does not carry the same meaning to me as it does to many Americans. In my view holism in medicine implies having a whole person view. That is, seeing each patient, not just as a constellation of physical symptoms to diagnose and treat, but also within their psychosocial context. After all, a person's unique psychology and cultural background determine how he or she reacts to physical illness, diagnosis, medical advice, and treatment prescribed. A doctor who makes attempt to understand these parts of his or her patients is apt to be more successful at treating them.

However, most Americans tend to think of a "holistic doctor" as one who is well-versed in alternative therapies and who bucks standardized approaches endorsed by the medical establishment, including the pharmaceutical industry and the FDA. This is not true of my practice, though I am aware of the existence of bias and limitation within the scientific process.

As of late, the term "holistic medicine" has actually become antiquated and has been replaced by the contemporary field of "integrative medicine." As defined by the wise Dr. Andrew Weil, one of its best known proponents:
"Integrative medicine is healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative."

By this description I am an advocate of integrative medicine, though, the key point here is "use of all appropriate therapies." The unfortunate truth is that many physicians who profess to practice integrative medicine treat multiple diagnoses that are not at all well-established by science, for example, "adrenal fatigue." In addition, many advocate use of products that lack sufficient evidence for safety and efficacy, for example DHEA or bio-identical hormones, and disavow standard FDA approved drugs for unclear reasons. This business too can be a money-making operation, as some of these physicians do not bill health insurance for their services, run a multitude of diagnostic lab tests of uncertain significance, and may even sell their non-approved "natural" products for significant profit.

Which complementary and alternative therapies are safe and reasonable to try? There are a number of resources that can help to guide both doctors and patients, such as NIH's National Center for Complementary and Alternative Therapy page on Herbs at a Glance. Unlike prescription drugs, the manufacturers of medicinal herbs and botanicals are not required to prove the safety and efficacy of their products prior to marketing them. In addition to the definite possibility that these substances might be ineffective, there are two major safety considerations--their potential for causing drug interactions and the risk of product contamination. If you are researching for negative reports on a particular substance you may find the NIH's index "How Safe is this Product or Practice?" to be useful.

In the case of my patient, she is on a fairly long list of medications for several serious health conditions. For example, she has a history of pulmonary embolus and also has an inherited condition that makes her prone to clotting. For this she takes a blood thinner. Her other drugs include strong pain medications and several psychotropic drugs with narrow therapeutic indices. My immediate concern was for the possibility of botanical-drug interactions, which might increase or decrease levels of her prescription drugs and cause toxicity or adverse medical events.

It turns out that my research was unable to shed light on any reliable information whatsoever about Raphanus Semen, nor the remaining six ingredients of the herbal medication that she showed me. I was left to shrug my shoulders and advise her, in this case, "probably not a good idea." On the other hand, I support the use of acupuncture for chronic pain and have been known to advise melatonin for sleep, probiotics for various digestive ails, and even strontium for osteoporosis.

Juliet K. Mavromatis, MD, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.

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1 Comments:

Anonymous Ryan the Circulation Vitamin Guy said...

What's interesting to me is the vast separation between traditional medicine and integrative medicine.

It seems that despite the obvious benefits of a more holistic approach to health, the two schools of thought are farther apart than they should be.

I just find that the traditional Dr's don't acknowledge the practices of holistic doctors like you'd think they should.

February 24, 2014 at 4:36 PM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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