Fall 2015Volume 7, Issue 1

www.ubcmj.comISSN: 1920 -7425

9 771920 742004

UBCMJNatural Health ProductsStan Bardal

Bringing Mindfulness into Medical PracticeDevon Christie

What is Good Medicine?Hal Gunn

Bridging the DivideAaron van Gaver & Vanessa Vaartnou

in this issue:

Alternative andComplementary Medicine

The University of British Columbia Medical Journal

(UBCMJ) is a peer-reviewed, student-run

academic journal with the goal of engaging students in medical dialogue and contributing meaningful

discourse to the scientific community.

This artwork portrays conventional medicine’s coexistence with complementary and alternative medicines (CAMs), which are currently gaining more recognition within the health care fields. The image showing small pills, commonly used in mainstream medicine, placed on “pressure points” at the fingertips illustrates a union between the two therapeutic approaches. Circular, coloured patches that are joined together in the foreground convey connections between pressure points on the body surface and different areas within the individual, a concept associated with reflexology. The increasing popularity of many CAMs, such as herbal remedies, is prompting more research to identify potential benefits and harms with their use.

Phoebe Cheng, Vancouver Fraser Medical Program, UBC Faculty of Medicine, Vancouver, BC

on the cover

DISCLAIMER: Please note that views expressed in

the UBCMJ do not neces-sarily reflect the views of the editors or the Faculty of Medicine or any organi-zations affiliated with this

publication. They are solely the authors’ opinion and are intended to stimulate

academic dialogue.

UBCMJ

in this issueeditorial

Khamis, N., Ribeiro, A. Incorporating Complementary and Alternative Medicine into Canadian Undergraduate Medical Education

4

Stansfield, Z., Xu, J., Purssell, A., Shaw, R.

An Overview of Complementary and Alternative Medicines 7

featureBardal, S. Natural Health Products: the Gap Between Perceptions and Reality 11Christie, D. Bringing Mindfulness into Medical Practice: UBC’s New Familty Medicine Residency

Program Delivers Mindfulness-Based Stress Reduction Curriculum13

Gunn, H. What is Good Medicine? 16

van Gaver, A., Vaartnou, V.

Bridging the Divide: Can Naturopathic and Medical Doctors Collaborate to Make Integrative Care a Reality?

18

academicWard, K., MacPhee, R. Investigating Complementary and Alternative Medicine Use Among Seniors 21

commentariesEgri, C., Pirani-Sheriff, T. A Doctor by Any Other Name 25McClymont, E. Dental Care in Canada: the Need for Incorporation into Publicly Funded Health Care 28

Yogendrakumar, V., Tsang, E., Fitzgerald, B.

Teaching Social Pediatrics: the Global Health Initiative Inner City Project 30

Napoleone, G. Addressing the Osteoporosis Health Care Gap in British Columbia with Fracture Liaison Services

33

news and lettersIp, A. Traditional Chinese Medicine: Learning from Dr. Henry Lu, PhD, Dr. TCM 36

Jones, A. Chronic Pain Management and Canadian Public Health Insurance: Do We Need More Comprehensive Health Care?

39

Lake, S. Evidence-Based Medicine and the Growing Populatrity of Complementary and Alternative Treatments

40

Verma, P. Regulating Health Professions in British Columbia 42

reviewsFingrut, W. The Need for Ethnically Diverse Stem Cell Donors 44

Grewal, G., Amlani, A. Garlic-induced Esophagitis and Gastroenteritis: A Review of Four Cases 48

Lukac, C., Twa, D. Complementary and Alternative Medicine in the Management of Lymphomas: Prevalence, Rationale, and Contraindications

52

Raski, M. Mindfulness: What it is and How it is Impacting Healthcare 56

global healthvan Soeren, M., Aragon, M. The Intersection of Biomedicine and Traditional Medicine in the Peruvian Amazon 60

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Incorporating Complementary and Alternative Medicine into Canadian Undergraduate Medical Education

Noren Khamisa,°, *, BSc; Amanda Ribeiroa,°, *, BSc (Hons)Citation info: UBCMJ. 2015: 7.1 (4-6)°Corresponding authors: nkhamis@alumni.ubc.ca; a.ribeiro@alumni.ubc.caa MD Candidate 2018, Faculty of Medicine, University of British Columbia, Vancouver, BC* Co-first authorship

With the increasing interest among Canadians in complementary and

alternative medicine (CAM), it has become paramount for Canadian physicians to be educated about the various modalities of CAM and their interplay with conventional medicine.1 Regardless of physicians’ stances on the utility of CAM in the context of conventional Western medicine, they must be aware of the prevalence of CAM use among their patient population and the issues related to this use. A study conducted on patients presenting to the Canadian College of Naturopathic Medicine clinic in 2005 found that 41.5 % of patients who use natural health products did not disclose this use to their family physicians, and 69.9 % of respondents indicated that their physicians did not ask about natural product use.2 Even more disappointing is that physicians have the least positive attitude toward patients’ use of CAM compared to all other health professionals.3

These negative attitudes might lead to poor communication between physicians and patients about CAM–associated risks, including adverse drug interactions, patient noncompliance with prescription medications, and uncertainty about the true effects of interventions.1 A baseline level of knowledge on the subject of CAM empowers physicians to be comfortable asking patients about their engagement with non–conventional medical services.1

Open communication between patient and provider regarding current treatment options is an important step in ensuring optimal patient safety and satisfaction. Furthermore, it facilitates dialogue between physicians and other health care providers, paving the way toward collaborative care.1

One solution to the need for increased physician competence in CAM is integrating

patients and other healthcare providers about this important topic.

Currently, no national guidelines exist for the incorporation of CAM teaching into Canadian undergraduate medical education. The only study ever published on this topic found that 13 of the 16 medical schools across the country in 1999 incorporated CAM education as a required component of their curriculum, while the remaining 3 were planning to do so in the future.8 To explore the current status of CAM education among future healthcare professionals, the Complementary and Alternative Medicine in Undergraduate Medical Education (CAM in UME) project was founded in 2006 with a total budget of $ 77,750.9 In 2013, the National Advisory

CAM training into undergraduate medical education. Research shows that a startling 84 % of physicians feel that increased CAM education was needed during their training in order to adequately address patients’ concerns.6 Similarly, a California study showed that 61 % of physicians do not believe that they have adequate knowledge about CAM, while 81 % report a desire for more education about CAM safety and efficacy.7 The Canadian undergraduate medical education system is focused on seven key competencies, as outlined in the CanMEDS Physician Competency Framework: Professional, Communicator, Collaborator, Manager, Health Advocate, Scholar, and Medical Expert.4 Physicians who are CAM–literate might be better suited to excel in each of these areas by having the knowledge needed to communicate effectively with patients regarding their CAM use. This enhanced knowledge and communication will enable physicians to better support their patients, potentially leading to improved patient outcomes. Furthermore, due to the cultural and personal aspects of many of these therapies, training physicians to be sensitive and accepting toward CAM use among their patient population can improve cultural sensitivity and appreciation for patient–centred care.1 The focus of these diverse medical practices on total–body wellness and on self–care might also encourage medical students to embrace concepts of wellness and disease prevention, which are proven to improve patient health outcomes and to reduce healthcare costs.1,5 Exposing students to fundamental aspects of CAM early in their medical career will allow them to build on this basic knowledge throughout their training and to ensure that they are well–equipped to speak with

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Open communication between patient and provider regarding current treatment options is an important step in ensuring optimal patient safety and satisfaction. Furthermore, it facilitates dialogue between physicians and other health care providers, paving the way toward collaborative care.

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Committee for the CAM in UME project compiled a list of CAM curricula across Canadian medical schools.9 The approach taken by different schools was found to vary widely from small group discussions to lecture–based instruction to student–directed projects.9 On one hand, this lack of a unified approach to CAM education reflects an inability of Canadian medical schools to come to a consensus on the most salient aspects of CAM or the method to transmit these aspects to students; on the other hand, there is value in generating a cohort of future physicians with different areas of expertise in CAM. Furthermore, the heterogeneity of CAM education reflects the diversity of teaching approaches and learning needs of students across the individualized curriculum of each medical school. Given this diversity, it might prove difficult to enforce standardized methods of CAM teaching; however, at the very minimum, there should be a set of core CAM competencies that all Canadian medical graduates must master, similar to the CanMED roles.

A goal of the CAM in UME project is to encourage undergraduate medical educators to develop and expand the CAM aspect of their curricula.9 The project’s website provides CAM–related learning

a correspondence letter published in the Canadian Family Physician journal raises the concern that including CAM therapy in undergraduate medical education may be perceived as wrongly advocating for therapies which lack sufficient evidence.14 Furthermore, as medical schools face limited funding and curriculum time, increasing the time spent on CAM education has the trade–off of limiting curriculum focus on other important topics.15 Schools must also find well–trained educators who have extensive knowledge of CAM and its relation to conventional Western medicine. While there are benefits to involving CAM practitioners in the design and teaching of these modules,15 it is important to ensure that all those involved in developing and delivering the curriculum remain impartial regarding the benefits and drawbacks of CAM. Another important issue is the fundamental difference between the evidence–based, biological understanding of the human body and disease in conventional medical education compared to the holistic approach to patient care adopted by CAM.15 This distinction leads to one of the most important and challenging barriers—that of resistance on the part of medical school program leaders due to their personal biases against CAM and their inability to fully appreciate the differences in scope and value of the two approaches.13

objectives and resources to facilitate knowledge translation about patient use of CAM.9 Because there is no national policy on CAM education among healthcare providers, this project provides a hopeful avenue for expanding the knowledge base and communicative abilities of future physicians regarding non–conventional medical therapies. In 2006, the project published a comprehensive overview of the rationale for integrating CAM education into undergraduate medical training along with a list of competencies that students should master ;10 however, it is unclear how much influence this resource has had on medical educators or on improving CAM knowledge among medical students. The project’s limited role to medical schools as a guiding hand rather than as a mandated program suggests that the project needs greater momentum and more promotion to medical educators in order to enact meaningful change.11

While the incorporation of CAM into undergraduate medical education certainly has its benefits, it is not without challenges. For one, it is difficult to provide a comprehensive overview of the subject due to the extensive scope of CAM and the variability of its usage across different geographical regions, age groups, and cultures.12 Variability also exists in the extent to which schools might educate students about CAM. On one extreme, schools can settle for the bare minimum by teaching students how to communicate effectively with patients who use CAM and how to seek out resources on the safety and efficacy of different practices.13 Alternatively, schools can delve deeper by preparing students to understand the different types of CAM practiced (along with their associated benefits and limitations, interactions with conventional medical therapies, and harm reduction), to advise patients about CAM therapy, to refer patients to alternative practitioners, and to even practice CAM therapy as an adjunct to their medical practice.14 No matter which option schools choose, they must apply the same rigour they would use to select other curriculum material in deciding what to teach and what level of evidence is sufficient to teach a type of CAM therapy to student doctors.13 In fact,

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Exposing students to fundamental aspects of CAM early in their medical career will allow them to build on this basic knowledge throughout their training and to ensure that they are well–equipped to speak with patients and other healthcare providers about this important topic.

To explore the current status of CAM education among future healthcare professionals, the Complementary and Alternative Medicine in Undergraduate Medical Education (CAM in UME) project was founded in 2006 with a total budget of $ 77,750.

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references1. Gaylord SA, Mann JD. Rationales for CAM educa-

tion in health professions training programs. Acad Med. 2007 Oct;82(10):927-33.

2. Busse JW, Heaton G, Wu P, Wilson KR, Mills EJ. Disclosure of natural product use to primary care physicians: a cross-sectional survey of natu-ropathic clinic attendees. Mayo Clin Proc. 2005 May;80(5):616-23.

3. Sewitch MJ, Cepoiu M, Rigillo N, Sproule D. A liter-ature review of health care professional attitudes toward complementary and alternative medicine.

Just as challenges exist with facilitating incorporation of CAM into medical curricula, there is also difficulty in assessing the outcomes of these initiatives. Options for evaluating student acquisition of knowledge can range from subjective self–assessments to objective standardized tests to practical examinations in which faculty members observe students’ behaviour and approach.5 With the wide range of options available, it is important that evaluation is consistent with the nature of the material taught and the manner in which it is taught. Assessment of CAM education must ultimately determine whether there is any positive change in physicians’ behaviour and patient outcomes; unfortunately, accurate assessment requires long–term monitoring and complex measurement strategies.5

Looking across the border to CAM education in the U.S., it is not surprising to see similar measures being undertaken. In 1999, the National Centre for Complementary and Alternative Medicine at the National Institute of Health invested $ 22.5 million in funding 15 grants to medical schools, nursing schools, and to the American Medical Student Association with the goal of encouraging the incorporation of CAM education into their curricula.13 Evaluation of these projects revealed that CAM training increased students’ self–awareness and self–care,

J Evid Based Complementary Altern Med. 2008 Oct;13(3):139-54.

4. Royal College of Physicians and Surgeons of Can-ada. The CanMEDS Framework [Internet]. 2005 [updated 2014; cited 2015 June 23]. Available from: http://www.royalcollege.ca/portal/page/por-tal/rc/canmeds/framework.

5. Benjamin RM, Sebelius K, Vilsack T, Duncan A, Leibowitz J, LaHood R, Solis HL, Napolitano JA, Jackson LP, Kerlikowske RG, Barnes M, Echo Hawk L, Velasco R, Gates RM, Donovan S, Holder EH, Shinseki EK, Lew JJ. National prevention strategy: America’s plan for better health and wellness. Washington (DC): National Prevention, Health Promotion and Public Health Council (US); 2011. 125p. Report No.: CS219065-E.

6. Corbin Winslow L, Shapiro H. Physicians want education about complementary and alter-native medicine to enhance communication with their patients. Arch Intern Med. 2002 May 27;162(10):1176-81.

7. Milden SP, Stokois D. Physicians’ attitudes and prac-tices regarding complementary and alternative medicine. Behav Med. 2010 Aug 7;30(2):73-84.

8. Ruedy J, Kaufman DM, MacLeod H. Alternative and complementary medicine in Canadian med-ical schools: a survey. Can Med Assoc J. 1999 Mar 23;160(6):816-7.

9. Complementary and alternative medicine issues in undergraduate medical education [Internet]. Sas-katoon (SK): University of Saskatchewan, College of Medicine; 2006 [updated 2015; cited 2015 June 23]. Available from: http://www.caminume.ca/.

10. Verhoef M, Epstein M, Neville A, Brundin–Mather R. A guide for the development, implementation, and sustainability of curriculum about comple-mentary and alternative medicine in undergrad-uate medical education programs. Toronto (ON): The Complementary and Alternative Medicine in Undergraduate Medical Education Project; 2006. 13p.

11. Sierpina VS, Kreitzer MJ, Burke A, Verhoef M, Brun-din-Mather R. Innovations in integrative healthcare education: undergraduate holistic studies at San Francisco State University and the CAM in Un-dergraduate Medical Education Project in Canada. Explore–NY. 2007 Mar ;3(2):174-6.

12. Gaster B, Unterborn JN, Scott RB, Schneeweiss R. What should students learn about complemen-tary and alternative medicine? Acad Med. 2007 Oct;82(10):934-8.

13. Pearson NJ, Chesney MA. The CAM Education Program of the National Center for Complemen-tary and Alternative Medicine: an overview. Acad Med. 2007 Oct;82(10):921-6.

14. Oppel L, Beyerstein B, Hoshizaki D, Sutter M. Still concerned about CAM in undergraduate medical education. Can Fam Physician. 2005 Aug 10;51(8):1069-70.

15. Owen DK, Lewith G, Stephens CR. Can doctors respond to patients’ increasing interest in com-plementary and alternative medicine? Brit Med J. 2001 Jan 20;322(7279):154-8.

16. Elder W, Rakel D, Heitkemper M, Hustedde C, Harazduk N, Gerik S, et al. Using complementary and alternative medicine curricular elements to foster medical student self-awareness. Acad Med. 2007 Oct;82(10):951-5.

17. Lie D, Shapiro J, Pardee S, Najm W. A focus group study of medical students’ views of an integrated complementary and alternative medicine (CAM) curriculum: students teaching teachers. Med Educ. 2008;13(3):1-13.

suggesting that the study of CAM can enhance overall physician performance, not only in the domain of CAM therapies, but also in the practice of conventional medicine.16 Another study conducted in a California medical school showed that students valued an experiential and hands–on delivery of CAM material over a didactic–focused curriculum.17 By drawing from the innovative approaches to CAM education arising from the U.S. and the rich volume of evaluative studies, Canadian medical schools can benefit from the expertise of American schools in shaping and evaluating their own CAM modules.

Overall, there is a growing trend toward incorporating elements of CAM into conventional undergraduate medical education in Canada. The focus of discussion should now shift away from whether there is a need to educate medical students about CAM toward developing methods, assessing integration, and identifying and overcoming barriers related to incorporating CAM into the medical curricula. One approach to facilitating this integration is the development and enforcement of national competencies for Canadian undergraduate medical students. Furthermore, while most curricula currently focus exclusively on making students more aware of the different varieties of CAM and their prevalence, schools might consider adding well–evidenced CAM to the body of medical therapies taught to students and practiced by physicians. This endorsement of CAMs by the medical profession will lead the way toward integrative care.

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Assessment of CAM education must ultimately determine whether there is any positive change in physicians’ behaviour and patient outcomes; unfortunately, accurate assessment requires long–term monitoring and complex measurement strategies.

disclosuresThe authors do not have any conflicts

of interest.

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An Overview of Complementary and Alternative MedicinesZachary Stansfielda,°,*, BSc; Jieqing Xua,°, *, BSc; Ruphen Shawb, *, BSc; Andrew Pursellb, *, PhDCitation info: UBCMJ. 2015: 7.1 (7-10)°Corresponding authors: zachary.stansfield@alumni.ubc.ca; jxu@alumni.ubc.caa MD Candidate 2018, Faculty of Medicine, University of British Columbia, Vancouver, BCb MD Candidate 2017, Faculty of Medicine, University of British Columbia, Vancouver, BC* Co-first authorship

Complementary and alternative medicines (CAMs) represent a diverse set of health practices that typically lie outside mainstream medicine. While these practices are widely used by Canadians,1 physicians may have a limited knowledge about their use, in many cases because of a lack of acceptance by medical communities. For example, the College of Physicians and Surgeons of BC Guidelines suggest caution regarding the use of CAMs by physicians and label these practices as “generally unproven”.2 Strictly speaking, this statement has some validity. Proponents of evidence–based medicine note that appropriate medical practice should be guided by two key elements: “clinical experience” and the “best available external clinical evidence.”3 In this current issue of the University of British Columbia Medical Journal (UBCMJ), Dr. Henry Lu, a North American leader in the practice of Traditional Chinese Medicine (TCM), explains how, traditionally, CAM practitioners in his field have tended to rely almost exclusively on clinical judgment.4

Moreover, even as research efforts on CAMs have expanded in the United States there are still few CAM practices which are supported by high-quality external evidence.4,5,6 For this reason, medical practitioners have a good reason to familiarize themselves with the diversity of CAMs, as well as the current body of available evidence, so that they may better counsel patients who choose to seek out these practices. This article does not aim to evaluate the effectiveness, safety or scientific validity of selected CAM practices, but instead aims to provide a descriptive overview of how and why these practices are used.  

In order to adequately classify these practices, it is necessary to first properly

of health.9 Spiritual beliefs about the interconnectedness of persons with other animals and the universe are intricately linked to Indigenous medical practice, which aims to promote physical, social, and spiritual health.10

Practices may include the use of herbal medicines, sweat baths or lodges, as well as psychological and spiritual counselling by elders or specialized practitioners and through ritual ceremony.10,11

Traditional Chinese Medicine refers to a set of health practices first documented in text over two thousand years ago in China, and which are still widely practised today.12

Core principles of TCM include the belief in an interconnectedness of individuals to the natural environment (holism), and the belief that a vital substance called “qi” travels through specific points in the body known as meridians, thereby maintaining homeostatic balance.13 This state of internal balanced is conceptualized as a harmony between “Yin” and “Yang” .13

Practitioners of TCM focus heavily on dietary and lifestyle advice for disease prevention, and perform a wide array of herbal treatments and body manipulation practices such as acupuncture.12

Naturopathy is derived from 19th–century European “natural healing” practices that were first brought to North America by Benedict Lust in 1902.10 The core principles of naturopathy emphasize preventative medicine, self–healing by the body and physiological balance; all of which are issues that practitioners aim to address before attempting to correct pathology.10,14

The scope of naturopathic practice is broad and variable. Naturopathic doctors (NDs) report key roles to include the use of herbal medicine, homeopathy, nutritional counselling, and supplementation, but also report that they frequently order laboratory tests, provide psychological counselling,

define conventional medical practice. For our purposes, we have defined “conventional medicine” as a set of practices derived from traditional Western medicine, which have evolved under the influences of biomedical and evidence–based approaches, and which currently receive broad international acceptance as a primary mode of medical care. In contrast, CAMs are marked by their diversity, lack of standardization and inconsistent acceptance by conventional practitioners.8 An extensive 2005 report by the Institute of Medicine and funded by the United States’ National Center for Complementary and Integrative Medicine (NCCIH, formerly NCCAM) summarized the status of CAMs as non–normative “health systems, modalities, and practices and their accompanying theories and beliefs” that may sometimes overlap with mainstream practices.8 Perhaps the most popular classification approach has been developed by the NCCIH, which organizes CAMs into broad systems of practice and treatment methods: “1) alternative medical systems; 2) mind–body interventions; 3) biologically–based treatments; 4) manipulative and body–based methods; and 5) energy therapies.”8

Here, we have utilized this classification system to organize a discussion of CAM practices and the common doctrines that serve to guide their use. Our aim is to provide a simple overview of these practices commonly used in Canada for early–career medical professionals who lack a significant background in this area.

1. Complementary and Alternative Medical Systems

Aboriginal Medicines refer to a diverse set of medical practices developed by North American Indigenous peoples and which emphasize holistic aspects

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utilize hydrotherapy, and engage in body–based practices such as naturopathic manipulation or acupuncture.15

Homeopathy was first developed in 1796 by a German physician, Samuel Hahnemann. According to a homeopathic theory known as the “principle of similars”, agents that cause symptoms that are similar to that of a disease should have curative properties for this disease — in other words, “like cures like.”16,17 Homeopathic products consist of symptom–producing agents that are serially diluted in water — often until the original substance no longer remains — under the assumption that additional dilution increases potency.16

2. Mind–Body Interventions

Mind–body therapies encompass a large number of practices that include meditation, hypnosis, biofeedback, and guided imagery.18,19 These therapies rest on the belief that a person’s mental state and thought processes can influence well–being, and aim to facilitate the influence of these processes on health.18 Mind–body therapies are easily implemented, inexpensive, and minimally invasive, which may, in part, contribute to their popularity as CAMs.18 In general, these therapies are used as complementary rather than stand–alone treatments, and are most likely to be used for anxiety, chronic pain, and psychiatric disorders.18,19

Meditation is an ancient practice originally stemming from religious traditions including Hinduism and Buddhism. It encompasses a wide variety of techniques, including yoga, Tai Chi, Mantra meditation, and mindfulness meditation.20 Despite this diversity, all meditative practices share in common a reliance upon the use of: 1) specific and clearly–defined techniques; 2) muscle relaxation techniques; 3) logic relaxation techniques; 4) self–induced states; and 5) self–focus skills.21 “Self–focus” refers to a means of controlling one’s attention, commonly through focusing on breathing or chants.20 Meditation is frequently used to assist patients suffering from disorders such as depression, anxiety, and substance abuse, as well as stress– or anxiety–induced disorders.20,22

Hypnosis is defined as a state of

chelation therapy, hydrotherapy, nutrition therapy, herbal medicine, prolotherapy, and speleotherapy.30

Chelation therapy involves using synthetic, metal-binding chemicals such as EDTA to remove certain cations and heavy metals from the body, as these materials are felt by practitioners to contribute to a state of ill health.31 Originally developed as a technique to treat lead poisoning, chelation therapy is now being used as a therapy for a variety of ailments.31 Hydrotherapy includes the practice of bathing in or consuming “medicinal waters” or water that has been heated to a specific temperature, as well as spa therapy, which aims to promote tissue growth and reduce pain.32 Nutrition therapy encompasses specialized diets and nutritional supplements aimed at optimizing health.28 Herbal medicine centres on the use of plants to make pharmacologically active preparations intended to promote health or treat disease.33 Four general types of herbal medicine exist: Asian, European, Indigenous, and Neo–Western. Prolotherapy, also known as proliferation therapy, involves the deliberate injection of irritants into an anatomical space, with the intention of inducing inflammation and tissue proliferation — processes which are claimed to subsequently restore function and relieve pain.34

Speleotherapy is the use of subterranean environments and their specific air characteristics in the treatment of airway disease. Specific qualities of the environment that are thought to be important are air quality, including humidity, salt, and mineral content, air temperature, and radiation.35

4. Manipulative and Body–Based Methods

Body–based therapies rely on the belief that health can be improved through physical manipulation of the body. The origins of modern manipulative and body–based therapies can be found in a wide range of cultures from many parts of the world.36 The primary therapies in this category are chiropractic and massage therapy.37

Chiropractic can trace its origins as a practice to D.D. Palmer, who, in 1895, pioneered the profession and developed

altered consciousness and heightened suggestibility.23 While in a hypnotic trance, the hypnotherapist may make therapeutic suggestions to the patient, either modifying a patient’s perception of sensations (such as pain) or behaviours during and after the session.24 Hypnosis is also used as a psychoanalytic tool, as well as to promote relaxation and decrease anxiety.24

Biofeedback is a self–regulation technique that seeks to enhance the user’s awareness of bodily sensations by using devices to monitor physiological signals which can then be relayed back to the user.25 The aim of these practices is to provide patients with better conscious control over their physiological processes.25

Biofeedback is used in disorders such as incontinence, as well as for stress awareness and management.25

Guided imagery practices also aim to use thought processes to influence physiological and psychological states. The user is placed into a state of deep relaxation and instructed to visualize herself as experiencing a specific physiological state.26

It is proposed that visualization during deep relaxation will produce positive physiological changes and will reduce negative cognition and emotions that may be evoked by a patient’s thoughts about her illness.27

3. Biologically–Based Treatments

Biologically–based therapies represent a diverse array of treatments that incorporate herbal and food–based products, as well as the use of vitamins and other dietary supplements.28,29 These substances are broadly intended to promote health.30 Among the many pharmaceuticals utilized in conventional medicine are compounds similar to or refined from these natural products.29 As such, this category of treatments includes practices that contribute to many medical systems including conventional medicine, naturopathic medicine, and Chinese medicine.

In addition to therapies identified by the Cochrane CAM Field organization of complementary and alternative therapies (completed in 2009), an updated list of biologically–based therapies includes

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much of its philosophy. His philosophy consisted of beliefs including: 1) that the body has an “innate intelligence” that enables self–healing; 2) that dysfunctional (subluxated) joints interfere with the body’s innate intelligence and thus may contribute to disease processes; 3) that manipulation of the spine and other body parts can repair subluxated joints, thus restoring this state of innate intelligence.38,39

Therefore, chiropractors manipulate the body with the intent not only to correct neuromusculoskeletal problems, but also to alleviate systemic disorders.40 Despite the broad scope of application defined by this philosophy, the most common problems for which patients are treated by chiropractors are musculoskeletal complaints.38

Chiropractors can be broadly categorized as either “straights” or “mixers”.41 Straights adhere closely to the original principles put forth by Palmer, which means that they subscribe to the belief that subluxation is the primary cause of disease in general, and they believe in the importance of innate intelligence in maintaining health. Therefore, the therapeutic approach utilized by straights focuses almost exclusively on spinal manipulation.41 On the other hand, mixers generally do not believe Palmer’s model of innate intelligence to be correct, and treat subluxation as only one of many potential causes of illness.41 Mixers often incorporate mainstream medical techniques and beliefs into their practice and are representative of the vast majority of modern chiropractic practitioners.38,41

energy from magnetic fields, is a prevalent form of pain therapy.49 Static magnets, which produce unchanging magnetic fields, are usually made from iron or an alloy and are commercially available in variable strengths.50 Given the prevalence of electrical activity in the body, this therapy stemmed from the belief that pathology, caused by a misalignment of the body’s natural magnetic fields, could be corrected by subtle application of magnetic forces.51 A variety of physiological mechanisms have also been proposed, which range from improving vascular circulation to lowering the resting membrane potential of cells.49

Reiki, a therapy developed in Japan in the 19th century, is believed to harness “universal life energy” as a modality to restore harmony, balance, and strength, and to promote health.52,53 A spiritually–trained practitioner claims to channel Reiki energy to facilitate a patient’s self–healing capacity by placing their hands on or above a specific area, thereby allowing the energy to flow to necessary regions in the body.53 Since illness is proposed to arise from energy blockage, this therapeutic process is believed to remove the obstruction and enhance the body’s inherent healing force to restore energy balance, leading to recovery and health.52,53

Massage therapy can trace its roots back to the ancient cultural practices of Greece, Rome, China, and India, among others.42 Massage is defined as the manual manipulation of soft tissue and is practised by holding, moving, or applying pressure to these tissues.37,42 In modern practice, massage therapy incorporates a broad range of practices, but most commonly refers to Swedish massage.43 Practitioners of massage therapy believe that these practices produce benefit by activating the parasympathetic nervous system, promoting restorative sleep, interfering with pain transmission, and influencing body chemistry.42 Additionally, the increased interpersonal attention experienced by patients undergoing massage therapy as opposed to mainstream treatments may also contribute to its benefit. Massage therapy is most commonly used for stress, anxiety, insomnia, musculoskeletal pain, as well as to improve blood flow, and to facilitate breathing in patients with respiratory dysfunction.42,44,45

5. Energy Therapies

Energy medicine refers to a broad category of practices encompassing therapies proposed to adjust and restore the balance of energy fields to achieve health, including acupuncture, static magnetic therapy, and Reiki therapy.30

Acupuncture, a therapy involving the use of thin needles inserted into specific sites throughout the body, is a fundamental element of TCM, and relies heavily upon the concept of qi.46 It is proposed that disruption or blockage of qi can lead to disharmony within the body, exhibited as pain and illness, and that practitioners may restore the energy equilibrium necessary for heath by inserting needles at appropriate sites along the meridians.46,47 Another component of TCM that aims to enhance qi is qigong, a practice which integrates breathing exercises, mindfulness, postural awareness, fluid movement, and meditation in order to achieve a state of relaxation. The balance of qi is believed to allow the body to optimize its self–healing functions and facilitate a process of health restoration.48

Magnetic therapy, a modality based on

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conclusionThis classification of doctrines aims

to categorize CAMs that have parallel therapeutic principles in order to delineate the variety of practices available to patients. By addressing both the rationale and scope of each modality, this simple overview serves as a foundation to help readers further explore this issue of the UBCMJ. Relevant articles, published alongside this commentary, examine a range of topics including the regulation of CAM practitioners and products, the need for high quality evidence to evaluate the use of CAM practices, as well as statements from CAM practitioners and integrative physicians describing their practices and philosophies. As physicians develop an improved knowledge base around the scope and rationale of CAM practices — including known benefits, limitations, and areas where better knowledge is needed

As the public interest in these therapies remains strong, it is imperative that health care providers of all practices communicate inter-professionally in order to identify optimal practices that promote patient–centred care.

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— we hope that the medical community as a whole will be better able to evaluate whether specific CAMs may be appropriate for integration into conventional care. Furthermore, a more comprehensive awareness of each modality may help underscore the reasons for which patients seek alternative care, leading to more informed communication between patients and practitioners. As the public interest in these therapies remains strong, it is imperative that health care providers of all practices communicate inter-professionally in order to identify optimal practices that promote patient–centred care.

1997;315(7100):115–117.12. O’Brien KA, Xue CC. The theoretical framework

of Chinese medicine. In: Leung P. A comprehen-sive guide to Chinese medicine. World Scientific; 2003.

13. Zeff J, Snider P, Pizzorno JE. Section I: philosophy of natural medicine. The textbook of natural medicine, 3rd edition 2006;1(1).

14. Verhoef MJ, Boon H, Mutasingwa DR. The scope of naturopathic medicine in Canada: an emerging profession. Soc Sci Med. 2006;63(2):409–417.

15. Jonas WB, Kaptchuk TJ, Linde K. A critical overview of homeopathy. Ann Intern Med. 2003;138(5):393–399.

16. Merrell WC, Shalts E. Homeopathy. Med Clin North Am. 2002 Jan;86(1):47–62.

17. Maddox J, Randi J, Stewart WW. “High–dilu-tion” experiments a delusion. Nature. 1988 Jul 28;334(6180):287–291.

18. Astin, JA. Mind–body therapies for the manage-ment of pain. Clin J Pain. 2004;20(1):27–32.

19. Ospina MB, Bond K, Karkhaneh M, Tjosvold L, Vandermeer B, Liang Y, Bialy L, Hooton N, Busce-mi N, Dryden DM, Klassen TP. Meditation practic-es for health: state of the research. AHRQ 2007; #07-E010.

20. Cardoso R, de Souza E, Camano L, Leite JR. Med-itation in health: an operational definition. Brain Res Protoc. 2004;14(1):58–60.

21. Krisanaprakornkit T, Sriraj W, Piyavhatkul N, Laop-aiboon M. Meditation therapy for anxiety disor-ders. Cochrane Libr 2009;1:1–24.

22. Wagstaff GF. The semantics and physiology of hypnosis as an altered state: towards a definition of hypnosis. Contemp Hypn. 2006;15(3):149–65.

23. Vickers A, Zollman C. Hypnosis and relaxation therapies. BMJ. 1999;319:1346–9.

24. Frank DL, Khorshid L, McKee MG. Biofeedback in medicine: who, when, why, and how? Ment Health Fam Med. 2010; 7(2):85–91.

25. Tusek DL, Church JM, Strong SA, Grass JA, Fazio VW. Guided imagery: a significant advance in the care of patients undergoing elective colorectal surgery. Dis. Colon Rectum. 1997; 40:172–8.

26. Gruzelier J. A review of the impact of hypnosis, relaxation, guided imagery, and individual differ-ences on aspects of immunity and health. Stress. 2002; 5(2):147–63.

27. Ventola, CL. Current issues regarding comple-mentary and alternative medicine (CAM) in the United States: part 1: the widespread use of CAM and the need for better–informed health care professionals to provide patient counseling. P T. 2010;35(8):461–468.

28. Waldman SA, Terzic A. Pharmacology and thera-peutics: principles to practice. Philadelphia: Else-vier/W. B. Saunders; 2008. p. 1536.

29. Wieland L.S., Manheimer E, Berman B.M. Devel-opment and classification of an operational defi-nition of complementary and alternative medi-cine for the Cochrane collaboration. Altern Ther Health Med. 2011;17(2):50–9.

30. Lamas G.A, Hussein S.J. EDTA chelation therapy meets evidence–based medicine. Complement Ther Clin Pract. 2006;12(3):213–5.

31. Langhorst J, Musial F, Klose P, Häuser W. Efficacy of hydrotherapy in fibromyalgia syndrome — a meta–analysis of randomized controlled clinical trials. Rheumatology (Oxford). 2009;48(9):1155–

9.32. Elvin-Lewis M. Should we be concerned about

herbal remedies. J Ethnopharmacol. 2001;75(2-3):141–64.

33. Rabago D, Slattengren A, Zgierska A. Pro-lotherapy in Primary Care Practice. Prim Care. 2010;37(1):65–80.

34. Beamon S, Falkenbach A, Fainburg G, Linde K. Speleotherapy for asthma. Cochrane Database Syst Rev. 2001;(2):CD001741.

35. Pettman E. A history of manipulative therapy. J Man Manip Ther. 2007;15(3):165–74.

36. Tabish SA. Complementary and alternative healthcare: is it evidence based? Int J Health Sci. 2008;2(1):VIX.

37. Meeker WC, Haldeman S. Chiropractic: a pro-fession at the crossroads of mainstream and alternative medicine. Ann Intern Med. 2002; 136(3):216–227.

38. Keating JC. The meanings of innate. J Can Chiropr Assoc. 2002;46(1):4–10.

39. Gouveia LO, Castanho P, Ferreira JJ. Safety of chiropractic interventions: a systematic review. Spine (Phila Pa 1976). 2009;34(11):405–13.

40. Kaptchuk TJ, Eisenberg DM. Chiropractic origins, controversies, and contributions. Arch Intern Med. 1998;158(20):2215–24.

41. Moyer CA, Rounds J, Hannum JW. A meta–anal-ysis of massage therapy research. Psychol Bull. 2004;130(1):3–18.

42. Field T. Massage therapy. Med Clin North Am. 2002;86(1):163–71.

43. Hernandez-Reif M, Field T, Krasnegor J, Martinez E, Schwartzman M, Mavunda K. Children with cystic fibrosis benefit from massage therapy. J Ped Psych. 1999;24(2):175–81.

44. Long L, Huntley A, Ernst E. Which complemen-tary and alternative therapies benefit which conditions? A survey of the opinions of 223 pro-fessional organizations. Complement Ther Med. 2001;9(3):178–85.

45. Berman BM, Langevin HM, Witt CM, Dubner R. Acupuncture for chronic low back pain. N Engl J Med. 2010;363:454–461.

46. Linde K, Allais G, Brinkhaus B, Manheimer E, Vick-ers A, White AR. Acupuncture for migraine pro-phylaxis. Cochrane Database Syst Rev. 2009;(1).

47. Jahnke R, Larkey L, Rogers C, Etnier J, Lin F. A com-prehensive review of health benefits of qigong and taichi. Am J Health Promot. 2010;24(6):1–25.

48. Eccles N. A critical review of randomized con-trolled trials of static magnets for pain relief. J Altern Complement Med. 2005; 11(3):495–509.

49. Pittler MH, Brown EM, Ernst. Static magnets for reducing pain: systematic review and meta–analy-sis of randomized trials. CMAJ. 2007;177(7):736–742.

50. National Center for Complementary and Inte-grative Health. Magnets for pain relief [Internet]. 2015 [updated 2015 January 27; cited 2015 June 20]. Available from: https://nccih.nih.gov/health/magnet/magnetsforpain.htm

51. Lee MS, Pittler MH, Ernst E. Effects of reiki in clin-ical practice: a systematic review of randomized clinical trials. Int J Clin Pract. 2008;62(6):947–954.

52. vanderVaart S, Gijsen VMGJ, de Wildt SN, Ko-ren G. A systematic review of the therapeu-tic effects of reiki. J Altern Complement Med. 2009;15(11):1157–1169.

references

editorials

1. 1. McFarland B, Bigelow D, Zani B, Newsom J, Kaplan M. Complementary and alternative med-icine use in Canada and the United States. Am J Public Health. 2002 Oct;92(10):1616–1618.

2. Professional standards and guidelines for com-plementary and alternative therapies [Internet]. Vancouver: College of Physicians and Surgeons of British Columbia; 2009 [cited 2015 Jun 20]. Available from: https://www.cpsbc.ca/files/pdf/PSG-Complementary-and-Alternative-Thera-pies.pdf

3. Sackett DL, Rosenberg WMC, Muir Gray JA, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71–72.

4. Ip, A. Traditional Chinese medicine: learning from Dr. Henry Lu, PhD, Dr. TCM. UBCMJ 2015;7(1):35-37.

5. Ernst E. How much of CAM is based on research evidence? Evid Based Complement Alternat Med 2011;2011:676490.

6. Imrie R, Ramey D. The evidence for evidence–based medicine. Complement Ther Med 2000;8(2):123–126.

7. Institute of Medicine (US) Committee on the Use of Complementary and Alternative Medi-cine by the American Public. The National Acad-emies Press, Washington, D.C. 2005.

8. Canada. Royal Commission on Aboriginal Peo-ples, Dussault R, Erasmus G. Report of the Royal Commission on Aboriginal Peoples: looking for-ward, looking back. Indian and Northern Affairs Canada; 1996.

9. Shankar K, Liao LP. Traditional systems of medicine. Phys Med Rehabil Clin N Am 2004;15(4):725–747.

10. Hill DM. Traditional medicine in contemporary contexts. Protecting and respecting indigenous knowledge and medicine. National Aboriginal Health Organization, Ottawa 2003.

11. Hesketh T, Zhu WX. Health in China. Traditional Chinese medicine: one country, two systems. BMJ.

disclosuresThe authors do not have any conflicts

of interest.

11ubcmj.com

it is a naturally–derived substance, SJW should not automatically be assumed to be safer than its synthetic counterparts. In fact, there are a number of plants capable of causing great harm to humans and a number of synthesized drugs that can do the same.

A pharmacologist, too, would draw no distinction between SJW and synthetic prescription drugs, including those in its therapeutic class. Although SJW has a variety of molecular targets in the body, its key mechanism in treating depression is believed to be inhibition of reuptake of neurotransmitters, such as serotonin—this is the same mechanism by which many of the widely–used antidepressants work.2 Much like other antidepressants, SJW elicits side effects and importantly, in Emily’s case, it is an inducer of cytochrome P450 enzymes and p–glycoprotein, an intestinal efflux pump that is increasingly implicated in a number of important drug–drug interactions.3,4

One of the clear distinctions between SJW and other antidepressants is that it can be readily obtained without consulting a health care provider, most notably a physician or a pharmacist. There are a number of options that might have proven beneficial for Emily, all with far less risk of harm than SJW. If she is suffering from mild depression, non–pharmacological interventions include psychotherapy, exercise, phototherapy, and a review of her current medications to ensure that none are responsible for her symptoms.5,6 In opting for what Emily believes to be a natural intervention—that she might perceive as “non–pharmacological” — she has unwittingly chosen a path that is the opposite of what she was intending. Perhaps more concerning, when patients

with more severe depression self–select products like SJW, they are less likely to be assessed or followed by a physician, and therefore, lack the supports they might need to monitor their clinical status and to ensure that they are not at risk of self–harm or of harming others.

Finally, to an evidence–based practitioner, what distinguishes NHPs from their synthetic counterparts is the general lack of evidence supporting their efficacy or safety. SJW is one of the most studied NHPs and it is generally accepted that SJW is likely superior to placebo for mild to moderate depression. However, there is still some uncertainty about this and about its associated harms because studies of SJW are heterogeneous in both design and results.7 For the majority of NHPs, the evidence is lacking.8-10

The question is, then, why — well into the 21st century — do we still have such a gap between perceptions of NHPs and reality? Though there is no easy solution to this problem, there are clues as to why it exists. With rare exceptions, NHPs are not patented in the same way that conventional pharmaceuticals are. This patenting process forms the basis of our current system for reviewing and approving pharmaceuticals, most notably because of the exorbitant expense associated with the process. Much of that expense is due to the (hopefully) well–designed, double–blind randomized controlled trials that lie at the heart of the drug approval process. The incentive for pharmaceutical companies to undergo this expensive and arduous process is the promise that they retain market exclusivity for their product for a number of years after approval. NHPs typically cannot be guaranteed the same promises of market

Natural Health Products: The Gap between Perceptions and Reality

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Stan Bardala,°, PhDCitation info: UBCMJ. 2015: 7.1 (11-12)°Corresponding author: bardals@uvic.caa Professor, Division of Medical Science, University of Victoria, Victoria, BC

Emily is a 49–year–old female who takes a number of prescription medications,

including warfarin. She has noted feeling “down” over the past several weeks, and, while motivated to do something to improve her quality of life, she is reluctant to add to the number of medications she already takes. She hears about a herbal product named St. John’s Wort (SJW). Unlike prescription antidepressants, which are synthetically–derived chemicals, she understands that SJW comes from a plant, and she believes that this herbal product presents a safer, more natural option for managing her depressed mood. After some deliberation, she heads to her local pharmacy, purchases a bottle of SJW, and begins taking it that day.

The above scenario, with obvious variations for indication and product choice, likely plays out countless times every day across Canada. A given patient self–selects a natural health product (NHP), either in a pharmacy, on the internet, or in a health food store, under the assumption that a natural, plant–derived product always presents a safer alternative to synthetically–derived prescription drugs. We know this is a common scenario because the NHP industry consistently records annual sales topping a billion dollars in Canada.1 However, as the above scenario plays out, there are a number of assumptions here that are not supported.

To a chemist, there is no difference between SJW and the prescription drugs that a patient, such as Emily, could potentially take for a given condition. SJW is a chemical derived from the lovely flower, Hypericum perforatum. However, when analyzed by a chemist, it has a chemical structure not unlike an antidepressant synthesized in the laboratory, and though

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exclusivity, because in most cases, these molecules were not patented upon discovery and have not been modified in a significant enough manner to justify patent protection.

In 2004, the government of Canada did attempt to improve this system with the NHP regulations, which were intended to address key issues, such as quality control, standardization, contamination, proof–of–benefit, and safety.11 A manufacturer, after having met the requirements of this process, receives a natural product number (NPN), analogous to the drug identification number assigned to “conventional” drugs approved for sale by Health Canada. The NPN is intended to provide some reassurance to the consumer that the product they are purchasing has met the above standards. However, enforcement of these regulations has been an issue,12

and these changes have done little to assist with scenarios such as Emily’s. The evidence upon which NHPs are used, with respect to both efficacy and safety, is still generally shaky at best, and they still fall under the radar of most practitioners,13 despite the clear need for their use to be more closely documented.

Although there are no easy solutions to issues with the use of NHPs, there are simple steps that can be taken to try to reduce the risk of harm from taking these agents. The first involves improved enforcement of existing legislation. The challenge facing enforcement is the sheer number of manufacturers with products

for sale and the availability of these products via the internet. As studies have suggested, even the seemingly simple goal of ensuring quality control has been a challenge.14 Given the resources that might be required to improve enforcement, perhaps a system that sets a much higher bar for manufacturers to achieve a NPN would provide an incentive for a few manufacturers to invest additional resources in their products. Alternatively, a system could be developed to provide guidance to consumers as to which manufacturers and products far exceed the standards. From the public perspective, Canadians need clear guidance as to the efficacy and safety of a given NHP, rather than having to rely on claims made by manufacturers.15 NHPs that have known safety issues or are widely considered as substitutes for proven remedies should not be sold anywhere other than a pharmacy. Ideally, patients would be required to consult with a pharmacist before purchasing such a NHP; however, this might not be practical, and some patients might resist discussing their health concerns in a pharmacy setting. Thus, another option would be to better educate patients by changing the terminology we use to refer to NHPs. This is because NHPs, like SJW, are, in reality, drugs derived from natural sources. The terms that we currently most often use to refer to these chemicals (i.e. “natural health products”, “herbals”, etc.) stand in stark contrast to the terminology we use to refer to prescription drugs (i.e. “drug”, “synthetic”, “pharmaceutical”, etc.), and it is thus no wonder that the public views them so differently. A more informed consumer might be the most efficient way to bridge the gap between perceptions of NHPs and reality.

Available from: http://www.statcan.gc.ca/pub/18-001-x/2013001/t004-eng.htm.

2. Sarris J. St. John’s wort for the treatment of psychiatric disorders. Psychiatr Clin North Am. 2013 Mar ;36(1):65-72.

3. Posadzki P, Watson LK, Ernst E. Adverse effects of herbal medicines: an overview of system-atic reviews. ClinMed. 2013 Feb 1;13(1):7-12.

4. Shi S, Klotz U. Drug interactions with herb-al medicines. Clin Pharmacokinet. 2012 Feb 1;51(2):77-104.

5. Ravindran AV, Lam RW, Filteau MJ, Lespérance F, Kennedy SH, Parikh SV, et al. Canadian network for mood and anxiety treatments (CANMAT) clinical guidelines for the man-agement of major depressive disorder in adults. V. Complementary and alternative medicine treatments. J Affect Disorders. 2009 Aug 8;117:S54-64.

6. Lam RW, Kennedy SH, Grigoriadis S, McIntyre RS, Milev R, Ramasubbu R, et al. Canadian network for mood and anxiety treatments (CANMAT) Clinical guidelines for the man-agement of major depressive disorder in adults. III. Pharmacotherapy. J Affect Disorders. 2009 Aug 11;117:S26-43.

7. Linde K, Berner MM, Kriston L. St John’s wort for major depression. Cochrane Database Syst Rev [Internet]. 2008 Oct 8 [cited 2015 April 4]. Available from: http://onlinelibrary.wi-ley.com/doi/10.1002/14651858.CD000448.pub3/abstract.

8. Bega D, Gonzalez–Latapi P, Zadikoff C, Simuni T. A review of the clinical evidence for com-plementary and alternative therapies in Par-kinson’s disease. Curr Treat Options Neurol. 2014 Aug 22;16(10):314.

9. Ernst E. Herbal medicine in the treatment of rheumatic diseases. Rheum Dis Clin North Am. 2011 Dec 3;37(1):95-102.

10. Holtmann G, Talley NJ. Herbal medicines for the treatment of functional and inflammatory bowel disorders. Clin Gastroenterol Hepatol. 2015 Mar 25;13(3):422-32.

11. Minister of Justice. Food and drugs act: nat-ural health products regulations (SOR/2003-196) [Internet]. Ottawa (ON): Government of Canada; 2003 Jun 5 [updated 2008 Jun 1; cited 2015 April 7]. Available from: http://laws-lois.justice.gc.ca/eng/regulations/SOR-2003-196/index.html.

12. Drugstore remedies: license to deceive [on-line broadcast]. CBC Marketplace. Canada: CBC Radio–Canada; 2015 Mar 13.

13. Monte AA, Anderson P, Hoppe JA, Wein-shilboum RM, Vasiliou V, Heard KJ. Accura-cy of electronic medical record medication reconciliation in emergency depar tment patients. J Emerg Med. 2015 Mar 19;S0736-4679(14):01440-1.

14. Posadzki P, Watson L, Ernst E. Contamination and adulteration of herbal medicinal products (HMPs): an overview of systematic reviews. Eur J Clin Pharmacol. 2012 Jul 29;69(3):295-307.

15. Thakor V, Leach MJ, Gillham D, Esterman A. The quality of information on websites selling St. John’s wort. Complement Ther Med. 2011 May 25;19(3):155-60.

feature

references1. Khamphoune B. Results from the 2011 func-

tional foods and natural health products survey [Internet]. Ottawa (ON): Statistics Canada; 2013 Sep 05 [cited 2015 April 04].

The question is, then, why — well into the 21st century — do we still have such a gap between perceptions of NHPs and reality? Though there is no easy solution to this problem, there are clues as to why it exists.

disclosuresThe author does not have any conflicts

of interest.

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Bringing Mindfulness into Medical Practice: UBC’s New Family Medicine Residency Program Delivers Mindfulness–Based Stress Reduction Curriculum

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Devon Christiea,°, MD CCFP GPPACitation info: UBCMJ. 2015: 7.1 (13-15)°Corresponding author: devon.christie@gmail.coma Connect Health, Centre for Integrative and Functional Medicine, Vancouver, BC

This summer, four R1 Rural Family Medicine residents will commence

their postgraduate training in the inaugural UBC Kootenay Boundary Rural Family Medicine residency program. As par t of their Behavioural Medicine curriculum, they will par ticipate in a 6–week Mindful Stress Reduction program, an adaptation of the traditional 8–week Mindfulness Based Stress Reduction (MBSR) program that was founded at the University of Massachusetts in 1979 by Jon Kabat–Zinn. MBSR has been subject to numerous RCTs and meta–analyses showing its effectiveness to alleviate symptoms and improve quality of life in cancer, cardiovascular disease, chronic pain, depression, anxiety disorders, and in prevention in healthy adults and children.1-4

A 2013 review identified 14 medical schools that offer mindfulness programs, including McGill, Brown, Georgetown, Duke, and Harvard.5 Only two of those institutions incorporated mindfulness as a mandatory component of their undergraduate medical curricula: University of Rochester and Monash Medical School (Australia).5 The Kootenay Boundary program will likely be the first postgraduate family medicine program to incorporate training in mindfulness into its core curriculum, in par tial fulfillment of the curriculum’s mandate for innovation. A recent publication shows that interest in mindfulness training among medical students is higher in those who are in clinical (72%) vs. preclinical (53%) stages of their training, which supports the integration of mindfulness into a postgraduate core curriculum.6

What is mindfulness?Mindfulness refers to a capacity

of mind, whereby one attends to his or her immediate experience arising both from within (e.g. mental states, thoughts, feelings, somatic sensations) and from our environment (e.g. auditory, visual, relationships, home, and work conditions) through vigilant observation while bearing the attitudes of kindness, acceptance, and non–judgment. In Kabat–Zinn’s concise words, “paying attention, on purpose, in the present moment, without judgment.”7 Mindfulness is often learned through meditation, but is not equivalent to it.8 Meditation describes varied formal practices (e.g. breath awareness, vocalizations/chanting, mantra, movement/yoga, loving kindness/metta) whereby one practices sustaining attention in the present, thereby cultivating mindfulness. In the MBSR program, formal practices include the body scan, yoga, walking meditation, focused–attention meditations (e.g. to breath, sound, body sensations), and a form of open–monitoring meditation known in MBSR as “choiceless awareness.”

Mindfulness has recently become a buzzword, owing largely to increasing media coverage and burgeoning literature, as exemplified by recent CBC coverage of a UBC study published January 2015 showing that mindfulness decreased stress and improved optimism and math abilities of grade four and five students in Coquitlam, B.C.9 A PubMed search of the term mindfulness returned 2231 citations published in the last ten years. By comparison, there were only 115 studies published in the preceding decade.

There is rising awareness about increasing rates of burnout among physicians, including estimates of up to 50% among residents, regardless of year of training.10 A 2015 US survey revealed 50% of family physicians are burnt out, a number that increased from 43% in 2013.11 The estimated costs of burnout among Canadian physicians is $ 213.1 million, with family physicians accounting for 58.8% of the costs.12 While burnout is not a recognized disorder in The Diagnostic and Statistical Manual of Mental Disorders, the World Health Organization International Classification of Diseases (ICD–10) defines burnout as “a state of vital exhaustion.”13 Burnout has three measurable dimensions: emotional exhaustion from overwhelming work demands, depersonalization (impersonal response toward patients or coworkers), and perceived lack of personal accomplishment.13 Burnout can lead to anxiety, substance abuse, depression, addiction, and suicide.14

Suicide is the only cause of death that is higher in physicians than the general population, and while rates are higher in both genders compared to all other professions, the rate in female physicians is an incredible 250–400% higher than the general population.15 Mindfulness is one of the few self–care practices with evidence of benefit for physician wellness.16 Encouraging studies show that mindfulness and meditation may play a protective role in the prevention

Why teach mindfulness to physicians? A balm for burnout

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culture void of routine psychological and emotional integration opportunities.29 This commonly leads to patterns of emotional distancing and repression, to sacrificing one’s own wellness, and eventually, to burnout. If not addressed prior to entering one’s career, these patterns can only provide a disservice to doctor and patient alike. It is imperative that medical curricula evolve to formally incorporate elements such as mindfulness practice that can serve to redress these patterns and plant the seed for lifelong attitudes and behaviours that foster physician self–awareness and well–being. This year, in line with leading medical institutions worldwide, UBC will be taking this step in Family Medicine training.

feature

references1. Gotink RA, Chu P, Busschbach JJ, Benson H,

Fricchione GL, Hunink MG. Standardized mindfulness-based interventions in health-care: an overview of systematic reviews and meta-analyses of RCTs. PLoS One. 2015 Apr 16;10(4):e0124344. doi: 10.1371/journal.pone.0124344. eCollection 2015.

2. Keng S–L, Smoski MJ, Robins CJ. Effects of mindfulness on psychological health: a re-view of empirical studies. Clin Psychol Rev. 2011;31:1041-56.

3. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness–based stress reduction and health benefits: a meta-analysis. J Psychosom Res. 2004;57:35-43.

4. Jorback LO, Arendt M, Ørnbøl E, Fink P, Walach H. Mindfulness–based stress reduction and mindfulness–based cognitive therapy—a systematic review of randomized controlled trials. Acta Psychiatr Scand. 2011;124:102-19.

Self-awareness and relationship–centred care

The College of Family Practictioners of Canada (CFPC) Principles of Family Medicine states, “family physicians have an understanding and appreciation of the human condition, especially the nature of suffering and patients’ response to sickness. They are aware of their strengths and limitations and recognize when their own personal issues interfere with effective care.”22 Self–awareness is the key to truly understanding the human condition and the nature of suffering, and it can be cultivated through mindfulness. Furthermore, mindful practitioners can attend to their own physical, mental, and emotional processes during patient encounters, enabling them to internally self–regulate while listening attentively and acting with “compassion, technical competence, presence, and insight.”23 This ultimately fosters a cultural shift from patient–centred care, where physicians tend to focus solely on the needs of the patient, to relationship–centred care.24 This reorientation toward mutuality highlights not only what we give but also what we receive in our practice, and increases both patient and physician satisfaction, and resilience.25,26

Medical training asks students who are often perfectionistic at baseline to acquire an overwhelming amount of knowledge in an environment of cross–examinations and occasional real abuse,27,28 while at the same time being exposed to highly emotionally charged and sometimes horrific situations in a

disclosuresDr. Christie is a member of the clinical

faculty at UBC, providing instruction to the UBC Kootenay Boundary Rural Family Medicine residency program. She has been involved in curriculum planning for the residency program as outlined in the ar ticle. She is also involved in planning a mindfulness and resilience program for healthcare providers at the Kalein Hospice Centre, where she works as a faculty member. She teaches mindfulness based stress reduction (as an MSP-funded group medical visit, where medically indicated) to patients. Dr. Christie also receives no compensation from any private parties.

and management of burnout.17 Medical students who participate in mindfulness programs develop reductions in psychological distress and burnout, and increased capacity for empathy.5

One week of compassion meditation training was found to counterbalance empathy fatigue and was accompanied by corresponding changes in the regions of the brain associated with compassion, positive emotions, and affiliation, thus supporting this as a possible coping strategy when confronted with distress of others.18

Improved safety in patient care

Studies also show that physician well–being affects patient care.19

Physicians have a professional obligation to maintain good health and practice good medicine, including making correct diagnoses and appropriate therapeutic decisions.13 Research shows meditators have improved perception, increased reaction–time consistency, decreased reactivity to stressful stimuli, faster return to baseline activity after stress arousal, decreased activity in anxiety–related brain regions (amygdala, insular cortex),

There is rising awareness about increasing rates of burnout among physicians, including estimates of up to 50% among residents, regardless of year of training. A 2015 US survey revealed 50% of family physicians are burnt out, a number that increased from 43% in 2013.

better control in buffering physiological responses to stressors (inflammatory and stress hormones), and even shrinkage of the amygdala over longer periods of practice.20 The Canadian Medical Protective Association Good Practices Guide recommends physicians “improve self–awareness and mindfulness” — including recognizing fatigue, being aler t to emotions, and recognizing that stress may interfere with reasoning — in order to increase situational awareness, one of the human factors that supports safe care and reduces medico–legal risk.21

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soc J [Internet]. 2014 Jun [cited 2015 Apr 25]. Available from: http://www.cmaj.ca/content/early/2014/06/02/cmaj.140588.full.pdf.

14. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374:1714-21.

15. American Foundation for Suicide Prevention. Facts About Physician Suicide [Internet]. 2015 [cited 2015 Apr 27]. Available from: https://www.afsp.org/preventing-suicide/our-ed-ucat ion-and-prevent ion-progr ams/pro-grams-for-professionals/physician-and-med-i c a l - s t u den t - d ep r e s s i o n - a nd - s u i c i d e /facts-about-physician-depression-and-suicide.

16. Kearney MK, Weininger RB, Vachon ML, Har-rison RL, Mount BM. Self–care of physicians caring for patients at the end of life. J Amer Med Assoc. 2009;301(11):1155-64.

17. Sotile WM, Sotile MO. Beyond physician burn-out: keys to emotional management. J Med Pract Manage. 2003;18:314-8

18. Klimecki OM, Leiberg S, Lamm C, Singer T. Functional neural plasticity and associated changes in positive affect after compassion training. Cereb Cortex. 2013;23(7):1552-61.

19. Halbesleben JR, Rather t C. Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patients. Health Care Manage Rev. 2008;33(1):29-39.

20. Ricard M, Lutz A, Davidson RJ. Mind of the meditator. Scientific American [Internet]. 2014 Nov [cited 2015 Apr 25]. Available from: www.scientificamerican.com.

21. Canadian Medical Protective Association. Sit-uational Awareness: What is going on around you? [Internet]. Toronto: Canadian Medical Protective Association; 2014 [cited 2015 Apr 23]. Available from: https://www.cmpa-acpm.ca/ser ve/docs/ela/goodpracticesguide/pag-es/human_factors/Situational_awareness/improve_self-awareness_and_mindfulness-e.html.

22. The College of Family Physicians of Canada. Four Principles of Family Medicine [Inter-

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net]. Toronto: College of Family Physicians of Canada; 2015 [cited 2015 Apr 23]. Available from: http://www.cfpc.ca/principles/#sthash.V01Om590.dpuf.

23. Epstein RM. Mindful Practice. J Amer Med As-soc. 1999 Sep 1;282(9):833-9.

24. Beach MC, Inui TI. Relationship–centered care: a constructive reframing. J Gen Intern Med. 2006;21(Suppl 1):S3-8.

25. Krupat E, Rosendranz SL, Yeager CM, Barnard K, Putnam SM, Inui TS. The practice orienta-tions of physicians and patients: the effect of doctor–patient congruence on satisfaction. Patient Educ Couns. 2000;39:49-59.

26. Dobie S. Reflections on a well–traveled path: self–awareness, mindful practice, and relation-ship–centered care as foundations for med-ical education. Acad Med. 2007;82(4):422-7.

27. Silver HK, Glicken AD. Medical student abuse: incidence, severity, and significance. J Amer Med Assoc. 1990;263:527-73.

28. Lubitz RM, Nguyen DD. Medical student abuse during third–year clerkships. J Amer Med Assoc. 1996;275:414-6.

29. Novack DH, Epstein RM, Paulsen RH. Toward creating physician–healers: fostering medical student’s self–awareness, personal growth and well–being. Acad Med. 1999;74(5):516-20.

5. Dobkin PL, Hutchinson TA. Teaching mindful-ness in medical school: where are we now are where are we going? Med Educ. 2013;47:768-79.

6. Van Dijk I, Lucassen PL, Speckens AE. Mind-fulness training for medical students in their clinical clerkships: two cross sectional stud-ies exploring interest and par ticipation. Med Educ. 2015 Feb;15(24):1-8.

7. Kabat–Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness (Revised and Updated Edition). New York: Bantam Books; 2013.

8. Briere J. Pain and Suffering: A Synthesis of Buddhist and Western Approaches to Trauma. In: Folette VM, Briere J, Rozelle D, Hopper JW, and Rome DI. Mindfulness Oriented Interven-tions for Trauma: Integrating Contemplative Practices. New York & London: The Guildford Press; 2015. p. 11-30.

9. British Columbia: On the Coast, All Points West CBC News. Goldie Hawn’s mindfulness program makes kids better at math, says UBC. CBC My Region [Internet]. 2015 [updated 2015 Jan 28; cited 2015 Apr 24]. Available from: http://www.cbc.ca/m/touch/canada/britishcolumbia/story/1.2932715.

10. Ishak WW, Lederer S, Mandili C, Nikravesh R, Seligman L, Vasa M, et al. Burnout during resi-dency training: a literature review. J Grad Med Educ. 2009;1:236-42.

11. Peckham C. Medscape Physician Lifestyle Re-port 2015. [Internet]. 2015 Jan [cited 2015 Apr 28]. Available from: http://www.med-scape.com/features/slideshow/lifestyle/2015/public/overview.

12. Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. Health Serv Res [Internet]. 2014 [cited 2015 Apr 25];14(254). Available from: http://www.biomedcentral.com/1472-6963/14/254.

13. Fralick M, Flegel K. Physician Burnout: Who will protect us from ourselves? Can Med As-

Self–awareness is the key to truly understanding the human condition and the nature of suffering, and it can be cultivated through mindfulness.

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When InspireHealth was founded in 1997, like today, many physicians tried as best as they could to bring these simple principles into their daily practice of medicine to support their patients’ health. However, at the time, these principles were sufficiently unconventional that some of our more conservative colleagues referred to InspireHealth (known at that time as Centre for Integrative Healing) as complementary or alternative medicine, a characterization that I’ve always considered odd. The principles above are, after all, essential aspects of good medicine, and they have guided Sir William Osler and many other physicians interested in the healing arts throughout the history of medicine. We do our profession an injustice by characterizing medicine that values patient empowerment, engagement, health, and choice as “alternative,” “complementary,” or “integrative.” These are, after all, basic principles of good medicine and are as important to the practice of medicine as technical skill and knowledge.

Most people know that a healthful diet and exercise are good for them and that smoking isn’t. The barriers to health engagement are typically more meaningful than simply a lack of information. These barriers are often unconscious, limiting patterns and internal barriers to self–love and acceptance. As human beings and physicians, we can’t take responsibility for someone else’s healing. If, instead, we take responsibility for our own healing, we inspire others to do the same. The more we heal, the greater our capacity to facilitate healing in others becomes, not because we are taking responsibility for their healing, but because we are taking responsibility for our own. If we have faced and released our fears (e.g., our fear of death) and our limiting patterns, we can be in a compassionate and empathetic

relationship with our patients without our own fears and patterns being triggered by their suffering. As we embrace the fullness of our humanity and of our own healing and learn to more fully love ourselves, our capacity for compassion increases, and we inspire others to connect with their own healing. At InspireHealth, we witness inspiration and joy in our patients as they release their limiting patterns and connect to their capacity to more fully love and care for themselves, which ripples out, inspiring their family and friends.

Patient empowerment is essential for health engagement. Full support of informed patient choice is an essential component of empowerment. When we empower patients, it means that we fully support their right to choose, even if their informed choice is different from the choice we would make for ourselves. If we wish to engage patients in their health, we must honour and support their right to choose.

Most physicians did not enter into medicine solely to master technical skills

What Is Good Medicine?

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Hal Gunna,°, MDCitation info: UBCMJ. 2015: 7.1 (16-17)°Corresponding author: hgunn@inspirehealth.caa Co-Founder and CEO of InspireHealth, Vancouver, BC

After practicing as a family doctor for 14 years, first in Tumbler Ridge and then in Vancouver, I came to recognize what many of my colleagues and, more recently, clinical research have discovered; an empowered, engaged patient who is active in supporting their own health optimizes outcomes and reduces treatment costs.1-3 At that time — 18 years ago — Dr. Roger Rogers and I recognized the importance of engaging people living with chronic disease in their own health, and we founded InspireHealth, based on the following basic principles of good medicine:

1. Patient empowerment, including supporting our patients in learning about their disease and about the ways that they can support their own health.

2. Healthful nutrition, exercise, love and connection, and stress reduction, including the options of meditation and yoga.

3. Patient choice. An essential foundation of patient empowerment and engagement is the full support of informed choice,4-6 even if (or from a practical perspective, especially if ) the informed choice is different from the one we would make ourselves or recommend. Honouring and supporting patient choice and informed consent are fundamental and essential aspects of good medicine, professionalism, and patient empowerment.

4. Recognition of the value of standard medical treatments.

5. Modeling health and happiness. We communicate more through who we are than through our words. Physician heal thyself.

6. Above all, do no harm.7

A holistic approach to care, one that honours and cares for the whole person, including patient empowerment and choice, has a lineage in medicine. It is important that we claim this lineage because it is the basis of good medicine.

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or knowledge. While these are important aspects of medical school education, they are only one aspect of what makes us a good doctor. Most physicians enter medicine because they had — and have — an interest in the human condition and healing and an interest in learning to empower, engage, and optimize healing, while minimizing unnecessary suffering. Most physicians have a longing to connect with their patients on a more meaningful level than simply prescribing treatments. At InspireHealth, we have sought to make the six principles above explicitly important in our work and to recognize and honour the important role that they play in empowering and engaging our patients in health and healing – in other words, to practice good medicine. Not alternative or complementary medicine. Good medicine.

A holistic approach to care, one that honours and cares for the whole person, including patient empowerment

and choice, has a lineage in medicine. It is important that we claim this lineage because it is the basis of good medicine. It is about understanding how to be more fully in compassionate empathy in the midst of human suffering. It is about connecting to our own life force and happiness and about celebrating life, death, and birth. This is what it means to be human. This is what it means to be a good physician.

To relegate these essential aspects of healing and health to “Eastern” or “complementary” medicine is to admit the inadequacies of our own profession and of ourselves as physicians. It takes courage to embrace human suffering with empathy. It takes courage and humility to be a compassionate guide rather than an “expert.” It takes courage, humility, and wisdom to recognize that we know far less about the human condition, healing. and the mystery of life and death than our schooling readily admits. It takes courage to embrace this mystery, to recognize the limitations of our own training, and to recognize that other healing traditions might have something positive to offer our patients, even if it is not part of our own training or easily researched. Good medicine includes humility and an openness to new ideas and to other ways of thinking.

If we are afraid of our own inadequacies, we label what frightens us as “other.” Good medicine includes a humble embrace of the mystery of the human condition and of the six principles above. Our connection to these principles, as human beings, is as strong in us as it was in Sir William Osler. In embracing these principles, we are rewarded with the remarkably fulfilling practice of supporting our patients and ourselves in a deeper understanding of health and healing and what it means to be human. This is not complementary or integrative medicine; this is good medicine.

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references1. Greene J, Hibbard JH, Sacks R, Overton V,

Parrotta CD. When patient activation levels change, health outcomes and costs change. Health Affair. 2015 Mar;34(3):431-7.

2. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; Delivery systems should know their patients’ ‘scores’. Health Affair. 2013 Feb;32(2):2216-22.

3. Mitchell SE, Gardiner PM, Sadikova E, Martin JM, Jack BW, Hibbard JH, et al. Patient activa-tion and 30–day post–discharge hospital utili-zation. J Gen Intern Med. 2014 Feb;29(2):349-55.

4. Brown SJ. Patient-centered communication. Ann Rev Nursing Res. 1999 Jan 1;17(1):85-104.

5. StayWell. Creating successful patient engage-ment within your ACO [Internet]. Yardley(PA): Krames Print Patient Education; 2013 Sept [cit-ed 2015 Jun 11]. Available from: http://cdn2.hubspot.net/hub/36339/file-341022444-pdf/docs/aco_white_paper_sept._2013.pdf.

6. Buetow S, Davis R, Callaghan K, Dovey, S. What attributes of patients affect their in-volvement in safety? A key opinion leaders’ perspective. Brit Med J Open. 2013 Aug 13;3(8):1-6.

7. Hippocrates. De Morbis Popularibus (Of the Epidemics) [Internet]. Jones WH, Greek translator. Adams CD, English translator. New York (NY): Dover. c1868 [cited 2015 Jun 11]. Available from: http://www.perseus.tufts.edu/hopper/text?doc=Perseus%3Atex-t%3A1999.01.0248%3Atext%3DEpid.

We do our profession an injustice by characterizing medicine that values patient empowerment, engagement, health, and choice as “alternative,” “complementary,” or “integrative.” These are, after all, basic principles of good medicine and are as important to the practice of medicine as technical skill and knowledge.

As human beings and physicians, we can’t take responsibility for someone else’s healing. If, instead, we take responsibility for our own healing, we inspire others to do the same. The more we heal, the greater our capacity to facilitate healing in others becomes, not because we are taking responsibility for their healing, but because we are taking responsibility for our own.

disclosuresDr. Hal Gunn is the co-founder CEO

of InspireHealth, a not-for-profit society that provides supportive care for people living with cancer.

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conventional resources and still show no improvement in their health. I see patients who explore alternatives because they are not getting better. Unfortunately, by the time I have the opportunity to work with these types of patients, they are frustrated and have spent both time and money without receiving any apparent benefits. The beauty of an integrative care model is the potential to streamline patients to the appropriate medical model. In many cases, a synergy can exist when both the conventional and naturopathic approaches are applied to a patient’s case. For this to happen however, the two professions have to understand the strengths and weaknesses of both approaches. It is vital that we as physicians recognize the following: when one approach is better suited over the other, understand how the two professions can work in tandem, and most importantly trust the treatment plan of the other doctor. Essentially, we must keep an open mind for true integrative care to become a reality.

Our two professions have come a long way in working alongside each other, and naturopathic doctors have gained ground and respect as medical practitioners, with the scope of practice continuing to evolve. There are four primary objectives for scope of practice for British Columbia naturopathic doctors.2 With these goals in mind, the British Columbia Naturopathic Association (BCNA) works tirelessly to expand the scope of naturopathic practice. These goals include prescribing rights, laboratory and diagnostic

access, specialist referral, and hospital privileges.2 In 2009, the first of these pillars was realized, with naturopathic doctors gaining prescribing privileges. Naturopathic doctors have the ability to order laboratory testing; however, patients are required to pay for each test. In addition to prescribing privileges, naturopathic doctors incorporate various modalities into patient treatment plans. These may include acupuncture, manual therapies (osseous manipulation, electrotherapy), injection therapies (neural therapy, prolotherapy), botanical medicine, use of neutraceuticals, and medical nutrition. Naturopathic doctors receive extensive training in these modalities and are able to make clinical judgments as to when one is indicated over another. A vital aspect

Bridging the Divide: Can Naturopathic and Medical Doctors Collaborate to Make Integrative Care A Reality?

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Aaron Van Gavera,°, BSc ND Inc.; Vanessa Vaartnoub

Citation info: UBCMJ. 2015: 7.1 (18-20)°Corresponding author: drvangaver@gmail.coma Naturopathic Physician, Sinclair Wellness Centre, Vancouver, BC; and Sessional Instructor, Boucher Institute of Naturopathic Medicine, New Westminster, BCb ND Candidate, Boucher Institute of Naturopathic Medicine, New Westminster, BC

Integrative healthcare is defined as an avenue of medicine and health

that ”reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare, and disciplines to achieve optimal health and healing.”1 For the purposes of this ar ticle, naturopathic doctors are the alternative approach. The term ‘integrative care’ is, in the current healthcare climate, simply an ideal. It is an idealized system for streamlining patient care — where the strengths of each profession, both naturopathic and conventional, are realized, and patients are directed to the appropriate practitioner for care. Vancouver is especially flooded with clinics operating under this apparently integrative model. While these operations are headed in a positive direction, they still have a ways to go before fully operating under the umbrella of true integrative care. My ten plus years of practice as a naturopathic physician in a healthcare system that has undergone extensive changes has created a unique perspective on the integrative healthcare model.

This is the healthcare world within which I would like to operate. However, I am not blind to the reality that we have a long way to go before that ideal system can be realized. As a naturopathic physician, I have had the benefit of seeing the ‘other’ side of healthcare — the side that the allopathic medical doctor (MD) is not always privileged to witness and participate in. For example, I often see patients who have exhausted

In many cases, a synergy can exist when both the conventional and naturopathic approaches are applied to a patient’s case. For this to happen, however, the two professions have to understand the strengths and weaknesses of both approaches.

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of naturopathic education is a thorough understanding of how these many modalities interact with each other when they are best implemented.

In British Columbia, naturopathic medicine was added to the Health Professions Act in 1996.3 Since then, we have become a self–regulating profession, providing support to our mutual patients while ensuring public safety by setting stringent guidelines for our education and training. Our scope of practice is still growing and we continue to be self–regulated under the College of Naturopathic Physicians of British Columbia (CNPBC). The greater the scope of naturopathic practice, the more equipped naturopathic physicians are to utilize our extensive training to manage cases as primary care practitioners (PCP). Increasing the scope of practice of naturopathic doctors further facilitates the creation of an integrative care system. The B.C. government has repeatedly highlighted the need for additional PCPs.4-6 Incentives for newly graduated doctors to work in rural communities exist; however, many city–dwellers also lack a PCP.4 Both the Premier and the current Minister of Health have voiced the shortfalls of the current healthcare system and continue to focus on the “GP for Me” program, which seeks to ensure B.C. residents have a PCP.7 Naturopathic doctors have the potential to be part of the solution. Naturopathic doctors are currently licensed as PCPs who specialize in natural medicine, but our current scope of practice is limiting. By practicing to our full potential and training, naturopathic physicians can, under an integrative model, alleviate the strain on the current system.

In my 12 years of practice in downtown Vancouver, I have witnessed tremendous growth between the two professions. In the past, I have had to fight for copies of patient test results, including blood work or ultrasound results, but I have since learned to respect the authority of the general practitioner (GP) and educate the patient on their options. Currently, any patient who comes to see me goes through an initial intake, which can

involve a full health history and physical exam. Depending on the chief concern, this can take anywhere from 30 to 90 minutes. Patients frequently seek out a naturopathic doctor because he or she wants assurance they are living a healthy life; this is where the naturopathic doctor excels. The strength of the naturopathic approach is that we, as naturopathic doctors, take inventory of many facets of a patient’s lifestyle. These include social history, family history, dietary habits, environmental stressors, emotional state, current medical treatments, and a review of systems. We do this because we believe it is necessary to treat the whole person, not just the individual symptom or system. This, in turn, provides us with valuable information to create targeted treatment protocols and work with the patient to treat the root cause of their ailment. In other cases, where the patient simply wants lifestyle support, gathering this degree of information facilitates disease prevention later on.

In the current system, where the ideal integrative model does not yet fully exist, there are several hurdles for patients who seek alternative care. If their GP is not open to complementary care from other health professionals, it potentially isolates that patient. I have experienced patients requesting that I do not communicate with or send lab results to their family doctor for fear of ruining that relationship. This is not a positive experience for the patient and something we should seek to avoid. Why can’t the patient feel free to explore other options? Why must their healthcare be managed by one avenue of medicine or, in some cases, an individual? I believe they should feel free to seek out additional care and utilize the strengths of other healthcare practitioners. The same goes for my profession: there are times when I have witnessed naturopathic doctors taking patients off of medications and instead recommending supplements in their place without regard for our MD counterpart’s treatment plan. There needs to be a better way for our two professions to interact. Improving

the relationship between our two professions will facilitate better patient experiences, and ideally, more positive patient outcomes.

The 2002 Romanow Report demonstrates the need and desire of Canadians for a more comprehensive healthcare system.8 He outlines a collaborative system where individuals receive care from a multitude of healthcare services delivered in a seamless fashion, as opposed to receiving isolated care from many healthcare practitioners. In his report, Romanow discusses the need for an integrative approach that works on prevention, promotion, primary care, community health, and mental health. This extensive report was a huge step for the naturopathic profession; in discussing the shortfalls of the current healthcare system, it created a niche for naturopathic doctors to exist in an integrative care model. It highlighted the importance of healthcare practitioners working together under an integrative model to streamline patient care.

The current healthcare climate in

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In my 12 years of practice in downtown Vancouver, I have witnessed tremendous growth between the two professions. In the past, I have had to fight for copies of patient test results, including blood work or ultrasound results, but I have since learned to respect the authority of the general practitioner (GP) and educate the patient on their options.

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British Columbia requires a revamp. Both the Romanow report and the B.C. Ministry of Health6 outline a shift in direction for our current system. Romanow discusses the need to re–evaluate key determinants of health. The B.C. Ministry of Health suggests several health goals for British Columbians, which can be addressed by moving towards an integrative health model.5,6 If we as healthcare professionals hope to empower a patient to live a healthier life, reduce the burden to healthcare, and improve patient experience, naturopathic and allopathic physicians need to start working together.

We do have a few areas where this integration has been easier; for example, in the oncology world, medical and naturopathic doctors work alongside each other at the Cancer Treatment Centers of America (CTCA), and there are a number of local naturopathic doctors who work with Inspire Health. Chronic care is another area where naturopathic doctors excel, and in several integrative clinics in the Vancouver area, naturopathic and medical doctors co-manage cases. Naturopathic doctors have the luxury of longer patient visits, which lends well to these types of cases.

While a plethora of positives for integrative care exist, implementing

this model is not without potential consequences. First and foremost, a clear definition is needed.9 This definition must clearly define the types of practitioners involved and their specific roles.9 It may be necessary to differentiate the naturopathic doctor from other alternative healthcare practitioners who lack the extensive science–based clinical education. In addition, a major barrier is the potential for mismanagement. Without a clear definition of physician roles there is the potential for patients to fall through the cracks. For example, monitoring a patient on a specific drug begs the question of who is the initial prescriber and which physician is ultimately responsible for following that patient’s progress. For this to work, naturopathic and medical doctors must recognize and respect each other’s judgment. On the flip side, the integrative model, in a world of specialists, has the potential to ensure a sole physician monitors a patient’s diverse care. In the current system, a GP has limited time with each patient to oversee cases managed by multiple physicians. In addition to the potential mismanagement of an integrative system, is the significant barrier of a naturopathic doctor’s fee for service. Naturopathic doctors are able to spend significantly more time per patient visit because they are paid privately. While every naturopathic doctor employs a different fee schedule, ultimately our services are more accessible to individuals who can afford to pay. If we hope to provide equal access to B.C. residents, this aspect would need to be addressed.

While our two professions have made great strides in working together, there is still a ways to go. As each profession continues to recognize the strengths of the other and how these strengths can best benefit a patient’s case, patients will be more effectively and efficiently cared for. A true integrative model is the ideal, and we are a ways from making it a reality. However, with an open mind and a willingness to take a few small steps in the short term, I believe it can be realized in the future.

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references1. Imconsortium.org. Introduction - Academic

Consortium for Integrative Medicine & Health [Internet]. 2015 [cited 21 May 2015]. Available from: https://www.imconsortium.org/about/about-us.cfm

2. CNPBC. College of Naturopathic Physicians of British Columbia [Internet]. 2015 [cited 15 April 2015]. Available from: http://www.cnpbc.bc.ca/.

3. Regulated Health Professions Act 1996, (B.C.). Available from: http://www.bclaws.ca/civix/document/id/complete/statreg/96183_01 retrieved on 2015-04-15

4. Shaw R. B.C. family doctor shortage worsen-ing, despite campaign promise. Vancouver Sun [Internet]. 2015 [cited 20 May 2015];. Available from: http://www.vancouversun.com/health/Family+doctor+shortage+worsening+de-spite+campaign+promise/11029139/story.html.

5. Provincial Health Services Authority 2014/15-2016/17 Service Plan. Vancouver (BC). Provin-cial Health Services Authority, 2014, June.

6. Ministry of Health. 2013/14 Annual Service Plan Report. Victoria (BC). Ministry of Health.

7. Agpforme.ca. Home Page | A GP For Me [Internet]. 2015 [cited 23 May 2015]. Available from: http://www.agpforme.ca/news-catego-ries/home-page.

8. Romanow RJ. Building on values: The future of health care in Canada. Ottawa (ON): Commission on the Future of Health Care in Canada; 2002 Nov. 392p. Report No.: CP32-85-2002E.

9. Stumpf S, Shapiro S, Hardy M. Divining Integrative Medicine. Evid Based Complement Alternat Med. 2008;5(4):409-413.

The strength of the naturopathic approach is that we, as naturopathic doctors, take inventory of many facets of a patient’s lifestyle. These include social history, family history, dietary habits, environmental stressors, emotional state, current medical treatments, and a review of systems.

disclosuresDr. Van Gaver is a board director on

both the BC Naturopathic Association and the Canadian Association of Naturopathic Doctors. He has no conflicts of interest to disclose.

Traditionally, students studying in Canadian medical schools have little exposure to naturopathy. The UBCMJ sought to present a naturopathic practitioner’s perspective on integrative medicine. In this article, Dr. Van Gaver presents his ideas on the challenges and benefits of integrating naturopathic and conventional Western medicine. The views expressed in this article are solely those of the author(s) and do not necessarily reflect the ideas or values of the UBCMJ or the Faculty of Medicine.

editorial statement

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Complementary and alternative medicine (CAM) typically includes therapies

or treatments that are not considered mainstream in North America. More specifically, CAM is defined as modalities that are not extensively taught in North American medical schools and are not widely used in North American healthcare institutions (i.e., hospitals or medical clinics).1 CAM is often used instead of, or in conjunction with, conventional treatment modalities (e.g., surgery, pharmaceuticals, etc.). According to the Public Health Agency of Canada, it is estimated that more than 70 % of Canadians regularly use at least one form of CAM.2,3 CAM can include acupuncture, chiropractic care, massage therapy, yoga, diet–based therapies, naturopathy, homeopathy, osteopathy, and herbal remedies.2

The results of previous research suggest that CAM is used more often by individuals who have chronic health problems because it reportedly gives them a sense of control over their health, and may improve quality of life.2,4,5 In addition, the literature suggests that

some of the factors that influence the use of CAM include dissatisfaction with traditional treatments2,4,6,7,8, personal attitudes2,4,6, culture5, and a holistic concept of health.6 While as many as 90 % of seniors (i.e., individuals aged 65 years or older) live with at least one chronic disease9 they tend to be less well represented among users of CAM, particularly when compared to younger individuals.7 To date, there is limited research on the use of CAM by seniors, which may be in part due to the potential for confounding effects with conventional treatments, and possible loss of follow–up due to death or illness.8

This study was designed to explore the attitudes and experiences of seniors with their use of CAM. This research also aimed to identify barriers that affect the use of CAM in seniors.

introduction

Investigating Complementary and Alternative Medicine Use Among Seniors

academic

Objectives: Complementary and alternative medicine (CAM) is used regularly by 70 % of Canadians,2,3 but when compared to younger users of CAM, seniors tend to use it less frequently. Using a phenomenological approach, this study sought to explore the attitudes and beliefs of seniors towards the use of CAM. Methods: This qualitative study used either in–depth personal interviews or focus group interviews as the primary means of data collection. Participants in the study were individuals who had either used CAM in the past, or who were currently using CAM. Results: Participants described that they would use conventional treatment for pathological disease, but would prefer to use CAM in certain circumstances as it was perceived to be a more natural approach. Exercise was also described as a form of CAM. Deterrents for CAM use include limited scientific evidence, cost, and the attitudes of others (e.g., physicians, the public). Conclusion: Participants felt that they had positive experiences using CAM as an adjunct to conventional medicine, and felt that they had no personal barriers to accessing CAM. A major deterrent of CAM use was the limited scientific evidence, while minor factors included cost and the attitudes of others. Open discussion about CAM use should take place between physician and patients.

abstract

Katrina M. Ward, BSc a, °, Dr. Renee S. MacPhee, PhD b

Citation info: UBCMJ. 2015: 7.1 (21-24)° Corresponding author: k.ward@alumni.ubc.caa MD Candidate 2018, Faculty of Medicine, University of British Columbia, Vancouver, BCb Assistant Professor, Faculty of Kinesiology and Physical Education, Wilfrid Laurier University, Waterloo, ON

materials & methodsData were collected via in–depth

personal or focus group interviews. In order to be eligible to participate in the study, participants had to be 65 years of

age or older and either previous or current users of CAM. Participants were recruited using one of two approaches: 1) purposeful convenience sampling, wherein prospective participants were known to the researcher; or 2) self-selection wherein posters and recruitment speeches at senior’s centres in Kitchener–Waterloo were used to inform prospective participants, who contacted the researcher directly via email or telephone. At the end of three weeks, a total of 16 participants had enrolled in the study; at this time, all recruitment posters were removed.

Interviews took place at a location that was convenient for both the participants and the researcher. Prior to the start of each interview, the researcher ensured that each participant met the inclusion criteria, and either a verbal or written informed consent was obtained. A standardized set of seven open–ended questions was used to guide each of the interviews. Key questions included: • Do you have any experiences, past

or present, with complementary and alternative medicine?

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Figure 1: Flow chart describing the participants’ age, sex, and place of residence.

• Do you have any reasons why you chose/choose to use complementary and alternative medicine?

• What are the barriers that affect your access or decision to use complementary and alternative medicine? All interviews were audiotaped.

During the interviews, the researcher took field notes that identified general observations and key phrases. Each interview was transcribed verbatim, and with identifying information removed to ensure confidentiality, each participant was sent his/her transcript and asked to review it in order to ensure the accuracy of the information.

Approval for this study was obtained from the Research Ethics Board at Wilfrid Laurier University. This study was done as an undergraduate thesis project. The participants did not receive financial compensation.

analysesUsing a phenomenological approach,

the data analysis sought to examine the lived experiences of participants. Because the study was evaluating the subjective experiences of more than one individual to find meaning in their lived experience, the phenomenological approach was the most suitable approach to analyze

geographical location of the participants relative to the researcher; the remaining three interviews were conducted in person.

Three focus group interviews were conducted. In each focus group, the number of participants ranged from two to four in each interview.

Participants had experiences with a wide range of alternative therapies, including yoga (n=12), massage therapy (n=9), tai chi (n=8), chiropractic care (n=7), acupuncture (n=6), osteopathy (n=4), and naturopathy (n=4). Other forms of CAM that were less frequently utilized included herbal remedies and natural health products (n=3), vitamins and probiotics (n=3), spiritual healing (n=2), homeopathy (n=1), aromatherapy (n=1), biofeedback (n=1), reflexology (n=1), and energy healing (n=1). All of the participants were using CAM in addition to traditional medical treatments.

The length of interviews ranged from 20 minutes to 90 minutes. Personal interviews ranged from 20 minutes to 36 minutes, taking on average 22 minutes to complete. Focus groups ranged from 25 to 90 minutes, taking on average 75 minutes to complete.

16 participants who met the inclusion criteria were included in the study. Three participants were recruited using the convenience sampling technique; the remainder of the participants (n=13) self–selected to participate in the study. The participants consisted of three men and 13 women. All participants were aged 65 years or older: 11 participants were between 65 and 74 years of age; two participants were between 75 and 84 years of age; and three participants were 85 years of age or older. The mean age of participants was 74.5 years. 12 participants resided in the Kitchener–Waterloo area, while the remaining four participants lived outside the province of Ontario. The characteristics of the participants are provided in Figure 1. Seven in–depth personal interviews were conducted in this study. Four of the interviews were conducted via the telephone due to

results

In order to maintain the privacy of the participants, abbreviations to denote participation in a focus group or personal interview were used in place of their personal identifiers (i.e., first and last

themes

While as many as 90% of seniors (i.e., individuals aged 65 years or older) live with at least one chronic disease9 they tend to be less well represented among users of CAM, particularly when compared to younger individuals.7

this qualitative study.10 The transcript was initially examined for broad, common, recurring themes. The broad themes were further broken down into sub–categories following subsequent detailed readings.11 Concepts that were identified by eight or more of the participants were described as a major theme. Furthermore, concepts that were articulated by three or more of the participants were identified as sub–themes. The transcripts were reviewed to the point where no further themes could be identified.

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names). Each of the three focus groups (FG) was assigned a number (e.g. FG1; FG2; FG3); personal interviews (PI) were numbered according to the participant that was interviewed. Each participant was assigned a number and identifiers were removed. A slash was used to separate the type of interview that was conducted and the number assigned to the participant. For example, FG2/8 described a quote by Participant 8 in focus group 2. A statement made by Participant 11 in a personal interview is denoted PI/11.

Major Theme 1: Participants tried to use CAM as an alternative to only prescription medications

The first major theme identified, which was identified by the vast majority of participants, was that CAM was used as an alternative to conventional medicine. Participants felt that they were responsible for their own health, and that CAM gave them more control over their health outcomes. • “I’d much rather try a natural thing

than have a medication. I don’t like taking medications; unfortunately at my age you have to.” (FG2/8)

• “…I tend to be a bit skeptical about medication and fixing symptoms and this is happening to your body for a reason, you know, what is it?” (FG1/5)

Sub–theme 1: Physical activity was considered to be a form of CAM by participants

A sub–theme that emerged was that many of the participants considered exercise to be a form of CAM. These participants included physical activity as a way of promoting good health, preventing disease, and speeding up recovery of musculoskeletal injuries: • “I consider any sport, any physical

activity, to be something that is health, uh, promoting, and health maintaining.” (FG3/14)

• “For example, I’ve been running for 42 years. I consider that medicine.” (FG3/16)

• “That’s a theme that I am seeing more and more in medicine, and that is that our bodies were made to move.” (FG3/16)

• “I maintain my heart condition is better because I exercise.” (PI/11)

Major Theme 2: Seniors’ decision to use CAM is influenced by several factors

All but one of the participants expressed that they did not feel that they had any personal barriers to accessing CAM. Factors that the participants felt influenced the use of CAM among seniors are expressed as sub–themes below:

Sub–theme 1: The limited regulation and scientific evidence related to CAM is a major factor that influences the use of CAM

Participants felt that one of the factors that influenced the use of CAM among seniors was the lack of regulation and scientific evidence. This theme was very prevalent in the third focus group interview, where all four of its participants felt that this deterred them from using certain alternative therapies, such as reflexology, naturopathy, or homeopathy: • “Many of those haven’t been— they

aren’t regulated so I wouldn’t really go for them.” (PI/1)

• “I don’t— well, I just don’t think that their remedies are as effective as a medical doctor… I don’t think they’re scientifically proven, and I don’t think they’re as effective. I think there’s a lot of placebo effect.” (FG3/16)

discussionThis study explored the use of

CAM by seniors through the use of in–depth personal interviews and focus group interviews. The study highlighted that because CAM has limited scientific evidence, seniors tend to seek conventional treatment for a pathological illness rather than using

An unexpected and very significant theme that emerged pertained to the belief that physical activity is very relevant in personal health promotion and maintenance. This finding was strongly expressed by 15 of the 16 participants in the study.

The importance of scientific evidence was made evident by participants who acknowledged that they would still seek conventional treatment for a pathological illness rather than using alternative medicine. • “As far as osteopenia is concerned, I

know certainly the drugs available are very beneficial, so I would use them. Were I to have an infection, I would feel that would need to be treated medically… I do believe that there are some true medical issues that need to be dealt with, you have to deal with them.” (PI/12)

Sub–theme 2: Cost as a deterrent for ongoing CAM use

Participants described cost as a factor that prevented people from continuing their use of CAM beyond what they felt was directly necessary for their healing process. Participants indicated that cost would not stop them from going for an initial visit, but if treatment were to be ongoing they might feel that CAM was too costly.

Sub–theme 3: External factors affect the use of CAM

This sub–theme was a reflection of the belief that the attitudes of the public, physicians, and the patient–physician relationship were all factors in seniors’ decisions to use CAM. Some participants felt that there was public judgment when deciding to use CAM. On the other hand, several participants expressed that there tends to be more acknowledgement of CAM now than there used to be. Participants who felt that they had a stronger patient–physician relationship were more comfortable bringing up their use of CAM with their physician.

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alternative medicine. With respect to musculoskeletal injuries or maintaining general well–being as they aged, some of the participants preferred to use CAM over a conventional therapy. This is consistent with the research literature that suggests that CAM is most often used for back and neck pain, followed by stress and anxiety.2 Older adults could benefit from an open discussion with their physicians about using CAM as an adjunct to conventional therapy when considering treatment options.

An unexpected and very significant theme that emerged pertained to the belief that physical activity is very relevant in personal health promotion and maintenance. This finding was strongly expressed by 15 of the 16 participants in the study. Physical activity is supported in the literature as being a factor in the prevention and management of numerous chronic diseases, including diabetes, obesity, hypertension, and heart disease.12 Furthermore, when looking at the traditional definition of CAM, self–directed daily exercise was not often included as a form of alternative therapy. A study done by McFadden et al. suggests that individuals who believe in the principles of CAM report doing more aerobic exercise than those who are not strong believers in CAM (p=0.041)6, and that CAM users are more likely to engage in a healthy lifestyle than nonusers.13 One participant expressed this theme by saying, “[for] example, I’ve been running for 42 years. I consider that medicine” (FG3/16). Self–directed physical activity, such as performing yoga at home, running, or walking, was part of the daily routine of more than half of the participants. These activities may also be less costly and more accessible than some of the other alternative therapies such as acupuncture. This finding may suggest that physical activity should be acknowledged as part of the definition of CAM and supports that physical activity should be a central part of the lives of seniors.

There were several limitations to this study. The first is that the study had a small sample size (n=16). This was due largely to the time constraints associated

with an undergraduate thesis. Despite this, interviews were conducted to the point of saturation.14 Another limitation is that the sample itself may not be representative of the senior population at large. Reasons for this may include: the majority of the seniors self–selected for the study (a possible form of recruitment bias because these individuals may have been in a better financial position to engage in CAM services); participants were predominantly female (female n=13; male n=3); participants had positive experiences with CAM such that they wanted to share and promote CAM; all the participants were residents of a suburban or urban area rather than a remote or rural community (the literature search suggests higher rates of CAM use in rural communities as compared to urban communities15,16); and only seniors who had used CAM were recruited due to time constraints.

conclusionIn summary, participants felt that

by using CAM they were actively taking control of their health needs. Overall, seniors did not feel that they had any barriers in their access to CAM, though in general, factors such as cost, attitudes, and regulation would affect their decision to use more alternative therapies. It was encouraging to hear that physical activity was viewed as such a positive factor in maintaining health and well–being of seniors, and some participants considered physical activity to be a form of CAM.

Future research could compare senior participants who do not use CAM with those who do in order to determine whether there are any differences in attitudes or beliefs, or perceptions of barriers. In addition, research could also examine how the use of CAM differs in rural and urban settings or among seniors of different ethnicities.

disclosuresThe authors do not have any conflicts

of interest that would affect this research.

1. Williamson AT, Fletcher PC, Dawson KA. Com-plementary and alternative medicine use in an older population. J Gerontol Nurs. 2003 May;29(5):20–8.

2. Esmail N. Complementary and alternative medicine in Canada: trends in use and public attitudes, 1997–2006. Public Policy Sources. 2007 May;87.

3. Complementary and Alternative Health [In-ternet]. Canada: Government of Canada; 2008 Apr 1 [cited 2015 Jan 25]. Available from: http://www.phac-aspc.gc.ca/chn-rcs/cah-acps-eng.php.

4. Williams AM, Kitchen P, Eby J. Alternative health care consultations in Ontario, Canada; a geo-graphic and socio–demographic analysis. BMC Complement Altern Med. 2011 Jun 22;11(47).

5. Loera J, Reyes-Ortiz C, Kvo Y-F. Predictors of complementary and alternative medicine use among older Mexican Americans. Complement Ther Clin Pract. 2007 Nov 1;13(4): 224–31.

6. McFadden KL, Hernández TD, Ito TA. Attitudes toward complementary and alternative medi-cine influence its use. Explore (NY). 2010 Nov-Dec;6(6):380–88.

7. Adams J, Lui C-W, McLauglin D. The use of complementary and alternative medicine in lat-er life. Rev Clin Gerontol. 2009 Nov;19:227–36.

8. Horneber M, Bueschel G, Dennert G, Less D, Ritter E, Zwahlen M. How many cancer patients use complementary and alternative medicine: a systematic review and metaanalysis. Integr Can-cer Ther. 2012 Sep;11(3):187–203.

9. Government of Canada – Action for Seniors Report [Internet]. Canada: Government of Canada; 2014 Jul 3 [cited 2015 Jan 25]. Avail-able from: http://www.seniors.gc.ca/eng/report/index.shtml#tc6.

10. Creswell JW. Qualitative inquiry and research design: choosing among five approaches. Cali-fornia: Sage Publications; 2006.

11. Patton MQ. Qualitative research & evaluation methods. 3rd ed. Thousand Oaks, California: Sage Publications, Inc; c2002. 598 p.

12. Pedersen BK, Saltin B. Evidence for prescribing exercise as therapy in chronic disease. Scand J Med Sci Sports. 2006;16(Suppl. 1):3–63.

13. Nahin RL, Dahlhamer JM, Taylor BL, Barnes PM, Stussman BJ, Simile CM, Blackman MR, Chesney MA, Jackson M, Miller H et al. Health behav-iors and risk factors in those who use comple-mentary and alternative medicine. BMC Public Health. 2007 Aug;7(217).

14. Guest G, Bunce A, Johnson L. How many in-terviews are enough? An experiment with data saturation and variability. Field Methods. 2006 Feb;18(1):59–82.

15. Adams J, Sibbritt D, Lui C-W. The urban–rural divide in complementary and alternative medi-cine use: a longitudinal study of 10,638 women. BMC Complement Altern Med. 2011 Jan;11:2.

16. Meurk C, Broom A, Adams J, Sibbritt D. Rurality, mobility, identity: women’s use of complemen-tary and alternative medicine in rural Australia. Health Place. 2013 Mar ;20:75–80.

references

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As a student tasked with learning all of the anatomy, physiology, and

pathology of the human body, I sometimes feel I’m barely able to tell up from down. But I do know that I want to do good. I want to make people, patients, feel well. And from the biopsychosocial model of health that is by now all–too–familiar, I am aware that wellness is more than just being free from disease.

As a medical student, I certainly identify with the above statement. But so does my colleague, a third year student at the Boucher Institute of Naturopathic Medicine. In fact, the above statement is an accurate description of both our experiences in our respective medical educations, as well as our motivations for choosing them. We both attended graduate school at Simon Fraser University, both working late hours by the benchside, cursing our cell cultures, and writing and rewriting our theses. It was after we finally secured our title as “Master’s of Science” that our paths diverged. The pursuit of a four–year degree that differs by one letter in the alphabet will have a profound impact on how we are viewed by society, the respect we are given, and the stereotypes we give one another.

To better grasp this one letter divide and address the misinformation, I simply decided to ask them some questions and share with you the answers.

introduction

A Doctor by Any Other Name

This interview–style commentary piece addresses some key concerns medical professionals might have about the care provided by complementary health care practitioners, specifically naturopathic doctors (NDs). As relative content experts in their respective fields, questions are asked by a medical student and answers provided by a student of naturopathic medicine. Readers will gain a first hand understanding of the ND route of education, scope of practice, as well as answers to some common myths around the practice of naturopathy.

abstract

Csilla Egri B.Sc, M.Sc a, °; Tasneem Pirani-Sheriff, M.Sc b, °Citation info: UBCMJ. 2015: 7.1 (25-27)° Corresponding author: c.egri@alumni.ubc.caa MD Candidate 2017, Faculty of Medicine, University of British Columbia, Vancouver, BCb ND Candidate 2016, Boucher Institute of Naturopathic Medicine, New Westminster, BC

how does the level of training compare between MD and ND?

what defines naturopathic medicine?

The ND and MD programs are both very similar in structure and length (Figure 1).3 A successful ND student must complete:4

1. A Bachelor’s degree including specific premedical science courses

2. A four–year degree program at an accredited school of naturopathic medicine which includes training in:5 a) Biomedical sciences: anatomy, physiology, histology, microbiology, biochemistry, immunology, pharmacology, and pathology; b) Clinical disciplines: physical, clinical, differential and lab diagnosis, radiology, naturopathic assessment and orthopaedics,

Naturopathic medicine is a system of healthcare that integrates modern scientific knowledge with traditional medicine. Six basic principles govern our treatment:1. First, do no harm2. The healing power of nature3. Prevention4. Identify and treat the root cause5. Treat the whole person6. Doctor as teacher

Naturopathic medicine is a system of healthcare that integrates modern scientific knowledge with traditional medicine... Our philosophy is to first remove the barriers to health and then stimulate and support the body’s own innate healing power.

Our philosophy is to first remove the barriers to health and then stimulate and support the body’s own innate healing power. We emphasize prevention, but in the case of disease, we stress the importance of identifying the underlying cause of dysfunction. NDs in British Columbia are regulated by the College of Naturopathic Physiciansof British Columbia (CNPBC) and governed by legislation and bylaws within the Health Professions Act.1,2

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are ND’s against conventional medicine?

No. Both naturopathic and conventional medicine have unique roles in patient care. Situations that require specialist–specific or emergent medical care go beyond our scope or level of expertise. In these cases,

what are some common conditions patients present with and what is an ND’s approach to treatment?

As primary health care providers, NDs see and treat a wide spectrum of patients with varying conditions, similar to general practitioners. However, many NDs choose to focus their practice on more specific areas including, but not limited to, oncology, paediatrics, women’s health, and sports medicine. Regardless of their type of practice, most NDs treat patients with concerns related to

Figure 1: Total educational hours: a comparison of various health professionals. Average total undergraduate (or equivalent) education hours of DC (Doctor of Chiropractic), DO (Doctor of Osteopathy), MD (Medical Doctor), ND (Naturopathic Doctor), PT (Physical Therapist), RMT (Registered Massage Therapist), LMT (Licensed Massage Therapist). Adapted from ProHealthSys.3

emergency medicine, and minor surgery; c) Naturopathic modalities: clinical nutrition, botanical medicine, traditional Chinese medicine and acupuncture, naturopathic osseous manipulation, homeopathic medicine, hydrotherapy, and lifestyle counselling

3. A passing grade on two comprehensive Naturopathic Physicians Licensing Examinations written after the second and fourth years of studyFollowing graduation, NDs are

required to obtain continuing medical education credits each year as outlined by the provincial regulatory boards.6 This combined knowledge, experience, and skill allows us to differentially diagnose and treat patients with a wide variety of health conditions.

As primary health care providers, NDs see and treat a wide spectrum of patients with varying conditions, similar to general practitioners. However, many NDs choose to focus their practice on more specific areas including, but not limited to, oncology, paediatrics, women’s health, and sports medicine.

NDs recognize their limitations and choose to refer patients to MDs for collaborative management.

When discussing the spectrum of care, NDs excel at optimizing lifestyle and health, preventing disease, and treating chronic conditions, whereas MDs excel in emergency and critical conditions. The area in between is ideally where NDs and MDs can work together to provide integrative, patient–centered medical care.

gastroenterology, endocrinology, mental health (depression, anxiety), and allergies, primarily because of our extensive training in these areas.7 Though we treat chronic disease, as mentioned, our primary goals are emphasizing prevention and maintaining optimal health.8

commentaries

is naturopathic medicine the same as homeopathy?

No. A naturopathic doctor is a licensed medical professional who provides comprehensive patient–centered care. Naturopathic medicine and homeopathy are not synonymous, and unlike NDs and MDs who are licensed physicians regulated by the government, homeopaths are not doctors and do not have a regulated profession.9

are all NDs anti–vaccine?

No. NDs are not anti–vaccine, though as a profession made up of

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are naturopathic practices rooted in evidence?

individual practitioners with their own thoughts and beliefs, there are a number of perspectives on the topic. The British Columbia Naturopathic Association (BCNA) does provide a position statement with regard to communications around giving vaccinations.10 Prevention is one of our primary principles, and vaccinations, proper hygiene, and adequate nutrition fall within that category. Our responsibility as NDs is to educate on the benefits and risks of any treatment, allowing patients to make informed choices about their health, vaccinations included.10

1. Legislation and Bylaws [Online]. Vancouver : College of Naturopathic Physicians of British Columbia; 2014 [cited 2015, Feb 19]. Avail-

references

We rely on the integration of scientific advancements with traditional forms of medicine to better diagnose and treat our patients (for example, with laser stimulation of acupuncture points and herbal support for multi-drug resistance in cancer and chemotherapy).11,12,13 Conventional medical research continuously presents support for the use of naturopathic medical practices, such as highlighting the importance of polyunsaturated fatty acids and the intestinal biome in health and longevity.14,15

able from: http://www.cnpbc.bc.ca/about-us/legislation-bylaws/

2. Health Professions Act [Online]. Victoria: Queen’s Printer ; 2015 [cited 2015, Feb 19]. Available from: http://www.bclaws.ca/civix/document/id/complete/statreg/96183_01

3. Professional Comparison [Online]. Burna-by: Professional Health Systems, Inc; 2015 [cited 2015, Feb 19]. Available from: http://prohealthsys.com/site/students/profession-al-comparison/

4. Naturopathic Training [Online]. Toronto: Ca-nadian Association of Naturopathic Doctors; 2015 [cited 2015, Feb 19]. Available from: http://www.cand.ca/index.php?45&L=0

5. Accredited Programs [Online]. Great Bar-rington: Council on Naturopathic Medical Ed-ucation; 2014 [cited 2015, Feb 19]. Available from: http://www.cnme.org/programs.html

6. BCNA Continuing Education 2015 [Online]. Vancouver : British Columbia Naturopathic Association; 2015 [cited 2015, Feb 21]. Avail-able from: http://www.bcna.ca/continuing-ed-ucation-2015/

7. ND Curriculum & Synopsis [Online]. New Westminster : Boucher Institute of Naturo-pathic Medicine; 2015 [cited 2015, May 10]. Available from: http://www.binm.org/pro-spective-students/nd-curriculum-and-synop-sis

8. Guiding Principles [Online]. Toronto: Cana-dian Association of Naturopathic Doctors; 2015 [cited 2015, May 10]. Available from: https://www.cand.ca/index.php?49&L=0

9. List of Regulatory Colleges [Online]. British Columbia: BC Health Regulators; 2015 [cited 2015, May 10]. Available from: http://www.bchealthregulators.ca/#list-of-colleges

10. BCNA Vaccination Position Paper [Online]. Vancouver : British Columbia Naturopathic Association; 2015 [cited 2015, Feb 21]. Avail-able from: http://www.bcna.ca/about-bcna/ar ticles/bcna-vaccination-position-paper/

11. Siedentopf CM, Golaszewski SM, Mottaghy FM, Ruff CC, Felber S, Schlager A. Functional magnetic resonance imaging detects activa-tion of the visual association cortex during laser acupuncture of the foot in humans. Neurosci Lett [Online]. 2002 Jul [cited 2015, Feb 21];327(1):53–6.

12. Zhang WT, Jin Z, Luo F, Zhang L, Zeng YW, Han JS. Evidence from brain imaging with fMRI supporting functional specificity of acu-points in humans. Neurosci Lett [Online]. 2004 Jan [cited 2015, Feb 21];354(1):50–3

13. 13. Chai S, To KKW, Lin G. Circumvention of multi–drug resistance of cancer cells by Chi-nese herbal medicines. Chin Med [Online]. 2010 Jul [cited 2015, Feb 25];5(26):1–9

14. Calder PC. Omega-3 Polyunsaturated fat-ty acids and inflammatory processes: nu-trition or pharmacology? Br J Clin Pharma-col [Online]. 2013 March [cited 2015, May 13];73(3):645–662.

15. 15. Kau AL, Ahern PP, Griffin NW, Good-man AL, Gordon JI. Human nutrition, the gut microbiome and the immune system.Nature [Online]. 2011 June [cited 2015, May 13];474(7351)327–336.

When discussing the spectrum of care, NDs excel at optimizing lifestyle and health, preventing disease, and treating chronic conditions, whereas MDs excel in emergency and critical conditions.

commentaries

disclosuresThe author does not have any conflicts

of interest and is not tied to naturopathic medicine.

Traditionally, students studying in Canadian medical schools receive limited exposure to the practice of naturopathy and other forms of complementary and alternative medicine (CAM). In this issue, the UBCMJ has sought to increase students’ awareness of CAM practices by presenting multiple opinions regarding their use. In this article, Csilla Egri, a third year medical student, interviews a naturopathic student and explores a number of common questions and concerns about this profession. The views expressed in response to these questions, as presented in this article, are solely those of the interviewee and do not necessarily reflect the ideas or values of the UBCMJ or the Faculty of Medicine. Please note that that the UBC Faculty of Medicine follows the Provincial Health Services Authority (PHSA) guidelines on vaccinations.

I’m grateful to my colleague for answering my questions and providing a better insight into the naturopathic profession. I know, however, that these few pages will not be enough to mend the historically poor relationship between MDs and NDs. As future physicians, some of our patients will seek alternative care, and it’s at this critical point we must not let our personal or cultural biases sabotage our efforts at optimal and continuous patient care. Our methods and approaches may differ, but we are colleagues in healing and wellness, and in this spirit I encourage you to keep the dialogue open.

editorial statement

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The former Minister of State for Public Health, Carolyn Bennett, made a salient

point when she said that Canada has a “health care system where the mouth is not considered a part of the body.”1 As outlined in the Canada Health Act, Canadians receive coverage for medically necessary physician and hospital services but not dental services. This means that we receive coverage for our lips, tongues, and throats but not our teeth and gums.2 Canada ranks second last in public financing of dental care when compared to other Organization for Economic Co-operation and Development nations3 with 95% of all dental services funded privately, a level similar to that of the United States.4 Canadians must pay for dental services through private health insurance, which is usually obtained from employment or by paying out–of–pocket. The 2010 Canadian Health Measures Survey found that 62% of Canadians had private insurance and 6% had coverage through publicly funded programs, leaving almost a third of Canadians with no dental insurance whatsoever.2 What little public dental care exists is primarily for low–income children, leaving other vulnerable and low–income groups without access to care. This represents a failure of the current system, as those who need care the most are unable to access it. As a result of the exclusion of dental services from publicly funded health care, only 71% of residents of Ontario, the province with the highest dental visit rates,

visited a dentist in 2012.5 Predictably, this value is very similar to the number of Ontarians with dental insurance (68%).5

Beyond the absurdity of not receiving care for our mouths but receiving it for all other parts of our bodies, dental care is a medical necessity. The most common infectious diseases in the world are dental diseases.6 Extensive evidence validates the importance of oral health to that of the rest of our body and the fact that many health issues can first be diagnosed through the mouth.1 For example, one of the first signs of AIDS can be severe gum infection and the first stages of osteoporosis can show up as bone loss in teeth.7 Oral examinations can also reveal nutritional deficiencies, microbial infections, immune disorders, and oral cancers.1

Not only can ailments within the body affect our oral health, but oral health can also affect the rest of our body. Infections resulting from poor oral health can complicate diabetes management7 and systemic inflammation resulting from periodontitis can complicate end–stage renal disease management.8 Additional studies have linked poor oral health to respiratory disease,9 premature labour, low birth weight babies,10 pneumonia, and Alzheimer’s disease.2 Despite the impact some diseases have on oral health, the public system does not cover the resulting necessary dental care. An example of such impacts is the effect that chronic renal disease has on the mouth including xerostomia, calcifications, enamel hypoplasia, and altered salivary pH.8

Largely represented in the group of uninsured Canadians are vulnerable populations including seniors, indigenous peoples, and people with low incomes.11, 12 Having dental insurance is the largest predictor of dental service utilization because without it, costs can be prohibitive.13, 11 Therefore, the current insurance scheme widens the gap between the rich and the poor as access to dental care is mostly provided to those with middle to high–income jobs. The situation might be worsening as costs of dental care have increased dramatically in the past 25 years while the incomes of low–income groups have remained largely constant.14 Increasing rates of part–time and temporary employment have also contributed to a decrease in employment–provided dental insurance that the majority of Canadians rely on.14 Inability to pay for private insurance or out–of–pocket costs can result in oral conditions causing impaired speech, impaired eating, and affected social perceptions which can in turn have negative effects on obtaining employment opportunities.15

The political climate of deficit reduction through program cuts that began in the 1980’s must come to an end. The absence of a single–payer system for dental care has led to increased costs and poorer health outcomes.16 The current format of employer–based dental insurance is not sustainable due to increasing costs.17 Canadians spent $12.1 billion on private dental care in 2010, second only to prescription drugs in terms of private

introduction

Dental Care in Canada: the Need for Incorporation into Publicly Funded Health Care

Dental care was recommended in the 1964 Royal Commission on Health Services that helped shape our current health care system but has yet to become a part of publicly funded health care. This has left almost one third of Canadians without dental insurance, leading to poor health outcomes and stark inequalities. Evidence indicates that dental care should be incorporated into Canada’s existing system as it is medically necessary, will decreased long term costs, and its inclusion will promote accessibility and comprehensiveness in our system. With the Health Accord expiring and an adequate number of dental professionals today, now is the time to incorporate dental coverage into the public health care system.

abstract

Elisabeth McClymont, BA (Health Science)a,° Citation info: UBCMJ. 2015: 7.1 (28-29)° Corresponding author: elisabethmcclymont@gmail.coma MSc Candidate 2017 in Reproductive and Developmental Science, University of British Columbia, Vancouver, BC

commentaries

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expenditures.18 Per capita expenditure on dental care was $35019 which, by international standards, is high.20

The lack of accessibility to dental care has led to increased use of expensive acute health care settings for acute dental problems that are preventable and best dealt with in a primary dental care setting.3 In 2006, Ontario’s expenditure on these acute dental visits was $16.4 million.3 These acute care visits increase the volume of people visiting emergency departments and the number of hospital admissions, which are costly care options for preventable oral health problems.3 Providing individuals with an improved ability to seek regular dental care through coverage promotes the utilization of less expensive preventative care options.

Many organizations, including the Canadian Association of Public Health Dentistry, have long been asking for the implementation of universal dental coverage,21 and now is the ideal time for this to happen. The Health Accord was a ten–year agreement that outlined the federal funding to be supplied to the provinces for health care. Following its expiration in 2014, there was no action to implement a new accord. The federal government did promise to continue providing some resources to the provinces,22 however, the federal government has progressively decreased its influence on health care delivery since the 1970’s when it began providing transfers in relation to gross national product rather than demand, and providing tax credits in lieu of cash transfers.22 Its increasingly hands–off approach to health care in combination with a lack of renegotiation of the Health Accord demonstrates a waning desire to coordinate health care policy across the country. It is important to seriously consider and implement universal dental coverage now, before the Health Accord has faded into a distant memory and the federal government becomes further distanced from health care policy.

The 1964 Royal Commission on Health Services, which formed the basis of our public health care system, called for the inclusion of dental care services within the framework that was to be developed.23 It did, however, acknowledge that at that point in time, it was not be possible due to a shortage of dentists.23 Today, the number of dentists is no longer prohibitory. Between the years of 1991 and 2001, the number of dentists in every province

of Canada increased with the exception of the Yukon.24 Between the years of 2000 and 2010, the number of dentists and dental hygienists increased by 41.6%, a growth rate almost four times that of the Canadian population.18 In addition, it has been shown that Canadian dentists today support the incorporation into the public system.25

Patchworks of targeted initiatives within provinces have come and gone, proving themselves vulnerable to political will. It is time for a lasting, comprehensive approach to dental care as we are now in a position to implement such a program within the public system. Undoubtedly this is no small task; it will require the coordination of federal and provincial governments as well as the dental industry.26 Those who are in need of dental coverage must be heard and supported by the general Canadian population, which stands for equity and public provision of health care. Canadians ranked dental care as their third choice overall in terms of spending priorities, indicating that advocates for dental coverage inclusion into the public system need to work towards improved positioning of dental care on the policy agenda.27 It has been demonstrated that dental care should be incorporated into our public health care system due to its medically necessary nature, the fact that it will promote accessibility and comprehensiveness in our system, and will decrease long–term costs. A shortage of dental professionals no longer persists and the need to renegotiate the federal role in health care is upon us as the Health Accord has expired. Dental care was always meant to be a part of our comprehensive health care system and now this much needed coverage should be implemented.

1. Picard A. Painful Dental Bills Hurt Health Care. Oral Health. 2005; 95(2):3,6.

2. Yalnizyan A and Aslanyan G. Introduction and Over-view. In: Canadian Centre for Policy Alternatives. Putting Our Money Where Our Mouth is: the Future of Den-tal Care in Canada. Ottawa: Canadian Centre for Policy Alternatives; 2011. p.7-10.

3. Quinonez C, Ieraci L, and Guttmann A. Potentially Preventable Hospital Use for Dental Conditions: Im-plications for Expanding Dental Coverage for Low Income Populations. J Health Care for the Poor and

references

Underserved. 2011; 22:1048-1058.4. Marchildon G. Canada: Health System Review. Health

Systems in Transition. 2013; 15(1):1-179.5. Sadeghi L, Manson H, and Quinonez C. Report on

Access to Dental Care and Oral Health Inequalities in Ontario. Toronto: Queen’s Printer for Ontario; 2012.

6. Gordon S, Barasch A, Foong WC, ElGeneidy A, and Saf-ford M. Does Dental Disease Hurt Your Heart? J Can Dent Assoc. 2005;71(2):93-95.

7. Wilson C. Dental Care - A Basic Human Right? Dental Practice Management. 2010:5.

8. Craig RG. Interactions Between Chronic Renal Disease and Periodontal Disease. Oral Diseases. 2008;14:1-7.

9. Aubin J. Good Oral Health for All. Ottawa: Canadian Institute of Health Research; 2010.

10. CIHR. Oral Health Research - From Tooth Decay to Dental Implants. Ottawa: Canadian Institute for Health Research; 2003.

11. Palencia L, Espelt A, Cornejo-Ovalle M, and Borrell C. Socioeconomic Inequalities in the Use of Dental Care Services in Europe: What is the Role of Public Cover-age? Community Dent Oral Epidemiol. 2014;42:97-105.

12. CIHR. Brush, Floss, Rinse - and Research. Ottawa: Cana-dian Institute of Health Research; 2011.

13. Quinonez C. Denticare, Denticaid, and the Dental In-surance Industry. In: Canadian Centre for Policy Alter-natives. Putting Our Money Where Our Mouth is: the Future of Dental Care in Canada. Ottawa: Canadian Centre for Policy Alternatives; 2011. p.13-14.

14. Ramraj C, Weitzner E, Figueiredo F, and Quinonez C. A Macroeconomic Review of Dentistry in Canada in the 2000s. J Can Dent Assoc. 2014;80 e55.

15. Zavras AI. “Teeth are Always in Style”: But Increasingly, Not for All. Heath Services Research. 2014;49:2.

16. Qutub A, Al-Jewair T, and Leake J. A Comparative Study of the Health Care Systems of Canada and Saudi Ara-bia: Lessons and Insights. Int Dent J. 2009;59:277-283.

17. Leake J. Why Do We Need an Oral Health Care Policy in Canada? J Can Dent Assoc. 2006;72(4):317.

18. CIHI. National Health Expenditure Trends 1975-2012. Ottawa: Canadian Institute for Health Information; 2012.

19. Andkhoie M, Pandovska-Pelivanova E, Emmanuel S, La-teef F, Szafron M, and Farag ME. Demand and Burden of Dental Care in Canadian Households. Int J of Econ and Finance. 2014;6(9):73-82.

20. Birch S and Anderson R. Financing and Delivering Oral Health Care: What Can we Learn from Other Coun-tries? J Can Dent Assoc. 2005;71(4):243.

21. Clovis J. Let’s Put Our Money Where Our Mouth Is. In: Canadian Centre for Policy Alternatives. Putting Our Money Where Our Mouth is: the Future of Dental Care in Canada. Ottawa: Canadian Centre for Policy Alternatives; 2011.p.15-17.

22. Loeppky R. Canada, Health and Historical Political Economy. J Australian Political Econ. 2014;73: 72-199.

23. 23. Hall E. Royal Commission on Health Services. Ot-tawa: Canada; 1964.

24. CIHI. Distribution and Internal Migration of Canada’s Dentist Workforce. Ottawa: Canadian Institute for Health Information; 2007.

25. Quinonez C, Figueiredo F, and Locker D. Canadian Dentists’ Opinions on Publicly Financed Dental Care. J Pub Health Dent. 2009;69(2):64-73.

26. Duncan L and Bonner A. Effects of Income and Dental Insurance Coverage on Need for Dental Care in Can-ada. J Can Dent Assoc. 2014;80:e6.

27. Ramji S and Quinonez C. Government Spending on Dental Care: Is it a Public Priority? J Pub Health Dent. 2012;72:246-251.

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disclosuresThe author does not have any conflicts

of interest.

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Population studies have demonstrated a correlation between social and

material inequities and poor health over the course of life.1,2 Children who face financial disadvantages are prone to experiencing developmental delays and to suffering poor relationships with their community and their school. There is a need to educate incoming physicians and health care practitioners about these health inequalities, to better prepare them to address similar concerns in the future. This has led to the development of Social Pediatrics as a sub–specialty. Utilizing a complement of primary and tertiary care resources, social pediatric initiatives aim to provide a holistic, community–based approach to address the medical and social issues of disadvantaged children.3 While exposure to social pediatrics occurs at the residency level, literature describing such exposure for medical students is sparse.3 The purpose of this ar ticle is to introduce an innovative program at the University of British Columbia (UBC), where first– and

second–year medical students learn and work in underserved communities.

The inner–city area of Vancouver, particularly the Downtown Eastside neighbourhood, ranks among the poorest in Canada.4 Two–thirds of the children from this region star t school developmentally–vulnerable.5 In 2006, the RICHER (Responsive, Intersectoral–Interdisciplinary, Child–Community, Health, Education and Research) social pediatrics initiative was developed to provide a holistic approach to improve child health within the inner–city population of Vancouver.4,6

Part of the RICHER framework involves a School Developmental Pediatric Outreach Service that provides developmental assessments to inner–city school children. This outreach service has been very well–received, based on informal feedback from schools and families. However, potential areas of improvement were observed by RICHER investigators: 1) the volume of children requiring assessments vastly outnumber the available providers; 2) there are always more medical trainees who would like to learn in this setting than available

positions; and 3) many children and families were unable to follow through on the long list of recommendations generated from the assessments, due to limited resources. As a result of these potential areas for improvement, UBC students and faculty developed the Global Health Initiative (GHI) Inner City Project. The project provided medical students with opportunities to learn while working with vulnerable communities and to help families and schools to meet the recommendations made during the developmental assessments. Students were also involved in recognizing the needs of children and families through formal classroom observations of behavior and through completion of developmental pediatric assessments.

The GHI Inner City Program is a two–year longitudinal program that operates on a volunteer basis. Ten first–year medical students were selected and underwent a training curriculum, designed and reviewed annually by medical students. Upon entering their second year of medical school, students were matched with children and began the formal assessment process.

introduction

Teaching Social Pediatrics: the Global Health Initiative Inner City Project

Social Pediatrics, a medical sub–specialty utilizing a community–based and holistic approach to pediatric care, is increasingly recognized for its effectiveness in addressing the medical and social issues of disadvantaged populations. Exposure to social pediatrics is prevalent throughout residency, but is limited for most medical students. The purpose of this article is to describe an innovative program available to junior medical students at the University of British Columbia (UBC) for learning and practicing social pediatrics within communities of Vancouver. Through this program, medical students are trained on relevant topics, such as the importance of cultural awareness, the effects of poverty on health, and the assessment of developmental pediatric disorders. Student then participate in developmental assessments of children and assist in the formulation of management plans with families and health care teams. In the process, students gain valuable skills in developmental pediatrics, with an emphasis on collaboration and integration with school and community supports.

abstract

Vignan Yogendrakumara,°, MD; Erica Tsangb,°, MD; Barbara Fitzgeraldc,°, MD FRCP(C)Citation info: UBCMJ. 2015: 7.1 (30-32)° Corresponding author: ertsang@alumni.ubc.caa Neurology PGY2, Division of Neurology, the Ottawa Hospital, Faculty of Medicine, University of Ottawa, Ottawa, ONb Internal Medicine PGY1, Department of Medicine, University of British Columbia, Vancouver, BCc Clinical Associate Professor, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC

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curriculumThe curriculum includes training

seminars, opportunities to shadow senior students during pediatric assessments, and monthly meetings to discuss cases and challenges (Table 1). Training workshops are complemented by a manual containing useful resources that students can use throughout the year as a reference guide to assist in their respective assignments. This system is unique in that the training program was fully designed by UBC medical students. With faculty supervision, students in all four years of training came together and designed a curriculum that would satisfy their learning needs. Since its inception in 2010, the training program and curriculum have been revised on a yearly basis by the cohort of students involved in the program in that academic year. Changes to the curriculum are based primarily on student feedback, but they also take into account input from schools taking part in the program, community program leaders, and UBC faculty supervisors. The training

outcomesDespite the growth and positive

reception of the program, there are still multiple challenges. One of the primary challenges for medical students has been providing families with support to access long–term community resources. Students are involved in the developmental assessment aspect of the program for one year, and it has been difficult to maintain continuity beyond this. In order to address this challenge, medical students are asked to provide continuity of care to previous assignments in addition to performing new assessments. Medical students are provided with the results and recommendations of previous assessments to ensure that previous recommendations are met and families continue to feel supported by the

Table 1: GHI Inner City: Training Program Seminars

Training Workshop Included Topics

Normal development in the pediatric population

• Introduction to child development with emphasis on kindergarten and early elementary school age groups

• Review of motor (gross and fine), communication, social, academic and adaptive developmental milestones, and red flags in child development

Information gathering • Interview skills with school professionals and others• Use and application of screening tools: Focused Ob-

servation Tool for Trainees (FOTT) nd Ages and Stages Questionnaire (ASQ)

Developmental delays • Introduction to common conditions resulting in devel-opmental delay (e.g. fetal alcohol spectrum disorder, autism spectrum disorder, attention deficit hyperactivity disorder, learning disabilities) including underlying etiolo-gies and diagnosis protocols

• Investigation and management of developmental delay

Child protection • Role of physicians and health care professionals in rec-ognizing and reporting child abuse

• Types of abuse, how to report abuse, and procedures when abuse is reported

Community mapping • Walking tour/exploration of inner city area in east Vancouver, including schools and surrounding residential areas

• Introduction to resources within the community and barriers faced by low socioeconomic status

• Basics and rationale of assessment mapping

seminars are administered by professionals from multiple disciplines, including social workers, developmental and general pediatricians, parents of special–needs children, and nurses.

The primary element of the project is the clinical observation, assessment, and longitudinal follow–up of select children in the Vancouver School System by medical students. Armed with training in child development, observation skills, and cultural sensitivity, medical students were tasked with eliciting the histories of select children and observing them in the classroom over a series of visits. Children (ages 5-12) were identified by teachers and staff—due to concerns about developmental delay and/or behavioral abnormalities—and were referred to the supervising developmental pediatrician. After consent from the family was obtained, medical students reviewed relevant school files and elicited histories from school professionals, including teachers, counselors, youth, and family workers. A full observational assessment of the children was performed over multiple visits to the classroom and playground. By utilizing tools such as the Ages & Stages Questionnaire (ASQ), medical students assessed the children based on multiple variables, including development milestone achievement, language and communication skills, and interpersonal interactions.7 Students often met with parents to better understand the children’s home environments and to discuss any parental concerns. Students ultimately reported their findings to the supervising developmental pediatrician, and the formal assessment was completed together with the children and their families. At the end of the assessment, the developmental pediatrician, the medical student, the school team, and the family created a follow–up and management plan. Medical students followed the children and families for one year and helped to connect them to medical services, assessments, and other community resources. In particular, medical students worked closely to facilitate recommendations with those families who have difficulty accessing health care resources. For instance, if a recommendation was made for a child to have an audiology assessment, the medical student would work with the family to ensure that it was carried out.

developmental assessment

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references1. Lloyd JE, Li L, Hertzman C. Early experi-

ences matter : lasting effect of concentrated disadvantage on children’s language and cognitive outcomes. Health Place. 2010 Mar ;16(2):371–80.

2. Stansfeld SA, Clark C, Rodgers B, Caldwell T, Power C. Repeated exposure to socioeco-nomic disadvantage and health selection as life course pathways to mid–life depressive and anxiety disorders. Soc Psychiatry Psychi-atr Epidemiol. 2011 Jul;46(7):549–58.

3. Guyda H. Razack S, Steinmetz N. Social paediatrics. Paediatr Child Health. 2006 Dec;11(10):643–5.

4. Lynam MJ, Scott L, Loock C, Wong ST. The RICHER social pediatrics model: fostering access and reducing inequities in children’s health. Healthc Q. 2011;14:41–6.

5. Kershaw P, Trafford K, Hertzman C. Early Experiences matter : lasting effect of concen-trated disadvantage on children’s language and cognitive outcomes. Health Place. 2010 Mar ;16(2):371–80.

6. Lynam, M.J., Loock, C., Scott, L., Wong, S. et al (2010). Social Pediatrics Initiative. Enacting a ‘RICHER” model. A report to the British Co-lumbia Medical Services Foundation and the Canadian Nurses Foundation. Vancouver, BC.

7. Kerstjens JM, Bos AF, ten Verger t EM, de Meer G, Butcher PR, Reijneveld SA. Support for the global feasibility of the Ages and Stages Questionnaire as devel-opmental screener. Early Hum Dev. 2009 Jul;85(7):443–7.

program. While our cohort of medical students remains quite small in number, we hope to conduct formal surveys with both the families and the medical students to assess the impacts of the GHI program and to identify further areas for improvement.

Overall, the GHI Inner City project has grown, and it continues to develop in response to medical student and faculty interest, coupled with an unmet need in the community. From a learner’s perspective, medical students are given the opportunity to perform developmental assessments, and in the process, to learn important observational skills in child

While exposure to social pediatrics occurs at the residency level, literature describing such exposure for medical students is sparse.

development and behavior. They also gain exposure to working with vulnerable populations, appreciate the value of integrating health care with community services and supports, and acquire first–hand experience in dealing with the social determinants of health. It would be valuable to examine whether this program impacts the medical students’ perspectives of empathy, advocacy, and social accountability. Further longitudinal follow–up would also be helpful in elucidating long–term impacts of the program, such as the students’ residency choices. From a community standpoint, the students serve as a liaison between different health care professionals to help families navigate the health care system. This grassroots initiative hopes to affect change in the lives of children living in vulnerable communities and will continue to evolve based on community need. In the coming years, formal evaluation of the program may lead to improved support for inner–city families and enhanced community partnerships.

commentaries

disclosuresThe authors do not have any conflicts

of interest.

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Low–trauma fractures, classified as fractures that occur with minimal

trauma (e.g., falls from a standing position or from coughing/sneezing), are common among Canadian older adults, particularly those over 65 years of age.1,2 Nationally, B.C. has the largest percentage of fall–related hospitalizations, with fractures accounting for 78% of all fall–related injuries.3 Additionally, B.C. has the fourth–highest population growth rate of older adults in the country, and this rate could increase by 23.8% by 2036.4

Older adults are more susceptible to low–trauma fractures, which are often the consequence of osteoporosis.5,6 Compared to the younger population, older adults present to the emergency room (ER) more frequently with fractures and have longer lengths of stay.5 In Canada, annual direct costs associated with hip fractures can reach $600 million and mortality within one year of a hip fracture is 28% for women and 37% for men.6,7 The Canadian Multicentre Osteoporosis Study concluded that hip fractures are the most costly of fragility fractures to the health care system; however, minor fractures, such as wrist and vertebral fractures, can also have major impacts on disability, chronic pain, and lost working days.8

facing the facts

Addressing the Osteoporosis Health Care Gap in British Columbia with Fracture Liaison Services

Fracture liaison services have been developed in parts of Canada, the United States, and other countries around the world and have proven to be a cost–effective means of managing osteoporosis and reducing recurrent fractures. Such a service has not been implemented in British Columbia. As a result, there exists a large gap in osteoporosis care. This gap costs the health care system millions of dollars, and it puts many older adults through needless pain and suffering. Recently, a knowledge translation research project has begun to assist in the development and implementation of a fracture liaison service in B.C.

abstract

Gabby Napoleonea,° Citation info: UBCMJ. 2015: 7.1 (33-35)° Corresponding author: gnapoleo@sfu.caa BSc Candidate 2017 in Biomedical Physiology, Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC

what needs to be doneDeveloping a program directly

addressing the current post–fracture care gap among older Canadians is urgently needed. While a primary fracture can be difficult to prevent, these fractures should be treated as a warning sign of osteoporosis.9,10 However, this is often not done, as fractures are usually treated and recognized as an acute injury by medical professionals. Indeed, fewer than 20% of women and 10% of men receive therapies to prevent future fractures.11 Fracture liaison services (FLS) are programs that can be implemented in a clinical setting and are designed to bridge this gap by taking a prophylactic approach to secondary fractures, thereby improving post–fracture care and avoiding future fractures that can be even more debilitating. A FLS model strives to meet three objectives, often referred to as the three “i’s”: identification, investigation, and initiation.12,13 An FLS model that includes all three of the listed objectives, referred to as a type A model, shows the best increases in the percentage of patients actually receiving osteoporosis treatment compared to models that only address one or some of the objectives.14

Care provided by FLS differs from the standard general practice and care. Current fracture care often begins in the ER, where patients receive good fracture

care but do not receive any investigation or appropriate treatments for osteoporosis or falls prevention.15,16 The orthopedic surgeons who follow–up on patients tend to focus on the immediate fracture care and rehabilitation but not on the prevention of future fractures.15,16 On the other hand, FLS begins by identifying all people over the age of 50 with low–trauma fractures for risk factors for osteoporosis and future fractures.12,15,16 Appropriate investigations include ordering bone mineral density (BMD) tests and calculating future fracture risk scores, while initiation of treatment is fulfilled by providing osteoporosis medication and education regarding falls prevention and bone health.11,16

FLS programs in other provinces and countries have proven to be cost–effective in preventing future fractures. The Osteoporosis Exemplary Care Program from the St. Michael’s Hospital in Toronto is one program currently in place that follows the FLS model. This program has been successful in reducing the number of subsequent hip fractures, with a net hospital cost savings of $48,950.17 Likewise, the Concord FLS in Sydney, Australia has seen positive gains by focusing on active identification of low–trauma non–vertebral fractures and post–fracture management.18 Results following implementation of the Concord FLS showed only 4.1% new fractures and a dramatic reduction of

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fracture rates (80%) over a four–year period in patients referred to FLS intervention, compared to a control group, which had an increased refracture rate and 19.7% new fractures.18 In 2012, the Southern California Permanente Medical Group developed the Kaiser Permanente Healthy Bones Program, a comprehensive osteoporosis management program that encourages pharmacological management of osteoporosis and patient engagement.19,20 This program saw not only a significant decrease in the risk of hip and distal radius fractures, but also a decrease in overall costs to the health system and an increase in patient quality of life.19-21 Similar health–economic benefits were demonstrated in an FLS randomized control trial conducted in Edmonton, Alberta.22 The intervention group was more likely to receive appropriate osteoporosis treatment (67% vs 26% in control group), and was found to have gained quality adjusted life years.22 With the modest cost of $56 per patient, this FLS program saved the healthcare system $260,000 over a two–year time period.22

Fraser Health that has a high proportion of older adults (29%) as well as a high prevalence of osteoporosis.25 The objective of the study is to demonstrate that a FLS in B.C. can break the cycle of recurrent fractures and to provide a FLS framework for dissemination to other health authorities.16 As a pre– and post–quasi experimental design, the FLS prototype will have two independent cohorts of patients, the control group and the intervention group. Using the above–mentioned type A model, patients in the intervention group will be identified at the PAH Orthopedic Cast Clinic, while a NP will begin the initiation and intervention.16 In B.C., NPs can order most diagnostic tests, prescribe medications, and communicate with family physicians for a successful transition from the FLS to the community.26 Patients in both groups will be contacted for a six–month follow–up.16 During this time, primary outcome measures will be considered fulfilled if one of the following had been achieved: BMD had been ordered, referral to an osteoporosis consultant had taken place, or the patient was started on osteoporosis medication.13,16

Although the prototype FLS is being implemented within the Fraser Health Authority, the potential to disseminate to other health authorities throughout B.C. is high. FLS analyzes fractures through a larger lens, by focusing on secondary prevention rather than viewing fractures as a single acute event. This has led to decreased recurrent fracture rates and health care costs in jurisdictions that have implemented FLS programs widely.11 The current B.C. FLS project has the potential to create a strong FLS prototype that could be expanded across B.C. and improve the health of older adults in British Columbia.

B.C. has a unique set of circumstances that could make the implementation of an FLS a challenge. One barrier is the limited access to BMD testing and osteoporosis medication through public drug plans and B.C. Osteoporosis Guidelines.11 Another is cost; most of the expenses incurred to implement a type A FLS in B.C. involve the hiring of a nurse practitioner (NP) at 27 full–time equivalents (37.5 hours/week).23 However, a cost–effectiveness analysis for B.C. by Osteoporosis Canada predicts that even with the cost of hiring a NP, the reduction of future fractures and potential long–term care admissions would lead to a savings of over $3 million by year one and $60,135,755 by year eight.23 A prototype FLS is currently underway at Peace Arch Hospital (PAH) in White Rock, B.C.16 This prototype program is working in collaboration with the Centre for Hip Health and Mobility (CHHM), a University of British Columbia research centre.16 Funding for the research and evaluation component of the program is being managed by the CHHM with funding provided by the Ministry of Health of B.C. and PAH Foundation.16,24 PAH provides health care to a community within

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what is being done now

acknowledgementsThank you to Dr. Sonia Singh MD,

Principal Investigator for the project, Breaking the Cycle of Recurrent Fracture: A Prototype Fracture Liaison Service at Peace Arch Hospital, for review of the manuscript.

references1. Eisman JA, Bogoch ER, Dell R, Harrington JT,

McKinney RE Jr, McLellan A, et al. Making the first fracture the last fracture: ASBMR task force report on secondary fracture prevention. J Bone Miner Res. 2012 Oct;27(10):2039-46.

2. Singh S, Foster R, Khan KM. Accident or osteo-porosis?: Survey of community follow–up after low–trauma fracture. Can Fam Physician. 2011 Apr;57(4):e128-33.

3. Scott V, Wagar L, Elliott S. Falls & Related Injuries among Older Canadians: Fall–related Hospitaliza-tions & Intervention Initiatives [Internet]. 2010 April [cited 2015 Feb 9]. Available from: http://www.hiphealth.ca/media/research_cemfia_phac_epi_and_inventor_20100610.pdf

4. Employment and Social Development Canada. Ca-nadians in Context-Aging Population [Internet]. 2011 [cited 2015 Feb 9]. Available from: http://www4.hrsdc.gc.ca/.3ndic.1t.4r@-eng.jsp?iid=33

5. Lutze M, Fry M, Gallagher R. Minor injuries in older adults have different characteristics, injury patterns, and outcomes when compared with younger adults: An Emergency Department correlation study. Int Emerg Nurs. 2015 Apr;23(2):168-73. doi: 10.1016/j.ienj.2014.10.004

6. Tarride JE, Hopkins RB, Leslie WD, Morin S, Adachi JD, Papaioannou A, et al. The burden of illness of Osteoporosis in Canada. Osteoporos Int. 2012 Nov;23(11):2591-600.

7. Jiang HX, Majumdar SR, Dick DA, Moreau M, Raso J, Otto DD, et al. Development and initial validation of a risk score for predicting in–hospital and 1–year mortality in patients with hip fractures. J Bone Miner Res. 2005 Mar;20(3):494-500.

8. Kaffashian S, Raina P, Oremus M, Pickard L, Adachi J, Papadimitropoulos E, et al. The burden of osteo-porotic fractures beyond acute care: the Canadian Multicentre Osteoporosis Study (CaMos). Age Ageing. 2011 Sep;40(5):602-7.

9. Port L, Center J, Briffa NK, Nguyen T, Cumming R, Eis-man J. Osteoporotic fracture: missed opportunity for intervention. Osteoporos Int. 2003 Sep;14(9):780-4.

10. dwards BJ, Bunta AD, Simonelli C, Bolander M, Fitz-patrick LA. Prior fractures are common in patients with subsequent hip fractures. Clin Orthop Relat Res. 2007 Aug;461:226-30.

11. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1864-73.

12. Osteoporosis Canada. Fracture Liaison Service—Osteoporosis Canada Toolkit [Internet]. 2013 [cited 2015 Feb 9]. Available from: http://www.osteoporo-sis.ca/fracture_liasion_service/

13. Miller AN, Lake AF, Emory CL. Establishing a Fracture Liaison Service: An Orthopaedic Approach. J Bone Joint Surg Am. 2015 Apr 15;97(8):675-81.

14. Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JR, et al. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int. 2013 Feb;24(2):393-406.

15. Ashe M, Khan K, Guy P, Janssen P, McKay H. Fragility fracture and osteoporosis investigation. BCMJ. 2004 Dec;46(10):506-9.

16. Singh S. Interviewed by: Napoleone G. 2015 Feb 9.

disclosuresThe author received funding from

Amgen Inc.

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17. Sander B, Elliot-Gibson V, Beaton DE, Bogoch ER, Maetzel A. A coordinator program in post-fracture osteoporosis management improves outcomes and saves costs. J Bone Joint Surg Am. 2008 Jun;90(6):1197-205.

18. Lih A, Nandapalan H, Kim M, Yap C, Lee P, Ganda K, et al. Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study. Osteoporos Int. 2011 Mar;22(3):849-58.

19. Dell R. Fracture prevention in Kaiser Permanente Southern California. Osteoporos Int. 2011 Aug;22 Suppl 3:457-60

20. Harness NG, Funahashi T, Dell R, Adams AL, Burchette R, Chen X, et al. Distal radius fracture risk reduction with a comprehensive osteoporosis

management program. J Hand Surg Am. 2012 Aug;37(8):1543-9.

21. Cosgrove DM, Fisher M, Gabow P, Gottlieb G, Halvorson GC, James BC, et al. Ten strategies to lower costs, improve quality, and engage patients: the view from leading health system CEOs. Health Aff (Millwood). 2013 Feb;32(2):321-7.

22. Majumdar SR, Beaupre LA, Harley CH, Hanley DA, Lier DA, Juby AG, et al. Use of a case manager to improve osteoporosis treatment after hip fracture: results of a randomized controlled trial. Arch Intern Med. 2007 Oct 22;167(19):2110-5.

23. Osteoporosis Canada. Potential Cost Savings of FLS by Province [Internet]. 2013 [cited 2015 May 1]. Available from: http://www.osteoporosis.ca/wp-con-tent/uploads/Appendix-F.pdf

24. Ministry of Health BC. Province provides grant for seniors’ fall prevention and mobility. News Release [Internet]. 2014 Nov 5 [cited 2015 May 1]. Available from: http://www2.news.gov.bc.ca/news_releases_2013-2017/2014HLTH0120-001670.htm

25. Government of British Columbia. Sub-Provincial Population Projections: P.E.O.P.L.E. 2012 [Internet]. BC Stats, BC Ministry of Labour and Citizens; 2012 [cited 2015 May 1]. Available from: http://www.bcstats.gov.bc.ca/StatisticsBySubject/Demography/PopulationProjections.aspx

26. College of Registered Nurses of British Columbia. Scope of Practice for Nurse Practitioners [Internet]. 2014 [cited 2015 May 1]. Available from: https://crn-bc.ca/Standards/Lists/StandardResources/688Scope-forNPs.pdf

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The Healing Garden. Baillie Redfern, Vancouver Fraser Medical Program, UBC Faculty of Medicine, Vancouver, BC

Traditional medicines have been used for thousands of years by Indigenous people in Canada, with demonstrated efficacy in treating a wide range of health issues. Many of the medicines in contemporary biomedical treatments are derived from plants and herbs used by Indigenous people throughout the world. “The Healing Garden” beadwork piece includes both traditional Indigenous medicines and traditional Chinese medicines. I created this piece to reflect the reality of being an Indigenous medical student living, working and studying in Vancouver. The amount of material medical students are responsible for is sometimes described as ‘drinking from a fire hose’ but it’s important to remember the demographic you serve as a physician and the teachings that a garden can grow.

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Traditional Chinese Medicine (TCM) originated in China over 2,500 years

ago and represents a myriad of modalities and techniques, such as acupuncture, herbal medicine, tui na (Chinese therapeutic massage), and tai chi.1 TCM is based on the idea that qi (the body’s vital energy) flows through the meridians (channels) of the body and keeps a person spiritually, emotionally, mentally, and physically healthy—in essence, qi maintains a state of “balance”.2 When qi is blocked, a person will tumble out of “balance” and suffer disease. Therefore, TCM treatments attempt to restore a state of “balance” in order to alleviate disease.2

In Canada, the history of TCM started with the significant immigration of Chinese workers during the gold rush and development of the Canadian Pacific Railway in the 1880s.3 Although the use of TCM was initially limited to the Chinese community, it is now more well–known and accepted within the Canadian population.3

For example, acupuncture has become very popular in Canada: 17 % of the Canadian population have used it at least once in their lifetime.4 In 2008, British Columbia became the first province in Canada to reimburse acupuncture treatments as part of its Medical Services Plan.5

While still in its early stages, the regulation of TCM in Canada is importantly becoming more rigorous. Five provinces in Canada have approved the legislation of TCM as a health profession and five corresponding provincial Colleges of TCM have been formed.3 These Colleges benefit from self–regulation and have established codes of ethics and professional practice standards. The entry–level occupational competencies for TCM practitioners and doctors of TCM have been respectively

developed in 2010 and 2014.3 National licensing examinations for various professions within the field of TCM (herbalist, acupuncturist, TCM practitioner, etc.) have been administered since 2013.3

Dr. Henry Lu, PhD, Dr.TCM is a licensed doctor of TCM in British Columbia and has practiced Chinese medicine since 1972. He received his PhD degree from the University of Alberta and has taught at the University of Alberta and University of Calgary. Dr. Lu has translated and published more than 30 books on TCM. He is most famous for his complete Chinese–to–English translation of Nei-Jing (colloquially known as the “Chinese Medical Bible”), a classic that not only inspired the development of TCM, but is also highly regarded by Chinese physicians. Dr. Lu founded the International College of Traditional Chinese Medicine of Vancouver in 1986. As President, he plays an active role in teaching TCM and developing its accredited curriculum. Dr. Lu has been involved in the introduction of legislation for TCM in British Columbia and has sat on the Federal Board of Natural Health Products in Canada. Dr. Lu was interviewed on the topic of TCM, including its role in today’s health care and how he believes TCM and conventional Western medicine can work together.6

How did you come to practice TCM?

I had chronic constipation and constant nasal discharge since high school. The symptoms continued into my college years when I moved to the city of Taipei, Taiwan. As Western doctors were available in the city, I did not think of TCM doctors because I did not believe in the practice of TCM. One by one, I consulted Western doctors, but none of them could help me. When I graduated from college, I had the chance to pursue graduate study in

the United States. I was excited because I thought that the United States was one of the most advanced nations in the world and that my chronic constipation and constant nasal discharge would have a cure at last. Upon my arrival in Honolulu, I was anxious to consult American doctors for my problems. However, I did not expect them to give me the same treatments as I had been given in Taiwan, the same laxatives that caused pain to my intestines. All in all, I was very disappointed. It made me realize that the use of laxatives in Western

Traditional Chinese Medicine: Learning from Dr. Henry Lu, PhD, Dr.TCM

news and letters

Alvin H. Ipa,°, BKinCitation info: UBCMJ. 2015: 7.1 (36-38)°Corresponding author: alvinip@alumni.ubc.caa MD Candidate 2016, Faculty of Medicine, University of British Columbia, Vancouver, BC

While still in its early stages, the regulation of TCM in Canada is importantly becoming more rigorous. Five provinces in Canada have approved the legislation of TCM as a health profession and five corresponding provincial Colleges of TCM have been formed. These Colleges benefit from self–regulation and have established codes of ethics and professional practice standards.

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news and letters

medicine to treat all types of constipation was a typical symptomatic treatment. Other solutions suggested to me include fruits, diet, and exercises, none of which helped me. My chronic constipation and constant nasal discharge were causing me extreme fatigue. Later on, I went back to Taiwan to visit my relatives and I had the chance to consult a Chinese herbalist. He gave me an herbal formula to take. I began to feel very energetic within a few days, which impressed me a great deal.

Why did you decide to establish the International College of Traditional Chinese Medicine of Vancouver?

I founded the International College of Traditional Chinese Medicine of Vancouver in 1986. I believe that if traditional Chinese medicine and acupuncture are to take root in the Western world, it is not sufficient to practice them, but also necessary to spread the knowledge of it to the Western people by means of education.

Why do you want to spread the knowledge of TCM? What role does TCM play in today’s health care?

People sometimes ask me why it is useful to study a system of knowledge as old as TCM. I believe the thinking of equating “old” with “obsolete” is not always valid. In the world of knowledge, there are

ever–changing phenomena and there are eternal principles. Medicine is no exception. Our knowledge about the stomach or kidneys or liver may be ever–changing, but some principles are not subject to change. There are men and women in the world, there are two eyes and two ears, and there is the stomach and liver and heart in the human body; the functions of these internal organs and their interrelationships remain the same from time immemorial. Such things were, are, and will always be the case and many fundamental principles inherent in TCM fall under this category; they are as valid in ancient times as they are today.

How are best practices in TCM determined and how does a practitioner stay up–to–date on them?

Up–to–date is not the key; treatment effect is the criterion. A treatment technique invented 3,000 years ago is still in common use because it is effective. A modern practitioner can tell you, “I have invented a new method of treatment which has proven very effective,” and every practitioner will follow suit. A modern practitioner can also say, “I have invented a new method of treatment which is up–to–date,” but no one is interested unless it is effective.

What methods do you use to define treatment effectiveness? How does TCM as a field monitor treatment safety and effectiveness?

If a patient has a headache and his or her headache is gone after treatment, this means that the treatment is effective. In other words, the patient is the judge of treatment effectiveness and not the practitioner. There is no centralized reporting system, but there are guidelines in many publications.7 As to treatment safety, several principles are common knowledge to TCM practitioners, such as “don’t needle patients right after a meal” and “forbidden points are not to be needled.”

Is there a system for ensuring that TCM practices are evidence–based?

TCM practices are evidence–based. For example, I cannot claim that I have cured atrophy of Peter’s gums unless Peter’s atrophy is gone. I cannot say I have cured Peter’s headache unless his headache is

gone. This is the best evidence. In many cases, the patient’s testimonial is the best evidence. I don’t need any other evidence. I would consider myself to be a successful TCM doctor with testimonials from all my patients. But of course, this is hard to come by.

What is the nature of the practitioner–patient relationship in TCM?

As a rule, friendship characterizes the practitioner–patient relationship in TCM; a patient often sees the same TCM doctor, like a family doctor in Western medicine.

How do you think that TCM and Western medicine can work together?

TCM and Western medicine are different from each other, so they cannot be merged. However, it is possible to build bridges between them by putting the two medical systems together to compensate for poor clinical effects, to increase patient satisfaction, or both. Each system has its own strengths and weaknesses; some diseases may be better treated by Western medicine, while others may be better treated by TCM, and still others may be better treated by a combination of the two systems. To a large extent, the interaction between the two medical systems is a comparative and competitive approach in clinical practice.

As a general principle, if a TCM doctor can treat a patient successfully, one should do so. If this is not the case, then referring the patient to a Western doctor for treatment would be appropriate. On the other hand, if a Western doctor can treat a patient successfully, he or she should do so. But if this is not the case, the patient should be referred to a TCM doctor for treatment.

I believe that TCM and Western medicine can work together in four interactive ways:

1. Use advanced methods of Western diagnostics to confirm or direct TCM diagnoses.

Many advanced methods of diagnostics used in Western medicine may be used to confirm a TCM doctor’s diagnosis or narrow down the possibilities so the TCM doctor may be more confident in finding the correct diagnosis. Methods of diagnostics include tissue biopsy, ultrasound, x-ray, and computed tomography.

TCM and Western medicine are different from each other, so they cannot be merged. However, it is possible to build bridges between them by putting the two medical systems together to compensate for poor clinical effects, to increase patient satisfaction, or both.

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From the patient’s viewpoint, both a Western doctor and a TCM doctor should understand the strengths and weaknesses of each system.

news and letters

2. Use advanced methods of Western diagnostics to evaluate TCM treatment effect.

Many advanced methods of diagnostics in Western medicine may be used to evaluate a Chinese doctor’s treatment effect. If a patient is treated for hepatitis, it is relevant to see if the virus or antibody, which was present before the treatment, is gone. If a patient is treated for hypertension, it is important to take blood pressure to see if it returns to normal following TCM treatment. If a patient is treated for cholecystitis, it is important to see if the gallstone is gone.

3. TCM offers Western medicine opportunities for treatment and research.

TCM doctors have successfully treated many symptoms and diseases and Western doctors can conduct research into the causes of their success. There are

1. Bielory L. Complementary and alternative therapies for allergic rhinitis and conjuncti-vitis [Internet]. Feldweg AM, editor. Waltham (MA): UpToDate [updated 2014 Dec 18; cited 2015 Apr 28]. Available from: http://www.uptodate.com/contents/complementa-ry-and-alternative-therapies-for-allergic-rhini-tis-and-conjunctivitis

2. Ahn AC. Acupuncture [Internet]. Rind DM, editor.  Waltham (MA): UpToDate [updated 2014 Nov 24; cited 2015 Apr 28]. Available from: http://www.uptodate.com/contents/acupuncture

3. Cao BB. Current status and future prospects of acupuncture and traditional Chinese med-icine in Canada. Chin J Integr Med. 2015 Mar ;21(3):166-72.

4. Esmail N.  Complementary and alternative medicine in Canada: trends in use and pub-lic attitudes, 1997-2006. Public Policy Sourc-es.  Vancouver (B.C.): The Fraser Institute; 2007. 53 p. Report No.: 87.

5. Ministry of Health. Acupuncture added as supplementary MSP benefit. [Internet]. 2008 Mar 30 [cited 2015 Mar 28]. Available from: http://www2.news.gov.bc.ca/news_releases_2005-2009/2008HEALTH0031-000429.htm

6. Ip, Alvin (MD Undergraduate Program, Facul-ty of Medicine, University of British Columbia, Vancouver, B.C.). Interview with: Dr. Henry Lu (International College of Traditional Chinese Medicine of Vancouver, Vancouver, B.C.). 2015 Mar 14

7. College of Traditional Chinese Medicine Practitioners and Acupuncturists of Brit-ish Columbia (CTCMA). Practice standards [Internet]. Vancouver (B.C.): CTCMA; 2004 [updated 2015 Apr 20; cited 2015 Apr 28]. Available from: http://www.ctcma.bc.ca/index.php?id=48

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many different herbs that are used in TCM but why are they effective, scientifically speaking?

4. TCM and Western medicine benefit from each other to improve clinical effects and patient satisfaction.

From the patient’s viewpoint, both a Western doctor and a TCM doctor should understand the strengths and weaknesses of each system. Patients have everything to lose if a disease can be better treated by Western medicine, but a TCM doctor is not aware of it and insists on TCM treatment. The same thing will happen if a disease can be better treated by TCM, but a Western doctor is not aware of it and insists on Western treatment. In the emergency department, for example, a patient is likely to have an accident, stroke, or heart attack and Western medicine is preferred for its access to modern technology. In such cases, after doctors of Western medicine have given initial care, they may hand the patient over to a TCM doctor for follow–up.

Author commentary

Most medical students have little to no knowledge regarding TCM and its diverse practices. As the use of TCM is becoming more prevalent among Canadians, it is important for medical students, physicians, and other health care professionals to be better informed on the topic in order to effectively interview patients, assess for potential drug and treatment interactions, and provide evidence–based recommendations. It is very encouraging to see the progressive development and regulation of the TCM profession in Canada. The practice of TCM is largely focused on tradition, practitioner experience, and outcomes of individual patients. It will be worthwhile to further explore and learn from the wealth of experience of TCM. However, it is also imperative to establish the safety and efficacy of TCM treatments through scientific research. In this interview, Dr. Lu also shared his thoughts on how TCM and Western medicine can work together. It will be important for the medical profession to continue to reach out to alternative medicine practitioners, listen to what they have to say, and work together to explore and address issues to best provide well–informed health care to patients.

Most medical students have little to no knowledge regarding TCM and its diverse practices. As the use of TCM is becoming more prevalent among Canadians, it is important for medical students, physicians, and other health care professionals to be better informed on the topic in order to effectively interview patients, assess for potential drug and treatment interactions, and provide evidence–based recommendations.

disclosuresThe author does not have any conflicts

of interest.

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news and letters

1. Merskey H, Bogduk N, editors. Classification of chronic pain: Descriptions of chronic pain syndromes and defini-tions of pain terms. Seattle (WA): IASP Press; 1994. p. xi.

2. Schopflocher D, Taenzer P, Jovey R. The prevalence of chron-ic pain in Canada. Pain Res Manag. 2011 Dec;16(6):445–50.

3. Stewart WF, Ricci J, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain condi-tions in the US workforce. J Amer Med Assoc. 2003 Nov 12;290(18):2443–54.

4. Jovey RD, Ennis J, Gardner–Nix J, Goldman B, Hays H, Lynch M, et al. Use of opioid analgesics for the treatment of chronic noncancer pain—a consensus statement and guidelines from the Canadian Pain Society, 2002. Pain Res Manag. 2003 Spring; 8 Suppl A:3A–28A.

5. The American Academy of Pain Medicine. Use of Opioids for the Treatment of Chronic Pain. [Internet]. 2013 Feb [cit-ed 2015 May 6]. Available from: http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf.

6. National Institute for Clinical Excellence (NICE). Low back pain: Early management of persistent non–specific low back pain. [Internet]. 2009 [cited 2015 May 6]. Available from: guidance.nice.org.uk/cg88.

7. Landmark T, Romundstad P, Dale O, Borchgrevink PC, Vatten L, Kaasa S. Chronic pain: One year prevalence and associated characteristics (the HUNT pain study). Scand J Pain; 2013 Aug 21;4(4):182–7.

8. Foltz V, St Pierre Y, Rozenberg S, Rossignol M, Bourgeois P, Joseph L, et al. Use of complementary and alternative therapies by patients with self–reported chronic back pain: A nationwide survey in Canada. Jt Bone Spine. 2005 Sep 07;72:571–7.

9. Metcalfe A, Williams J, McChesney J, Patten SB, Jetté N. Use of complementary and alternative medicine by those with a chronic disease and the general population—results of a national population based survey. BMC Complement Altern Med; 2010 Oct 18;10(1):58.

10. Krames ES, Olson K. Clinical realities and economic con-siderations: Patient selection in intrathecal therapy. J Pain Symptom Manage. 1997 Sep;14 suppl 3:S3-S13.

11. BC Ministry of Health. Investing $1 million in easing pain and giving hope [Internet]. 2014 Apr 28 [cited 2015 May 6]. Available from: http://www2.news.gov.bc.ca/news_releases_2013-2017/2014HLTH0033-000536.htm.

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Chronic pain is defined as ongoing pain that lasts longer than the typical period of time expected for healing, usually taken to be three months.1 It can occur as a result of an injury such as back strain or an ongoing condition such as cancer, or it can have no known cause. Approximately one in five Canadian adults currently lives with chronic pain.2 Shockingly, over half of those who report chronic pain also report suffering for ten years or more, indicating that a significant proportion of their life has been affected by this condition.2 This multifaceted disorder is associated with significant disability and financial burden,3

making effective and adequate treatment a top priority for patients, clinicians, and policy makers alike. This article will briefly discuss the treatment modalities for chronic pain and the lack of coverage for non–biomedical treatment options under Canadian public health insurance.

Conventional biomedical treatment options for chronic pain include prescription opioid analgesics and surgical intervention. While both of these practices remain important therapies for pain management, they are often not recommended as first–line therapy for mild–to–moderate cases.4-6

Recommendations for first–line therapy vary according to the source, location, and strength of chronic pain symptoms, and they often include non–biomedical treatments.4-6 For example, according to the 2009 guidelines for persistent, nonspecific low–back pain released by the National Institute for Health and Care Excellence (NICE), the recommendation for early treatment is one of exercise, manual therapy, or acupuncture; psychological and/or pharmaceutical treatment can also be included in the treatment plan, depending on the patient and the nature of their symptoms.6

Currently, treatments for chronic pain management included in Canadian public health insurance plans are largely restricted to the conventional biomedical

treatment options provided by physicians. This is problematic, as several pain management guidelines recommend the use of psychological, behavioural, or less–invasive physical interventions, either on their own or in conjunction with conventional pharmaceutical treatment.4-6 In Canada, patients are often required to pay out–of–pocket for less invasive, non–conventional treatment options, such as acupuncture, cognitive behavioural therapy, or customized exercise plans. This creates an issue of access, where not all patients can afford uninsured treatment, especially patients who are low–income or without private health insurance. The prevalence of chronic pain is high among people with low income and people who are work–disabled,7 suggesting that the affordability of health care is a relevant issue in chronic pain management.

Currently in Canada, services for chronic pain management are fragmented across the public and private health systems, with an emphasis toward biomedical treatment within the public system. Patient demand for less–conventional treatment is evidenced by the very high use of complementary and alternative medicine by people with chronic pain.8,9 In addition to this, under–treatment of chronic pain is a consistently–identified health care problem,4,10 possibly due to a combination of physicians’ fear of over–prescribing and a lack of other publically–insured treatment options. Pain care advocacy groups have made multiple efforts to improve the treatment of chronic pain, and in 2014, the government of British Columbia invested one million dollars to support the training of patients and medical professionals in chronic pain management.11 Hopefully such efforts already have and will continue to have a positive impact on the lives of those affected. However, if we consider access to chronic pain management a fundamental human right, and if we value

efficacy over convention, a more integrated approach to public health care—one that includes coverage for a wider range of non–biomedical treatment options—is necessary.

Chronic Pain Management and Canadian Public Health Insurance: Do We Need More Comprehensive Health Care?

Andrea Jonesa,°, MSc Citation info: UBCMJ. 2015: 7.1 (39)° Corresponding author: andrea.jones@alumni.ubc.caa PhD Candidate 2017, School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC

disclosuresThe author does not have any conflicts

of interest.

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news and letters

Although society has experimented with unorthodox methods of treating

health problems for centuries,1 the business of complementary and alternative medicine (CAM) has grown and diversified dramatically over the past few decades.2

Despite the unconventional nature of CAM interventions, their extensive promotion through mainstream outlets blurs the lines between what is and is not scientifically accepted. For example, cardiothoracic surgeon and popular television personality Dr. Oz recently came under fire at a U.S. Senate hearing after encouraging viewers to take various products that he deemed “miracle” weight–loss cures, despite his awareness of their lack of scientific evidence.3 While it is hard not to be enticed by the promise of CAM, keeping a close eye on its evidence will be critical as the overlap between personalized and evidence–based medicine increases.

Between 29 % and 42 % of American adults have used some form of CAM in the previous year.4 Studies of CAM use among children living with cancer from various countries around the world have recorded CAM prevalence rates as high as 91 % in some samples.5 Despite the popularity of CAM treatments, we still know shockingly little about them. This is because CAM interventions are regulated (and sometimes not regulated at all) completely separately from conventional medicine,6 and they therefore may be marketed and used without standing up to the same clinical tests of efficacy and safety. In contrast to conventional medicine, testimonial reports, such as those from Dr. Oz, often form the basis of CAM marketing. In reviewing CAM websites, researchers have found various anecdote–based recommendations for therapies that have been scientifically shown not only to have little benefit, but to even

be potentially dangerous.7 Not bound by the same regulations as conventional medicine, CAM marketers may conveniently select compelling anecdotes that, despite holding no validity of measure, present as hopeful messages to a desperate patient.

While some CAM trials appear to exhibit strong scientific rigour, many others are fraught with methodological shortcomings.8 One common drawback to clinical CAM research is a lack of comparison to a placebo—or control—group.9 The problem with relying solely on treatment group outcomes is the utter neglect of effects that could arise from not receiving the treatment, such as natural improvement, regression to the mean, and the placebo effect, a physiological improvement arising from simply going through the motions of being “treated.” Unless we are able to measure baseline and post–treatment effects in both a treatment group and a control group, there is no way to confirm that the benefits gained were actually due to the treatment itself. In cases where CAM randomized controlled trials (RCT) exist, study validity is still called into question. For example, a Lancet review, which stirred controversy between CAM and conventional medicine proponents,10

concluded that, after controlling for biases in both CAM and conventional RCTs, there was only weak evidence for a specific effect of CAM therapies, while there was strong evidence in support of conventional therapies.11

As more patients adopt an interest in CAM, its integration with conventional practice is becoming more common. For example, roughly 40 % of American mainstream physicians have referred patients for acupuncture and/or chiropractic therapies.12 These types of CAM treatments might appear more favourable to physicians due to their longer histories of scientific

scrutiny, which have allowed them to be increasingly seen as accepted practices.13-15 Physicians might also be integrating CAM into their practice in an effort to prevent the dangers of patients using it without their consultation. For example, despite decades of research showing the popular herbal supplement St. John’s wort to be an effective treatment for some forms of depression,16,17 patients taking this product without physician consultation run the risk of suffering potentially dangerous reactions due to the supplement’s ability to interact with a long list of conventional drugs.18,19 It is becoming increasingly important for physicians to be aware of the evidence base surrounding different CAM options in order to develop a safe and effective treatment plan for their CAM–using patients. Evidently, there is a strong and ongoing need for rigorous scientific evidence to inform the use of CAM.

But if we apply the same evidence–based model for CAM, would we be moving past the point of CAM altogether? As science writer Michael Specter has so simply put it,

Evidence–Based Medicine and the Growing Popularity of Complementary and Alternative Treatments

Stephanie Lakea,°, BHSc MScCitation info: UBCMJ. 2015: 7.1 (40-41)° Corresponding author: s.lake@alumni.ubc.caa PhD Candidate 2018, School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC

It is becoming increasingly important for physicians to be aware of the evidence base surrounding different CAM options in order to develop a safe and effective treatment plan for their CAM–using patients.

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1. Whorton JC. Conversations in complementary and alternative medicine: insights and perspec-tives from leading practitioners. Cella D, editor. Mississauga (ON): Jones and Bartlett Learning; c2006. Chapter 1, History of complementary and alternative medicine; p. 1-8.

2. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alter-native medicine use in the United States, 1990-1997: results of a follow–up national survey. J Amer Med Assoc. 1998 Nov 11;280(18):1569-75.

3. Associated Press; Daily Mail Reporter. Dr. Oz skewered on Capitol Hill for advertising ‘mira-cle’ products — as he admits they ‘don’t pass scientific muster’. The Guardian. [Internet]. 2014 Jun 17. [updated 2014 Jun 18;cited 2015 May 3]. Available from: http://www.dailymail.co.uk/news/ar ticle-2660450/Dr-Oz-scolded-hearing-weight-loss-scams.html.

4. Miller FG, Ezekiel JE, Rosenstein DL, Straus SE. Ethical issues concerning research in comple-mentary and alternative medicine. J Amer Med Assoc. 2004 Feb 4;291(5):599-604.

5. Bishop FL, Prescott P, Chan YK, Saville J, von Elm E, Lewith GT. Prevalence of complementary medicine use in pediatric cancer : a systematic review. Pediatrics. 2010 Mar 22;125(4):768-76.

6. Vogel, L. ‘Hodge-podge’ regulation of alter-native medicine in Canada. Can Med Assoc J. 2010 Sep 7;182(12):E569-70.

7. Schmidt K, Ernst E. Assessing websites on com-plementary and alternative medicine for cancer. Ann Oncol. 2004 May;15(5):733-42.

8. Linde K, Jonas WB, Melchart D, Willich S. The methodological quality of randomized con-trolled trials of homeopathy, herbal medi-cines and acupuncture. Int J Epidemiol. 2001 Jun;30(3):526-31.

9. Nahin RL, Straus SE. Research into com-plementary and alternative medicine: prob-lems and potential. Brit Med J. 2001 Jan 20;322(7279):161-4.

10. Rutten ALB, Stolper CF. The 2005 meta–analysis of homeopathy: the importance of post-publication data. Homeopathy. 2008 Oct;97(4):169-77.

11. Shang A, Huwiler-Müntener K, Nartey L, Jüni P, Dörig S, Sterne JAC, et al. Are the clinical ef-fects of homoeopathy placebo effects? Com-parative study of placebo-controlled trials of

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homoeopathy and allopathy. Lancet. 2005 Aug 27;366(9487):726-32.

12. Astin J, Marie A, Pelletier KR, Hansen E, Haskell WL. A review of the incorporation of com-plementary and alternative medicine by main-stream physicians. Arch Intern Med. 1998 Nov 23;158(23):2303-10.

13. Meeker WC, Haldeman S. Chiropractic: a pro-fession at the crossroads of mainstream and al-ternative medicine. Ann Intern Med. 2002 Feb 5;136(3):216-27.

14. World Health Organization. Acupuncture: re-view and analysis of reports on controlled clin-ical trials. Geneva (Italy): World Health Organi-zation; 1996, p. 5.

15. Bell IR, Caspi O, Schwartz GE, Grant KL, Gaudet TW, Rychener D, et al. Integrative medicine and systemic outcomes research. Arch Intern Med. 2002 Jan 28;162:133-40.

16. Linde K, Ramirez G, Mulrow CD, Pauls A, Weid-enhammer W, Melchart D. St John’s wort for depression—an overview and meta–analysis of randomised clinical trials. Brit Med J. 1996 Aug 3;313(7052):253-8.

17. Linde K, Berner MM, Kriston L. St John’s wort for major depression. Cochrane Database Syst Rev [Internet]. 2008 Oct 8 [cited 2015 May 3]. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000448.pub3/ab-stract.

18. Mills E, Montori VM, Wu P, Gallicano K, Clarke M, Guyatt G. Interaction of St John’s wort with conventional drugs: systematic review of clinical trials. Brit Med J. 2004 Jul 1;329(7456):27-30.

19. Henderson L, Yue QY, Bergquist C, Gerden B, Arlett P. St John’s wort (Hypericum perfora-tum): drug interactions and clinical outcomes. Brit J Clin Pharmacol. 2002 Oct 23;54(4):349-56.

20. Specter M. Denialism: how irrational thinking hinders scientific progress, harms the planet, and threatens our lives. New York: The Penguin Press; 2009. p. 158.

21. Kienle GS, Albonico HU, Fischer L, Frei-Erb M, Hamre HJ, Heusser P, et al. Complementary therapy systems and their integrative evalua-tion. Explore-NY. 2011 May;7(3):175-87.

22. Fonnebo V, Grimsgaard S, Walach H, Riten-baugh C, Norheim AJ, MacPherson H, et al. Researching complementary and alternative treatments—the gatekeepers are not at home. BMC Med Res Methodol. 2007 Feb 11;7:7.

23. Verhoef MJ, Lewith G, Ritenbaugh C, Boon H, Fleishman S, Leis A. Complementary and al-ternative medicine whole systems research: beyond identification of inadequacies of the RCT. Complement Ther Med. 2005 Aug 15;13(3):206-12.

24. Weatherley-Jones E, Thompson EA, Thomas KJ. The placebo–controlled trial as a test of com-plementary and alternative medicine: obser-vations from research experience of individu-alised homeopathic treatment. Homeopathy. 2004 Oct;93(4):186-9.

25. Therapeutic Research Center. Natural Medi-cines [Internet]. Somerville (MA): Therapeutic Research Center ; 2015 [cited 2015 May 2]. Available from: https://naturalmedicines.thera-peuticresearch.com/.

news and letters

for CAM, such as the Natural Medicines database,25 should be used by conventional practitioners and shared with patients. Safe and positive results could be possible with CAM, so long as we are able to set biases aside and to separate the evidence from the anecdote.

“If we were to do that, there would really be nothing ‘complementary’ or ‘alternative’ about CAM.”20

CAM approaches the healing process as a function of the “whole system,” rather than through targeting a single physiological component, where the effect of the CAM approach is said to be greater than the sum of its individual effects.21 As such, CAM proponents argue that in applying conventional study design to unconventional interventions, the true effect of the treatment is being diluted through the process of attempting to single it out.22-24 The deductive evidence–based model by which conventional medicine is accepted into practice (i.e., understanding the molecular biology of a therapy before moving on to various stages of clinical trials and eventual practice) stands in stark contrast to the inductive approach used for CAM (i.e., widespread use of a CAM therapy before evaluation through clinical trials and eventual understanding of its molecular biology).22

Authors have suggested developing a separate framework for the evaluation of CAM, which takes into account its holistic philosophy to bridges the gap between the widespread positive anecdotal reports of CAM and the conventional-style evidence that opposes them.22 Accordingly, CAM researchers are advocating for a comprehensive evidence-based evaluation model that uses observational (e.g., cohort, case-control, case series) research to complement RCTs, while considering the patient perspective, the conceptual basis, and the medical professionalism of the therapy through qualitative analysis.21 Advocates of this so-called Whole Systems Research model suggest that the integration of non-randomized studies will help to capture health outcomes that may have been missed under the highly manipulated RCT environment (i.e., the effect of the treatment on the body, mind, and spirit as a whole).21

As we move into the era of individualized, integrated, and alternative medicine, we will have to decide what we are willing to accept as a “gold standard” for CAM, and whether this can stray from the pre–defined, single–outcome approach with which conventional practitioners are so comfortable. In the meantime, available unbiased and evidence–based resources

disclosuresThe author does not have any conflicts

of interest.

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news and letters

Regulating Health Professions in British Columbia

Pretty Vermaa,°, BScCitation info: UBCMJ. 2015: 7.1 (42-43)° Corresponding author: pretty.verma@alumni.ubc.caa MD Candidate 2016, Faculty of Medicine, University of British Columbia, Vancouver, BC

Walking down Davie Street to reach St Paul’s Hospital, one encounters a wide variety of businesses and shops. Turning to walk up to the Thurlow Street hospital entrance, one will pass a marijuana dispensary, a naturopathic clinic, and an acupuncture shop, each offering their own unique treatments for chronic pain. Here on the west coast, the depth and breadth of diverse medical services available all on one block is remarkable. As a third–year medical student undergoing rigorous training with endless qualifications and examinations to pass, I start to wonder about the training and legal rules facing healthcare professionals besides physicians. For naturopathic, homeopathic, and traditional Chinese medicine practitioners, what regulations are in place to ensure a high standard of care?

In British Columbia, the Ministry of Health regulates 26 professions, of which 25 have self–regulated bodies and colleges guided by the Health Professions Act. These colleges have the authority to govern their members’ practices, and they must do so with the public interest in mind. Just as the Royal College of Physicians and Surgeons’ mandate is to serve and protect the public, such is also the case for the 26 self–regulated professions. This means that any comment or concern raised by the public against a service provided by a practitioner goes directly to his/her overseeing college, which can choose to investigate the comment, assess the practitioner, and if needed, suspend or remove licenses to practice. In reality, practitioners do not undergo regular inspections. Bodies that are regulated under the Health Professions Act include: Dentistry, Pharmacy, Medicine, Chiropractics, Dietetics, Massage Therapy, Licensed and Registered Nursing, Naturopathic Medicine, and Traditional Chinese Medicine and Acupuncture.1 Homeopathy, on the other hand, is notable

for being currently unregulated by the B.C. government; instead, the profession is guided by a group of invested organizations, such as the Vancouver Homeopathic Academy, the North American Society for Homeopaths (NASH), and the Council for Homeopathic Certification (CNC) in conjunction with European and International Councils for Homeopathy.2

Given that each profession has its own regulatory body, what comprises these bodies, and what are their guiding principles beyond what the Health Professions Act authorizes? Regarding governance, provinces and territories are tasked with overseeing the provision of health services in their jurisdictions, while federal regulations are limited to safety and sales of natural health products under the Food and Drug Administration.3,4 Currently in B.C., homeopaths belong to an unregulated body. Homeopathic practitioners train for four years; each year consists of eleven three–day training sessions that run longitudinally, as per the program offered by the Vancouver Homeopathic Association.5 In contrast, naturopaths in B.C. are guided by the British Columbia Naturopathic Association. Naturopaths are required to possess a bachelor’s degree in arts or sciences, followed by four years at an accredited naturopathic college.6 Lastly, those practicing traditional Chinese medicine work under the College of Traditional Chinese Medicine Practitioners and Acupuncturists of B.C. (CTCMA) and have different training requirements for Acupuncturists, Traditional Herbalists, Traditional Medicine Practitioners, and Doctors of Traditional Chinese Medicine.7,8

More important than depth and scope of training, however, is the question of how the Health Professions Act regulates the scope of practice of various health disciplines. A glance at the Ministry of Health website quickly links

to “regulation” and “scope of practice” as part of each profession’s bylaws. For instance, naturopathic medicine is defined as “the health profession in which a person provides the services of prevention, assessment and treatment ... using education and naturopathic techniques, therapies or therapeutics to simulate or support healing processes;”9 an accompanying scope of practice statement declares that “a registrant may practice naturopathic medicine.”9 This is followed by a list of permitted but restricted activities, including “procedures on the tissues below the dermis or below the surface of a mucous

... any comment or concern raised by the public against a service provided by a practitioner goes directly to his/her overseeing college, which can choose to investigate the comment, assess the practitioner, and if needed, suspend or remove licenses to practice. In reality, practitioners do not undergo regular inspections.

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defense tactics, and frustration. We now strive to function on a model governed by a “Theory of Continuous Improvement”,12 which is more sensitive to the cost and ineffectiveness of relying on inspection to improve quality. These are measures that must continue but that do not actively improve care to the same extent as initiatives such as continuing education.12

Now as I walk by the shops on Thurlow Street advertising their cures for Crohn’s disease, back pain, and weight loss, I am reminded that health care practitioners of many schools of thought are governed by a set of rulings that are strictly regulated and enforced. However, the responsibility for bringing substandard practices to light lies with the clients who seek out these health services; in essence, the efficacy of the regulations is directly proportional to the public’s willingness to engage with the process. Ultimately, it appears that our laws are only as strong as the people who support them.

references

news and letters

2015 Mar 8]. Available from: http://www.bcna.ca/about-bcna/becoming-naturopathic-doc-tor/

7. Ministry of Health, Government of British Co-lumbia. Traditional Chinese Medicine and Acu-puncture [Internet]. 2015 [cited 2015 Mar 8]. Available from: http://www.health.gov.bc.ca/professional-regulation/notice/tcm_and_acu-puncture.html

8. College of Traditional Chinese Medicine Prac-titioners and Acupuncturists of British Colum-bia. Registration Examinations Requirements [Internet]. 2015 [cited 2015 Mar 9]. Available from: http://www.ctcma.bc.ca/index.php?id=6

9. Health Professions Act of 1996, Naturopathic physicians regulation, BC Reg 282/2008 [Inter-net]. 2008 [cited 2015 Mar 9]. Available from: http://www.bclaws.ca/EPLibrar ies/bclaws_new/document/ID/freeside/282_2008#sec-tion5

10. Royal College of Physicians and Surgeons of British Columbia. Complaints Process [Inter-net]. 2015 [cited 2015 Mar 5]. Available from: https://www.cpsbc.ca/for-public/faqs

11. College of Naturopathic physicians of British Columbia. Public Notifications, Notices of Consents Orders and/or Disciplinary Action [Internet]. 2014 [cited 2015 Mar 8]. Available from: http://www.cnpbc.bc.ca/public/pub-lic-notifications/

12. Ministry of Health of British Columbia. Re-view of British Columbia Health Profession’s’ Quality Assurance Programs [Internet]. 2003 Mar [cited 2015 Mar 8]. Available from: http://www.health.gov.bc.ca/professional-regulation/pdfs/Quality_Assurance_Program_Review.pdf

1. Government of British Columbia. Professional Regulation, Ministry of Health [Internet]. 2015 [cited 2015 Mar 8]. Available from: http://www.health.gov.bc.ca/professional-regulation/

2. Vancouver Homeopathic Academy. Regulation of Homeopathy [Internet]. 2011 [cited 2015 Mar 9]. Available from: http://www.v-ha.com/index.php?option=com_content&view=ar ti-cle&id=59&Itemid=65

3. Health Canada. Provincial/Territorial Role in Health, Health Care System Delivery [In-ternet]. 2014 May 16 [cited 2015 May 10]. Available from: http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/ptrole/index-eng.php

4. Health Canada. Complimentary and Alter-native Health Care: the other mainstream? [Internet]. 2005 Aug 9 [cited 2015 May 10]. Available from: http://www.hc-sc.gc.ca/sr-sr/pubs/hpr-rpms/bull/2003-7-complement/in-dex-eng.php

5. Vancouver Homeopathic Academy. Practi-tioner Course [Internet]. 2011 [cited 2015 Mar 9]. Available from: http://www.v-h-a.com/index.php?option=com_content&view=ar ti-cle&id=47&Itemid=53

6. British Columbia Naturopathic Association. Becoming a Naturopathic Doctor : yours questions answered [Internet]. 2015 [cited

membrane”, “administration of substances by injection, inhalation, irrigation, enteral instillation…”,9 and so forth. Subsequent to the list, clarifications regarding drug formulary allowances and prescription privileges are detailed.9

If there is an issue with the service one receives, a patient can file a comment with the appropriate college, which will investigate further. If a patient is unhappy with the college’s final decision, they can apply to have the matter reviewed by the Health Professions Review Board (HPRB), which is an independent tribunal that reviews the thoroughness of the college’s investigation and the fairness of their decision.10 Thus, similar to the medical profession, other health disciplines are given boundaries, scopes of practice, and are largely regulated by their own colleges in most provinces. But how successful is the model of self–regulation? Colleges only disclose the name of the practitioner involved with a complaint once formal disciplinary action is taken. While colleges, such as the College of Naturopathic Physicians of British Columbia, publish lists of practitioners with disciplinary actions, it is hardly a proper account of the efficacy of our regulatory systems, as the total number of complaints is not listed.11 Furthermore, a list of complaints is not indicative, as some might be biased or not sufficient to warrant disciplinary action.

Overall, the strength of regulation depends on community reporting to bring about change. As it stands today, there are simply not enough financial resources to support routine inspection of all healthcare practitioners, and many feel this is unnecessary. Of those colleges that do perform office visits, it is worthwhile to note that the purpose of the review is for “education and practice improvement, not to discipline,”12 as stated on page 39 of the Ministry of Health’s Quality Assurance program document. Indeed, the review itself is usually “limited to a visual inspection” with “no observation of clinical service delivery to patients, in part because of privacy issues.”12 The Quality Assurance Program Review notes that identifying “bad apples” is a more traditional stance on quality improvement, an assessment that engenders distrust,

...the responsibility for bringing substandard practices to light lies with the clients who seek out these health services; in essence, the efficacy of the regulations is directly proportional to the public’s willingness to engage with the process. Ultimately, it appears that our laws are only as strong as the people who support them.

disclosuresThe author does not have any conflicts

of interest.

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quantity of membership on Canada’s Stem Cell Donor Database.11 A majority of the males we recruit at our stem cell drives are non–Caucasian (53%), and we also hold ethnically–targeted stem cell drives to recruit Aboriginal Peoples and members of other ethnic minorities.11-12 The primary aim of this review article is to provide an overview of the evidence behind the need for ethnically–diverse stem cell donors. This paper will be used to equip our team with an evidence–based resource to inform our stem cell drive campaigns, which currently feature targeted recruitment of ethnically–diverse Canadians as stem cell donors. This review seeks to inform donor registry strategic planning and to offer guidance to any group or individuals who coordinate or volunteer at stem cell drives.

The Need for Ethnically Diverse Stem Cell Donors

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Warren Fingruta,°, BSc MDCitation info: UBCMJ. 2015: 7.1 (44-47)°Corresponding author: wfingrut@alumni.ubc.caa Internal Medicine PGY1, Faculty of Medicine, University of Toronto, Toronto, ON

A majority of patients who are in need of a stem cell transplant cannot find a suitable genetic match in their families and rely on unrelated donors, individuals who have registered with a stem cell donor database. Many unrelated stem cell donor registries currently direct their donor recruitment teams to target and recruit ethnically–diverse individuals as stem cell donors. However, despite a large body of evidence in the literature highlighting the need for ethnically–diverse stem cell donors, no resource exists that explains why building an ethnically–diverse stem cell donor database is important or needed. The purpose of this review article is to summarize evidence in the literature that highlights the extent of ethnic and racial disparity in match rates in registries in North America and worldwide. Further, the author explains the multifactorial nature of this disparity, with contributing factors including ethnic differences in representation, genetic diversity, and attrition rates. This review aims to 1) equip donor recruitment staff and volunteers with a resource to inform their recruitment efforts; and 2) to support the donor recruitment team to target recruitment of ethnically–diverse stem cell donors.

abstract

Over 70% of patients who need a stem cell or bone marrow transplant

cannot find a match in their family and require an unrelated donor to proceed with treatment.1 These donors are recruited at stem cell drives where individuals are invited to swab their cheeks and to sign a consent form to register as potential stem cell donors.2 A growing body of literature highlights the need for ethnically–diverse stem cell donors.3-9 Patients in need of a stem cell transplant are more likely to find a genetically–matched donor from their own ethnic group. This is due to the association between individuals’ genetic heritage and their Human Leukocyte Antigen (HLA) alleles, which are used to match patients to donors. Minority status is often associated with less–common HLA types, underscoring the importance of building ethnic diversity into the world’s stem cell and marrow donor registries.10

Some registries, including the U.S. National Marrow Donor Program (NMDP)’s “Be The Match” registry, have already adapted their recruitment approach to specifically target ethnic and racial minorities.4

The Stem Cell Club was founded in 2011 at the University of British Columbia to improve both the quality and the

introduction

by Allan et al., Canadian patients who self–identified as East Indian or Caucasian were most likely to find a donor, with respective success rates of 59.6% of 47 requests and 50% of 2058 requests.13 However, patients who self–identified as Black (24.5% of 53 requests) or Chinese (14.3% of 14 requests) had much lower match rates.13 In a 2012 study, Gragert et al. used HLA haplotype frequencies to project HLA match rates for the different populations served by the Canadian OneMatch registry of the Canadian Blood Services. They calculated that match rates for Canadian patients searching for adult unrelated stem cell donors ranged from 2% for the Black

many ethnic and racial minority groups experience lower match rates

In Canada, over 50% of patients do not have a suitable donor on the Canadian unrelated donor registry, and patient ethnicity has been shown to influence the likelihood of finding a donor.13 In a study

Minority status is often associated with less–common HLA types, underscoring the importance of building ethnic diversity into the world’s stem cell and marrow donor registries.

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The aforementioned studies demonstrate both decreased donor pools and decreased representation of specific ethnic/racial groups (within registries and on the world’s combined registries), as well as increased genetic diversity of specific ethnic groups. However, ethnic/racial differences in donor availability also contribute to observed differences in match rates between ethnic groups.

Some ethnic groups are more likely to be unavailable at the time of donation, due to higher rates of donor ambivalence and attrition. In general, a significant proportion of individuals listed in a stem cell donor registry are not available to donate when called upon. Some registrants have changed addresses and cannot be reached, some

group to 46% for the Caucasian group.14

Similarly, in the United States, multiple studies looking at the U.S. NMDP’s “Be the Match” registry have confirmed that patients from U.S. racial– and ethnic– minority groups are consistently less likely to find an HLA–matched donor.5-9,14-17 Unrelated donor genetic match rates for Caucasian, Hispanic, Asian/Pacific Islander, and African–American ethnic groups, estimated a number of different ways, have been shown to range from 68-75% for Caucasian people, 34-44% for Hispanic people, 27-68% for Asian/Pacific Islanders, and 19-35% for African–American people.5-9, 14-17

This trend holds true outside of North America, as well. A study by Heemskerk et al. analysed unrelated donor searches performed for patients at Dutch transplantation centres, searching the Bone Marrow Donors Worldwide network of donor registries.18 The authors demonstrated that a patient’s country of origin influenced match rates; between 1996 and 2000, only 11% of the patients of Northwest European origin (n=211) lacked a compatible donor somewhere in the world, compared to 50% of patients of non–Northwest European origin (n=56).18 A 2013 study found that patients of Israel’s Arab minority had a significantly lower chance than patients of Jewish origin of finding a match on Israel’s local donor registries (25% versus 64%, respectively).19 Another study in India modelled differences in donor match rates among 14 regional subgroups—each with different ethnic/racial demographics—and showed differences in match rates between these regional groups.20

Marrow Network, as of May 2015, 71% of registrants are Caucasian.21 Canadian Black donors, Aboriginal donors, and Southeast Asian donors each make up less than 1% of Canada’s registry, despite making up 2.9%, 4.3%, and 2.8% of the Canadian population, respectively.21-22 Similarly, in 2009, on the U.S. NMDP’s “Be The Match” registry, African–American donors and Hispanic donors made up 7.9% and 9.9% of the registry, despite making up 13.1% and 16.9% of the American population.23-24 Non–Caucasian groups are also underrepresented on worldwide network of potential stem cell donors. The vast majority of the world’s registered stem cell donors are from registries based in Western Europe and the United States, with most countries in Africa, Asia, and Eastern Europe—and their ethnic/racial populations—being dramatically underrepresented.25 This disproportionate representation of specific ethnic groups, both within individual registries and worldwide, contributes to observed differences in match rates between ethnic groups.

disproportionate representation of ethnic and racial minorities on stem cell donor databases

ethnic/racial differences in genetic diversity

ethnic/racial differences in attrition from stem cell donor databases

Today, many non–Caucasian ethnic groups are not properly represented on the world’s registries. This is certainly true within individual countries. For example, on Canada’s OneMatch Stem Cell and

The above studies highlight both smaller donor pools and disproportionate representation of ethnic and racial groups as contributors to decreased match rates. However, studies have also shown that some ethnic/racial groups have more diverse HLA alleles and would be less likely to find a match even if they had an equal proportion of potential donors as Caucasians. A 1995 study by Beatty et al. demonstrated that African–Americans are more polymorphic with respect to HLA and are therefore less likely to find donors at any given registry size.16 The authors demonstrated this in two ways. First, they modelled new HLA phenotype acquisition, which is the chance that a newly recruited stem cell donor has a novel combination of HLA alleles. They showed that 90% of newly recruited African–American donors had new HLA phenotypes, compared to 72% or 74% respectively for Asian–American or Caucasian donors. Second, the authors modelled match rates in

hypothetical registries composed of donors solely of the same ethnic group. They found that Hispanic and African–American people in these hypothetical ethnically–homogenous registries were still less likely to find a match than were Caucasian, Asian–American, or Native American people. Another study by Mori et al. examined HLA allele phenotypes of the NMDP donors. These authors found that African–American and Asian–American people had a large number of HLA alleles unique to their ethnic groups, whereas Caucasian, Latin American, and Native American people shared a large number of common HLA alleles.26

Switzer et al.’s study also demonstrated that, across all ethnic and racial groups, ambivalence played a critical role in donation–related decisions.

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have health conditions that prevent them from donating, some are temporarily unavailable due to travel or work commitments, and some are no longer willing to contribute.27 The U.S. NMDP statistics show that 20% more Caucasian registrants move forward with the donation process when contacted, compared to non–Caucasians (the authors reported a 60% attrition rate for minority groups vs. 40% attrition rate for Caucasians).27 A study by Confer found that, on the U.S. NMDP, rates of donor unavailability were higher among donors who identified as Black, Asian/Pacific Islander, or American Indian/Alaska Native.28 Racial and ethnic minority populations were shown to be significantly more likely than Caucasian populations to be unable to be contacted, to be contacted but not interested when asked to donate, or to be potentially interested to donate but temporarily unavailable. In contrast, the rates for donor deferral for medical reasons were similar across racial and ethnic groups.28 A similar study looking at The U.K. Anthony Nolan registry found that African, African–Caribbean, Asian, Jewish, and Mediterranean donors were significantly more likely to be unavailable for later stages of the donation process, compared to Caucasian donors.29

The increased attrition rates among members of ethnic and racial minority groups disproportionately disadvantage minority patients searching for a donor. This increased attrition is not necessarily due to differences in general willingness to donate, and it might be secondary to specific barriers to proceeding with the donation process. A study conducted by Switzer et al. identified multiple cultural,

psychosocial, and donation–related factors associated with race/ethnic group attrition from the registry.27 Compared with Caucasians, potential donors from African–American, Hispanic, and American Indian groups reported more religious objections to donation; African–American people and Asian/Pacific Islanders reported less trust that stem cells would be allocated equitably; Asian/Pacific Islanders and Hispanic people reported more concerns about donation; and Asian/Pacific Islanders reported a greater likelihood of having been discouraged from donating.27 The authors suggest that these findings could be used to inform media campaigns and key messaging at the time of recruitment for stem cell drives targeting these ethnic and racial minority groups in the United States.

Switzer et al.’s study also demonstrated that, across all ethnic and racial groups, ambivalence played a critical role in donation–related decisions.27 The authors propose that at stem cell drives, ambivalent potential donors from all racial and ethnic groups could be identified, and any concerns that may be producing ambivalence could be directly addressed (including medical concerns about the donation process, religious objections, or mistrust of the medical system).27 The authors suggest that registrants be offered a cooling–off period if residual concerns remain, similar to what is recommended in the context of living solid–organ donation.30 They further suggest that, for all groups, self– and social– identification as a potential donor could be emphasized as a potential buffer against attrition.27

Overall, addressing the barriers that limit participation of minority groups will be paramount to boosting registration and lowering attrition rates of ethnically–diverse stem cell donors. To achieve this, further research is needed to explore the barriers experienced by specific ethnic and racial groups and to identify strategies to mitigate those barriers.

optimal U.S. NMDP registry size for each race and concluded that there is not an optimal amount of donors registered yet for any ethnicity.5 Furthermore, the authors completed a benefit–cost analysis and expanded their analysis in a 2011 paper to include individuals of mixed race.7

They found that the benefits of recruiting additional donors exceeded costs for all races/ethnicities. African–American people were shown to have the highest benefit–cost ratio for being recruited as potential stem cell donors, with benefits being ten times the costs. Mixed–race African–American/Hispanic individuals and African–American/Caucasian individuals had the next highest benefit–cost ratios of 9.1 and 8.4, respectively. Recruitment of Caucasian individuals was lowest, at a 4:1 benefit–cost ratio.7

Altogether, the above studies demonstrate ethnic differences in HLA match rates. These differences result from a combination of smaller donor pools and disproportionate representation of ethnic/racial groups on the world’s stem cell donor registries, and ethnic/racial differences in both HLA diversity and donor attrition rates. Targeted recruitment of ethnically–diverse individuals to become potential stem cell donors is warranted to capture a range of HLA phenotypes and to improve equity in match rates between Caucasians and other ethnic groups.

Overall, addressing the barriers that limit participation of minority groups will be paramount to boosting registration and lowering attrition rates of ethnically–diverse stem cell donors.

conclusionDespite the continued expansion of

the global stem cell and marrow network, people of all ethnicities are needed to register as potential donors. In a 2009 paper by Bergstrom et al., the authors estimated

acknowledgementsThe author would like to acknowledge

OneMatch Stem Cell and Marrow Network for their partnership, training, supplies, and support, and for providing their ethnic demographic breakdown data. Thank you to Dena Mercer, Associate Director of OneMatch Stem Cell and Marrow Network, for providing access to the Stem Cells National System Solution database. Thank you to Dr. Tanya Petraszko, Dr. David Allan, and Dr. Hans Messner for their mentorship and support. Thanks to the Stem Cell Club executive team and volunteers for their efforts in coordinating stem cell drives and recruiting potential donors. The Stem Cell Club is funded by the Canadian Blood Services BloodTechNet Competition, Doctors of BC, Canadian Federation of Medical Students (CFMS), and the UBC

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10. Bortin MM. Allogeneic bone marrow trans-plantation in leukemia patients. Curr Probl Cancer. 1986 Jan 1;10(1):1-52.

11. Fingrut W, Parmar S, Walters T, McGinnis E, Graham A, Wang XQ, et al.The UBC stem cell club: recruiting the most-needed stem cell do-nors [abstract]. In: Almiski M, editor. Canadian Society for Transfusion Medicine 12th Annual Conference Proceedings; 2015 May 21-24; Winnipeg (MB): Canadian Society for Trans-fusion Medicine; 2015. p. 47. Abstract no. 036.

12. Fingrut W. Top of the world stem cell drive: A case study in rural stem cell donor recruit-ment. UBCMJ. 2014 Oct 21;6(1):41-3.

13. Allan DS, Takach S, Smith S, Goldman M. Im-pact of declining fer tility rates in Canada on donor options in blood and marrow trans-plantation. Biol Blood Marrow Transplant. 2009 Dec 1;15(12):1634-7.

14. Gragert L, Maiers M, Smith S, Garcia Y, DeK-oven A, Green M, et al. HLA haplotype fre-quencies and match rates for the Canadian OneMatch registry. Hum Immunol. 2012 Aug 31;73:S110.

15. Anasetti C, Hillgruber R, Nye V, Ayala E, Khar-fan–Dabaja M, Fernandez HF, et al. Patient ethnicity markedly affects the probability of finding an HLA–A, –B, –C and DRB 1 allele matched unrelated donor for hematopoietic cell transplantation. Biol Blood Marrow Trans-plant. 2010 Feb 1;16(2 Suppl 1):S172.

16. Beatty PG, Mori M, Milford E. Impact of racial genetic polymorphisms on the probability of finding an HLA-matched donor. Transplant. 1995 Oct 27;60(8):778-83.

17. Dehn J, Arora M, Spellman S, Setterholm M, Horowitz M, Confer D, et al. Unrelated donor hematopoietic cell transplantation: factors as-sociated with a better HLA match. Biol Blood Marrow Transplant. 2008 Dec 1;14(2):1334-40.

18. Heemskerk MB, van Walraven SM, Cornelis-sen JJ, Barge RM, Bredius RG, Egeler RM, et al. How to improve the search for an unrelated haematopoietic stem cell donor. Faster is bet-ter than more! Bone Marrow Transplant. 2005 April 1;35(7):645-52.

19. Israeli M, Yeshurun M, Stein J, Ram R, Shpil-berg O, Levi CL, et al. Trends and challenges in searching for HLA–matched unrelated donors in Israel. Hum Immunol 2013;74:942-5.

20. Maiers M, Halagan M, Joshi S, Ballal SH, Jagan-natthan L, Damodar S, et al. HLA match like-lihoods for Indian patients seeking unrelated donor transplantation grafts: a population–

based study. Lancet Haematol. 2014 Oct 1;1: e57-63.

21. Fingrut, Warren (Summer Intern, Canadian Blood Services, Vancouver BC). Data pro-vided by: Dena Mercer (Associate Director, OneMatch Stem Cell and Marrow Network, Vancouver BC). 2015, June 17.

22. Statistics Canada. Ethnocultural portrait of Canada – data table [Internet]. Ottawa (ON): Government of Canada. 2009 Jul 28 [cited 2015 Mar 10]. Available from: http://www.stat-can.gc.ca/tables-tableaux/sum-som/l01/cst01/demo26a-eng.htm.

23. Be The Match Unrelated Donor Registry. Na-tional marrow donor program and be the match key messages, facts & figures [Internet]. [place unknown]: National Marrow Donor Program; 2013 Jan 1 [cited 2015 Mar 10]. Available from: http://bethematch.org/news/facts-and-figures--pdf-/.

24. United States Census Bureau. State & County QuickFacts [Internet]. Washington (DC): US Department of Commerce; [updated 2015 Feb 02; cited 2015 Mar 10]. Available from: http://quickfacts.census.gov/qfd/states/00000.html.

25. Bone Marrow Donors Worldwide. BMDW Annual Report 2012. Drukkerij Groen (Leiden): BMDW; 2013. 1-30 p.

26. Mori M, Beatty PG, Graves M, Boucher KM, Milford EL. HLA gene and haplotype frequen-cies in the North American population: the national marrow donor program donor reg-istry. Transplant. 1997 Oct 15;64(7):1017-27.

27. Switzer GE, Bruce, JG, Myaskovsky L, DiMar-tini A, Shellmer D, Confer DL, et al. Race and ethnicity in decisions about unrelated hema-topoietic stem cell donation. Blood. 2013 Feb 21;121(8):1469-76.

28. Confer D. The national marrow donor dro-gram: meeting the needs of the medically underserved. Cancer. 2001 Jan 1;91 Suppl 1:274-8.

29. Lown RN, Marsh SGE, Switzer GE, Latham KA, Madrigal JA, Shaw BE. Ethnicity, length of time on the register and sex predict donor avail-ability at the confirmatory typing stage. Bone Marrow Transplant. 2014 Apr 1;49(4):525-31.

30. 30. Marcos A, Shapiro R, Dew MA, Switzer GE, DiMartini AF, Myaskovsky L, and Crow-ley-Matoka, M. Psychosocial aspects of living organ donation. In: Marcos A, Shapiro R, ed-itors. Living Donor Transplantation. New York (NY): Informa Healthcare; 2007. p. 7-26.

Medical Undergraduate Society. This work was funded by a Canadian Blood Services Summer Internship Program Grant.

references1. Kopolovic I, Turner R. Five Things to Know

About...: Donation and transplantation of al-logeneic hematopoietic stem cells. Can Med Assoc J. 2011 Nov 22;183(17):2014.

2. Fingrut W. Anatomy of a stem cell drive: an evidence–based approach to stem cell drive organization. UBCMJ. 2015 Feb 24; 6(2):44-6.

3. Kollman C, Abella E, Baitty RL, Beatty PG, Chakraborty R, Christiansen CL, et al. Assess-ment of optimal size and composition of the U.S. national registry of hematopoietic stem cell donors. Transplant. 2004 Jul 15;78(1): 89–95)

4. Johansen KA, Schneider JF, McCaffree MA, Woods GL. Efforts of the United States’ na-tional marrow donor program and registry to improve utilization and representation of mi-nority donors. Transfus Med. 2008;18(4):250-9.

5. Bergstrom TC, Garratt RJ, Sheehan–Connor D. One chance in a million: altruism and the bone marrow registry. Am Econ Rev. 2009 Sept 1; 99(4):1309-34.

6. Dehn J, Buck K, Yang SY, Schmidt AH, Hartz-mann R, Maiers M, et al. 8/8 high resolution HLA match rate: the impact of race. Biol Blood Marrow Transplant. 2011 Feb 1;17:S170–1.

7. Bergstrom TC, Garratt R, Sheehan-Connor D. Stem cell donor matching for patients of mixed race. Be J Econ Anal Poli. 2011 Jul 12;12(1):1-27.

8. Dehn J, Buck K, Maiers M, Confer D, Hartz-man R, Kollman C, et al. 8/8 and 10/10 high–resolution match rate for the be the match unrelated donor registry. Biol Blood Marrow Transplant. 2014 Oct 1;21:137-41.

9. Gragert L, Eapen M, Williams E, Freeman J, Spellman S, Baitty R, et al. HLA match like-lihoods for hematopoietic stem–cell grafts in the U.S. registry. N Engl J Med. 2014 Aug 25;371:339-48.

disclosuresThe author does not have any conflicts

of interest.

UBCMJ

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Garlic-induced Esophagitis and Gastroenteritis: A Review of Four Cases

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Gurinder S. Grewala,°*, Adam Amlania*Citation info: UBCMJ. 2015: 7.1 (48-51)° Corresponding author: gsgrewal@alumni.ubc.caa MD Candidate 2016, Faculty of Medicine, University of British Columbia, Vancouver, BC* Co-first authorship

Garlic, or Allium sativum, is a common culinary ingredient used as a natural medicine for hypertension, hyperlipidemia, cancer prevention, treatment of fungal infection, and atherosclerosis prevention. We reviewed all cases of garlic–induced esophagitis and gastroenteritis available in academic literature. A literature search using combinations of the MeSH headings “garlic”, “Allium sativum”, “esophagitis”, and “deglutition disorders” was conducted in the Embase and PubMed computer databases. References involving reports of esophagitis and gastroenteritis were retrieved. Additional relevant articles were found by analyzing the references provided within the retrieved articles. Our review uncovered four published case reports of garlic–induced esophagitis, and one possible garlic–induced gastroenteritis. In three cases, the inflammation was caused by direct injury, both by mechanical and possibly caustic effects. Garlic was thought to have caused eosinophilic inflammation in the remaining two cases, both of which involved a significant atopic medical history. Given the prevalence of garlic in both culinary and therapeutic settings, we believe clinicians should be aware of its potential for gastrointestinal symptoms. Esophagitis and gastroenteritis should be on the differential as a cause of upper gastrointestinal symptoms in garlic users, especially in atopic patients. In suspect patients, thorough medical histories, endoscopy, biopsies, and cutaneous testing may all be useful and should be utilized when appropriate. Management should include avoidance of the offending agent, and supportive care. Oral corticosteroids may be useful in certain patients. Follow–up endoscopy can be considered, especially in patients who have experienced direct injury.

abstract

Esophagitis refers to inflammation of the esophagus. Typical symptoms

include retrosternal pain or discomfort, odynophagia, and dysphagia.1,2 Rarely, hematemesis, abdominal pain, and weight loss can occur.1,2 Etiologies include infection, gastroesophageal reflux, trauma, caustic ingestion, medications, and allergy.3

Medication–induced esophagitis can occur via both systemic and direct causes.4 Direct mucosal injury of the esophagus may occur with prolonged contact between oral medications and the esophageal lining, causing pill–induced esophagitis. Several medications may cause pill–induced esophagitis, including NSAIDs, antibiotics, potassium chloride, and bisphosphonates.4 It is more frequently seen in females and patients with advanced age, diabetes, and/or ischemic hear t disease.4

Eosinophilic esophagitis is an

atopic, IgE–mediated condition, usually occurring in response to food allergens. It is an important consideration for patients presenting with complaints of retrosternal discomfort and dysphagia, especially when unresponsive to treatments for gastroesophageal reflux disease. The most common food culprits in adults include legumes, nuts, fruits, wheat, milk, eggs, and soy.5-7 In children, the common triggers include milk, eggs, wheat, beef, soy, and chicken.8 Diagnosis typically requires eosinophilia of the esophageal epithelium on biopsy.9 Management usually involves treatment with oral cor ticosteroids and initiation of an elimination diet avoiding the six common allergic food triggers.6,9,10 Gradual stepwise reintroduction is used to identify the offending foods.6,9,10

Garlic (Allium sativum) is a common culinary ingredient often used therapeutically as a natural medicine for hypertension, hyperlipidemia, cancer prevention, treatment of fungal infection,

and atherosclerosis prevention.11 Aside from causing a mild blood pressure decrease in hypertensive patients, quality evidence for the remainder of the indications is currently insufficient and limited.11 Side effects of garlic use are usually mild and include malodorous breath and dyspepsia.11 Rarely, garlic can cause significant gastrointestinal problems, including gastroenteritis and esophagitis.12-16

Herein, we review all cases of garlic–related esophagitis and gastroenteritis available in the academic literature, including both direct and allergic causes.

introduction

methodsA literature search using combinations

of the MeSH headings “garlic”, “Allium sativum”, “esophagitis”, and “deglutition disorders” was conducted in the Embase and PubMed computer databases. References involving reports of esophagitis and gastroenteritis were retrieved.

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Additional relevant articles were found by analyzing the references provided within the retrieved articles. Articles were then reviewed by two independent evaluators to compare and contrast each of the cases with respect to the characteristics of the patients, the identification and management strategies employed, and the eventual outcome of the case. The findings are summarized in the Results section.

after consuming sliced raw fish and garlic.14

Esophagogastroduodenoscopy (EGD) was performed and a 2.7 x 1.5 cm piece of garlic was retrieved via forceps. Bullous necrotic changes were seen at the site of impaction. The patient was admitted for supportive care and was put on NPO (nothing by mouth) protocol. Her symptoms resolved shortly afterwards. A follow–up EGD three days after admission

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Our literature search revealed a total of four published case reports of garlic–induced esophagitis, and one possible garlic–induced gastroenteritis. Results are summarized in Table 1.

Kim et al. (2008) reported a case of a 60–year–old female presenting with severe and sustained chest pain 12 hours

Table 1: Cases of garlic-induced esophagitis and gastroenteritisStudy Age Gender Past medical

historyHistory of presenting illness Primary

presenting symptoms

Identifica-tion

Manage-ment

Outcome and Follow-up

Kim et al. 2008

60 F None men-tioned

Symptoms started 12 hours after eating sliced raw fish and garlic

Severe sus-tained chest pain

EGD 2.7x1.5 cm piece of gar-lic removed by forceps. Admitted for support-ive care. NPO.

Cest pain improved when garlic removed. Follow-up EGD after 3 days revealed dramatic improvement, tiny whit-ish scarring, and grey mucosal changes at the site of impaction.

Adachi 2010

42 F Pollinosis, asthma

None relevant Diarrhea, urticaria, heartburn, peripheral eosinophilia

EGD, biopsy, patch test-ing, trial of removal of causative agents

Avoidance of causative agents

Symptoms resolved.

Ergül andÇakal2012

46 M Hypertension History of swallowing garlic without water one day before symptoms occured.

Acute onset odynophagia and retroster-nal pain x 12 hours

Immediate upper en-doscopy

Liquid diet, lansoprazole 30 mg BID and sucral-fate QID.

Resolved in 3 days. Repeat endoscopy 4 weeks later showed no lesion.

Dogan et al. 2013

54 M Hypertension History of swallowing garlic with little water

Acute onset odynophagia and retroster-nal pain x 12 hours

Upper endoscopy

Therapeutic push of garlic into stomach, liquid diet, lansoprazole 30 mg BID and sucral-fate QID.

Resolved in 5 days. Repeat endoscopy 4 weeks later showed no lesion.

Mane et al. 2013

58 M 1. Allergic Rhinitis

2. Asthma3. Auto-

immune alopecia

4. Auto-immune thrombo-cytopenia

5. Splenecto-my

>15 year history of upper gastrointestinal symptoms re-fractory to GERD treatment. Subsequent 6 years worsening dysphagia. EGD and biopsy confirmed eosinophilic esoph-agitis. Patient was treated with swallowed viscous budesonide, but this was taken irregularly. Next 2 years had increased nausea, dyspepsia, dysphagia. A second EGD showed normal mucosa but repeat biopsies showed eosinophils. Referred to allergy/immunology, under-went skin prick testing.

Dysphagia, nausea, dys-pepsia

EGD, biopsy, history, skin prick testing

Avoidance of garlic and cottonseed, regular intake of viscouse budesonide 0.5 mg BID in sucralose powder between meals.

Marked improvement within a few weeks. After 3 months, budesonide frequency was reduced to once daily. Patient became largely asymptomatic.

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showed dramatic improvement, and the patient was discharged with no further complications.

Adachi (2010) shared a case of a 42–year–old woman with a history of pollinosis and asthma presenting with urticaria, heartburn, diarrhea, and peripheral eosinophilia.16 She was found to have marked eosinophils in the mucosa of her alimentary tract and was therefore diagnosed with eosinophilic gastroenteritis, and subsequently underwent cutaneous patch testing. Patch testing was positive for garlic and sesame, and given that improvement was seen with removal of these two allergens, it was thought that one or both of garlic and sesame were the causative agents.

Ergül and Çakal (2012) detailed a case of a 46–year–old male with a history of hypertension presenting with 12 hours of odynophagia and retrosternal pain.12 History revealed that the patient had swallowed garlic as treatment for hypertensive attack on the previous day without water. Immediate upper endoscopy was performed and revealed an edematous, fragile mucosal area with superficial ulcers in the upper esophagus. The patient was managed with a liquid diet, lansoprazole, and sucralfate. Esophageal symptoms resolved in three days, and repeat endoscopy four weeks post–discharge showed no persisting lesion.

Dogan et al. (2013) reported a strikingly similar case of a 54–year–old man with hypertension, also presenting with 12 hours of odynophagia and retrosternal pain and a history of swallowing garlic with little water for hypertensive attack.13 Endoscopy showed garlic in the upper part of the esophagus which was therapeutically pushed into the stomach. A 2.5 cm long lesion was seen in addition to edematous, fragile mucosa. Management, as in the case reported by Ergül and Çakal (2012), consisted of a liquid diet, lansoprazole, and sucralfate. Symptoms resolved in five days, and follow–up endoscopy in four weeks showed no lesion.

Mane (2013) published a case of a 50–year–old male with a history of allergic rhinitis, asthma, and autoimmune

disease who had been treated for gastroesophageal reflux disease for over 15 years for upper gastrointestinal symptoms, but only experienced partial improvement.15 In the subsequent six years, symptoms worsened and he began to experience significant dysphagia. EGD and biopsies confirmed eosinophilic esophagitis, and the patient was given swallowed viscous budesonide as treatment, which was taken irregularly. The patient experienced two more years of worsening nausea, dysphagia, and dyspepsia. A second EGD showed normal-appearing mucosa, although biopsies showed the presence of eosinophils. The patient was seen in an allergy and immunology clinic for food hypersensitivity testing. Skin prick testing with 44 food extracts was positive only to garlic and cottonseed. Medical history did not reveal consumption of cottonseed or any of the typical suspect foods, but was positive for frequent consumption of garlic. Thus, the diagnosis of garlic–induced eosinophilic esophagitis was made. The patient was recommended garlic and cottonseed avoidance and treated with regular budesonide. Marked improvement was seen within a few weeks, and the frequency of his budesonide was decreased after three months. The patient became largely asymptomatic with the exception of occasional symptoms following consumption of garlic–containing foods.

discussion

pump inhibitor, and sucralfate. Follow–up EGD in the case reported by Kim et al. (2008) was performed three days after discharge, whereas follow–up endoscopies in the cases reported by Ergül and Çakal (2012) and Dogan et al. (2013) were performed four weeks following discharge.

As suggested by Ergül and Çakal (2012), garlic may have had a caustic effect in the cases due to its acidic pH. Direct esophageal injury from mechanical trauma is another possible mechanism. Lifestyle measures, including adequate water intake and avoidance of lying supine after meals, are likely to reduce the incidence of all types of “pill–induced esophagitis”, including those caused by foods such as garlic.

When comparing the two cases of eosinophilic inflammation, both patients had a positive atopic history.15,16 EGD, biopsy, and cutaneous testing were diagnostically instrumental in both cases, and avoidance of garlic was a common strategy in management. Symptoms were different due to the different sites of inflammation. Elimination of typical agents via a thorough medical history seemed to play a larger role in the case reported by Mane et al. (2013), and unlike the patient reported by Adachi (2010), management included viscous budesonide and sucralfate. There was no mention of follow–up endoscopies in either case.

Although standard elimination diets, stepwise reintroduction of suspect foods, and oral corticosteroids are the typical management strategies of eosinophilic

In comparing the three cases of direct injury caused by garlic, similarities can be seen.12-14 In all three cases, symptoms started within 24 hours of garlic ingestion, and presenting symptoms included retrosternal chest pain consistent with an esophageal source. Endoscopy was a key diagnostic tool in all three cases. Symptom improvement was seen within three days and follow–up visualization via endoscopy showed significant improvement in all three cases. However, there were differences in management strategies and follow-up timelines. One case was managed with supportive care and NPO protocol, whereas the others were managed with the combination of a liquid diet, proton–

Endoscopic investigation was crucial in the diagnostic evaluation of all cases. In addition to allowing visualization and an opportunity to obtain biopsies, endoscopy can play a key role in treatment...

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esophagitis, sole use of these strategies would not have detected the true cause of the inflammation in the eosinophilic cases presented above. The six–food elimination diet, by design, is only diagnostically effective with respect to the six foods in the diet. It can also be a challenging treatment strategy for patients to follow. Clinicians should consider cutaneous testing in suspected cases of eosinophilic esophagitis and gastroenteritis to rule out atypical foods, such as garlic, as causes of inflammation. Cutaneous tests were paramount in diagnosing the cases presented by Adachi (2010) and Mane et al. (2013).

Endoscopic investigation was crucial in the diagnostic evaluation of all cases. In addition to allowing visualization and an opportunity to obtain biopsies, endoscopy can play a key role in treatment, as demonstrated in the case presented by Dogan et al. (2013). Furthermore, endoscopy is important in follow–up, particularly in cases involving direct injury, as it allows for evaluation of healing and treatment efficacy. We agree with the suggestion made by Mane et al. (2013) regarding a low threshold for biopsy in symptomatic patients with normal appearing mucosa, due to the possibility of an underlying eosinophilic process. This, however, should only be considered if an eosinophilic cause makes sense within the clinical context of the patient.

references

sis and management of esophageal eosino-philia and eosinophilic esophagitis (EoE). Am J Gastroenterol. 2013 May;108(5):679-92.

10. Greenhawt M, Aceves SS, Spergel JM, Rothen-berg ME. The management of eosinophil-ic esophagitis. J Allergy Clin Immunol Pract. 2013 Aug;1(4):332 40; quiz 341-2.

11. Li L, Sun T, Tian J, Yang K, Yi K, Zhang P. Garlic in clinical practice: an evidence–based overview. Crit Rev Food Sci Nutr. 2013;53(7):670-81.

12. Ergül B, Çakal B. Dysphagia caused by garlic induced esophagitis. Clin Res Hepatol Gastro-enterol. 2012;36(6):e134.

13. Dogan Z, Sarikaya M, Filik L, Ergül B. Garlic in-duced esophagitis. Acta Gastro-Enterol Belg. 2013 Jun;76(2):262.

14. Kim H-K, Kim J-S, Cho Y-S, Park Y-W, Son H-S, Kim S-S, et al. Endoscopic removal of an un-usual foreign body: a garlic–induced acute esophageal injury. Gastrointest Endosc. 2008 Sep;68(3):565-6.

15. Mane SK, Jordan PA, Bahna SL. Eosinophilic esophagitis to unsuspected rare food al-lergen. Ann Allergy Asthma Immunol. 2013 Jul;111(1):64-5.

16. Adachi A. [Two cases of eosinophilic gastro-enteritis whose causative allergens are use-fully diagnosed by patch test]. Arerugi Allergy. 2010 May;59(5):545-51.

17. Government of Canada PHA of C. Comple-mentary and Alternative Health — Canadian Health Network — Public Health Agency Canada [Internet]. 2008 [cited 2015 Mar 9]. Available from: http://www.phac-aspc.gc.ca/chn-rcs/cah-acps-eng.php

1. Nurko S, Furuta GT. Eosinophilic esophagitis. GI Motil Online [Internet]. 2006 [cited 2015 Mar 2]; Available from: http://www.nature.com/gimo/contents/pt1/full/gimo49.html

2. Patcharatrakul T, Gonlachanvit S. Gastro-esophageal reflux symptoms in typical and atypical GERD: roles of gastroesophageal acid refluxes and esophageal motility. J Gastroen-terol Hepatol. 2014 Feb;29(2):284-90.

3. Noffsinger AE. Update on esophagitis: con-troversial and underdiagnosed causes. Arch Pathol Lab Med. 2009 Jul 1;133(7):1087-95.

4. Abid S, Mumtaz K, Jafri W, Hamid S, Abbas Z, Shah HA, et al. Pill–induced esophageal inju-ry: endoscopic features and clinical outcomes. Endoscopy. 2005 Aug;37(8):740-4.

5. Lucendo AJ, Arias Á, González–Cervera J, Yagüe–Compadre JL, Guagnozzi D, Angueira T, et al. Empiric 6–food elimination diet in-duced and maintained prolonged remission in patients with adult eosinophilic esopha-gitis: a prospective study on the food cause of the disease. J Allergy Clin Immunol. 2013 Mar ;131(3):797-804.

6. Lucendo AJ, Arias A. Treatment of adult eo-sinophilic esophagitis with diet. Dig Dis Basel Switz. 2014;32(1–2):120-5.

7. Gonsalves N, Yang G-Y, Doerfler B, Ritz S, Dit-to AM, Hirano I. Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology. 2012 Jun;142(7):1451-9.e1; quiz e14-5.

8. Spergel JM, Brown-Whitehorn TF, Cianfer-oni A, Shuker M, Wang M-L, Verma R, et al. Identification of causative foods in children with eosinophilic esophagitis treated with an elimination diet. J Allergy Clin Immunol. 2012 Aug;130(2):461-7.e5.

9. Dellon ES, Gonsalves N, Hirano I, Furuta GT, Liacouras CA, Katzka DA. ACG Clinical guide-line: evidence based approach to the diagno-

Garlic is a common food ingredient frequently used by individuals for therapeutic effects. It is important to be aware of its rare potential for harm. Thorough dietary and medication histories are important for identification of adverse effects such as esophagitis or gastroenteritis. Garlic–induced esophagitis and gastroenteritis have a small reported incidence in the academic literature. However, more than 70% of Canadians use complementary and alternative health care therapies regularly, and clinicians would benefit from broadening their differential diagnoses to include complications of these therapies.17

Clinicians should be aware of both direct and allergic causes of inflammation in the gastrointestinal tract. Esophagitis and

conclusion

Garlic–induced esophagitis and gastroenteritis have a small reported incidence in the academic literature. However, more than 70% of Canadians use complementary and alternative health care therapies regularly, and clinicians would benefit from broadening their differential diagnoses to include complications of these therapies.

gastroenteritis should be on the differential diagnosis for gastrointestinal symptoms, especially in the setting of an atopic patient. Thorough medical histories, endoscopy, biopsies, and cutaneous testing may all be useful in the evaluation of these patients, and should be utilized when appropriate. Management can include avoidance of the offending agent, supportive care, and possibly oral corticosteroids. Follow–up endoscopy can be considered, especially in patients who have experienced direct injury.

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disclosuresThe authors do not have any conflicts

of interest.

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Complementary and Alternative Medicine in the Management of Lymphomas: Prevalence, Rationale, and Contraindications

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Christine D. Lukaca, BSc, David Twab,°, BScCitation info: UBCMJ. 2015: 7.1 (52-55)° Corresponding author: david.twa@bccancer.bc.caa MPH Candidate 2016, School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BCb MD PhD Candidate 2021, Faculty of Medicine, University of British Columbia; and Department of Lymphoid Cancer Research (BC Cancer Agency)

In Canada, lymphomas are the fifth most prevalent cancer and the incidence of this heterogeneous group of malignancies is increasing. Though recent advances in allopathic medicine with molecularly precise therapies have improved patient survival, many lymphoma patients still succumb to their disease. Often patients also experience reduced quality of life as a result of their cancer and allopathic treatment–related side effects. In light of these outcomes, studies have reported that patients frequently use complementary and alternative medicine (CAM) to help manage their disease. As most patients elect to engage in CAM concurrently with allopathic therapy, it is necessary to consider common CAM modalities that may have outright and/or synergistically harmful side effects that limit the efficacy of allopathic therapy in treating lymphomas. Despite limited scientific evidence supporting CAM efficacy, healthcare providers should still acknowledge the reasons for why patients might choose to use CAM. Here, we examine recent findings on prevalence, rationale, and contraindications for CAM usage by lymphoma patients. Taken together, we believe this analysis may facilitate informed discussion on the disadvantages and advantages of CAM, and when it might be used to appropriately manage lymphomas and allopathic treatment–related symptoms.

abstract

Lymphoma is a type of adaptive immune cell cancer that, unlike leukemia, usually

manifests as a fleshy tumour in lymphoid organs.1,2 The majority of lymphomas are derived from the B–cell lineage and can be categorized as either Hodgkin or non–Hodgkin lymphomas.1,2 In Canada, lymphomas rank fifth in prevalence with over 9,000 incident diagnoses in 2014 alone.3 As with other solid cancers, therapeutic mainstays include radiation, cytotoxic, and immune modulatory therapeutics, and stem cell transplantation.2 Of note are the latest advances in molecularly precise biological medicine (e.g. Rituxan®/rituximab) that specifically target malignant cells while sparing surrounding tissue. Although instrumental in improving overall patient survival, such allopathic therapies (alternatively and perhaps inappropriately termed conventional, Western or mainstream therapies) are incapable of successfully managing all

lymphoma patients.4 Indeed, treatment–related side effects that are both immediate and long–term (e.g. secondary cancers, organ damage/failure, and opportunistic infections) are of ongoing concern.2 As a result of disease symptoms and allopathic treatment–related side effects, lymphoma patients often choose complementary and alternative medicine (CAM) to derive a perceived benefit in lymphoma management.5

Here, we define CAM as encompassing non–allopathic supplements (including vitamins/minerals and herbs) and manual manipulative practices (acupuncture, massage and traditional medicine, among others). The medical community recognizes two methods of implementing CAM: (1) complementary therapy which involves the concurrent use of allopathic therapy and (2) alternative therapy which sees the complete replacement of allopathic therapy.6 While the vast majority of cancer patients fall into the former category, the lack of peer–reviewed, randomized control clinical trials assessing the efficacy of CAM

against gold standards of care underlies the concerns of healthcare practitioners.7-

11 Especially concerning are the inherent toxicities of certain complementary therapies, their harmful drug synergies with allopathic therapies, and the resulting depressed efficacy of allopathic anti–cancer treatments.6,12 Furthermore, while studies cite the placebo effect and patient empowerment as potential benefits of CAM usage, these advantages must be ethically weighed against the potential harms of propagating misinformation and false hope.13 Finally, some CAM modalities remain unregulated in cost, administration, and adherence to safety standards. This may ultimately expose patients to risky and unsound healthcare practices in CAM delivery, as has been reported previously.14

In spite of these and other concerns, CAM should still not be dismissed without critical appraisal; some patients appear to derive benefit from CAM and too little is known of CAM to rule out its place in healthcare.5,11,15,16 Between physicians and their patients, CAM therapies should be

introduction

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discussed and assessed scrupulously on a case–by–case basis to determine the best comprehensive treatment plan for the management of lymphoma. To help inform such discussions and decisions, we examine three questions regarding CAM in lymphoma treatment: (1) what forms of CAM are most frequently used, (2) what are the intentions of patients when engaging in CAM, and (3) what potential contraindications exist for CAM therapies.

of control in managing their disease, and engaging in CAM with curative intentions (Table 2). To date, the authors are not aware of any peer–reviewed, prospective randomized control trials that have found significant association between any of the aforementioned patient intentions and any modality of CAM for the management of lymphoma. Further, studies have found

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Table 1: Usage of complementary and alternative medicine modalities in the man-agement of lymphomas and related malignant lymphoid entities, as derived from the literature.

Type Prevalence (%) References

Overall usage 38/56 (68) (29)

18/68 (26) (30)

194/319 (61) (17)

636/719 (88) (10)

Herbal supplements* 21/38 (55) (29)

4/18 (22) (30)

320/636 (50) (10)

Vitamin & mineral supple-ments†

2/18 (11) (30)

557/636 (88) (10)

Alternative techniques‡ 33/38 (87) (29)

389/636 (61) (10)

*Green tea, flaxseed, herbal teas, garlic, Echinacea, Ginkgo biloba, ginseng, saw palmetto, Aloe, parsley, St John’s wort, shark cartilage, and grape seed extract; †multivitamins, calcium, vitamins A, B6, B12, C, D and E among others, folic acid, magnesium, zinc, iron, niacin, selenium and beta-carotene; ‡chiropractic, massage, relaxation, meditation, spiritual, yoga, acupuncture and therapeutic touch therapies. Homeopathic and naturopathic therapies, among others, were not considered on the basis of the studies surveyed.

Table 2: Summary of beliefs and reasoning of complementary and alternative medicine users in managing lymphoma and related malignant lymphoid entities, as derived from the literature.

Beliefs Prevalence (%) References

Curative intentions 2/38 (5) (29)

26/636 (4) (10)

Derive a sense of control* 8/38 (21) (29)

122/636 (19) (10)

Completely safe† 2/38 (5) (29)

62/636 (10) (10)

Improve allopathic therapy efficacy

9/38 (24) (29)

110/636 (17) (10)

Relief from symptoms‡ 11/38 (29) (29)

123/636 (19) (10)

4/18 (22) (30)

*Mental and physical; †no perceived side effects; ‡symptoms related to allopathic treatment and/or lymphoma.

Based on the studies surveyed, the intentions of lymphoma patients engaging in CAM were varied. They included: a perceived reduction in side effects resulting from allopathic therapy and from the cancer itself, improving the efficacy of allopathic treatments, deriving a sense

Large–scale studies surveying patients with several types of cancer have reported a prevalence of CAM usage as high as 80 %, with the majority of such patients engaging in the complementary form of therapy administration.5,11 Among lymphoma patients, a range of 26 88 % has been reported across four peer–reviewed studies, each surveying at least 50 lymphoma or lymphoma–related entities (Table I). In 1,162 cumulative cases across these studies, 76 % of patients reported using some form of CAM therapy (Table I). Two studies assessing distribution of usage by sex found significantly greater usage of CAM among women than men (P < 0.0001 and P = 0.009).10,17 No surveyed study reported any significant correlation between CAM usage and lymphoma stage, although one paper found increased CAM usage associated with T– and natural killer cell–derived lymphomas (P = 0.04), both of which are known to have a more aggressive clinical course.2,10

In assessing three major modalities of CAM therapy, vitamins/minerals (e.g. beta–carotene and selenium) were most frequently employed among 85 % of patients across the surveyed studies. This was followed by manual manipulative CAM techniques (e.g. acupuncture and massage) at 62 % and herbal supplements (e.g. garlic and Ginkgo biloba) at 50 % (Table I). While most of the information derived from the distribution CAM usage among lymphoma patients is based on the study by Rausch Osian et al., which had the greatest sample size (N = 719), the prevalence of CAM usage is important in considering any harmful drug interactions with allopathic therapies, as discussed below.10

1. prevalence

2. rationale

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As has been discussed, a substantial proportion of lymphoma patients engage in CAM concurrently with allopathic treatments; many do so based on scientifically unsupported claims and do not acknowledge the potentially toxic and hazardous side effects (Table 2). Compared to some perceived CAM activities that are anecdotally believed to improve patient health however, several means by which CAM therapies can negatively alter clinical course have been studied and have been scientifically reproduced.

Molecularly precise therapies aside, two established allopathic lymphoma modalities are gamma radiation and anthracycline chemotherapeutics (e.g. Adriamycin®/doxorubicin).2 One way these therapeutics induce neoplastic cell death is through the generation of reactive oxygen species (ROS).6,18,19 In cellular nuclei, ROS interact with chromatin, resulting in a level and quantity of DNA damage that surpasses the threshold of DNA repair mechanisms and triggers the apoptotic cascade.20 Unwanted treatment–related side effects result from both the subsequent release of cancerous apoptotic cell debris and the unintentional destruction of healthy cells as a result of the imprecise nature of radiation and non–targeted chemotherapy.2 Although conventional therapies can help manage some side effects, lymphoma patients occasionally employ CAM supplements with antioxidant properties, in spite of limited evidence supporting their efficacy.6 Beyond limited efficacy, some evidence exists suggesting that CAM therapies with antioxidant properties are associated with worse patient outcomes.6 Studies in head and neck cancers have shown the concurrent use of allopathic therapy with the antioxidants beta–

that as many as 10 % of patients believe that CAM is not associated with any toxic side effects (Table 2), in spite of literature suggesting multiple harmful activities of supplemental CAM modalities resulting either directly from their use or in synergy with allopathic drugs.

carotene and/or vitamin E was associated with more frequent cancer relapse.21-25 Although the mechanism is incompletely understood, antioxidant CAM therapies presumably counteract the activity of therapeutically–generated ROS, lessening efficacy. The means by which CAM and allopathic therapies are synergistically absorbed, metabolized, and excreted (termed pharmacokinetics), adds to the complexity in understanding these drug interactions and is an important area of ongoing research. Lessons learned from future pharmacokinetic studies can be applied paradigmatically to instances where antioxidant CAM therapies are taken concurrently with ROS–generating allopathic modalities, as is the case in lymphoma management. The most commonly employed herbal CAM supplements with antioxidant properties are listed in Table 3 for reference.

CAM supplemental therapies are also known to possess blood clot modulating and hormone signaling properties, in addition to immune modulating activities (Table 3).5,6,12 CAM therapies recognized as immune system modulators are of particular relevance to lymphomas. This is not only because the neoplasm is derived from immune cells but also because the surrounding tumour microenvironment is composed of a heterogeneous reactive cellular infiltrate susceptible to immune modulation. The complexity of the tumour microenvironment is not to be underestimated; paradoxically, certain tumour microenvironment gene signatures have been variably associated with both favorable and unfavorable

prognoses.1,2,26 As such, long–term usage of CAM therapies with immune modulatory properties can produce results opposite of those historically ascribed by CAM practitioners. Prolonged use of Echinacea, for example, has been shown to reduce the number of circulating white blood cells.27 Furthermore, some immune modulatory CAM compounds can reduce the efficacy of lymphoma restaging, as is the case with the concurrent use of Nerium oleander and positron emission tomography.28 Taken together, caution should be exercised as there is little scientific data demonstrating how immune modulating CAM therapies might reshape the composition of the tumour microenvironment.

Contraindicated CAM usage is not limited to the oral supplement forms of therapy; CAM techniques, such as acupuncture, can also put patients at risk of unfavorable outcomes. Characteristically, lymphoma patients have a depressed immune system resulting from a combination of allopathic treatment and the population of dysfunctional immune cells that constitute the lymphoma. The few functional immune cells that remain are often insufficient in number and inactive in biological function to respond to infectious agents potentially introduced into the body through acupuncture. Additionally, as noted in the Canadian Cancer Society patient handbook for complementary therapies, massage therapy may be contraindicated for late stage lymphoma and multiple myeloma patients who have cancer infiltrations and lesions that weaken the bone architecture.2

Table 3: Summary of known activities of historically the five most commonly employed oral herbal complementary and alternative therapies in North America, as described by Sparreboom et al. (5)

Supplement Antioxidant Immune modulator

Blood clotting modulator*

Hormonal properties

References

Echinacea X X X (12, 31, 32)

Garlic X X X (6, 12, 33)

Gingko biloba

X X (5, 6, 31)

Ginseng X X X X (6, 12, 31)

Soy X (12)

*Includes interactions with allopathic drugs affecting blood clotting (e.g. warfarin).

3. select, known contraindications

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1. Scott DW, Gascoyne RD. The tumour micro-environment in B cell lymphomas. Nat Rev Cancer. 2014;14(8):517–34.

2. Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4 ed. Lyon, France: IARC Press; 2008. p. 1–439.

3. Canadian Cancer Society’s Advisory Com-mittee on Cancer Statistics. Canadian Cancer Statistics 2014. Toronto, ON: Canadian Cancer Society; 2014. p. 1–132.

4. Sehn LH, Donaldson J, Chhanabhai M, Fitz-gerald C, Gill K, Klasa R, et al. Introduction of combined CHOP plus rituximab therapy dra-matically improved outcome of diffuse large B-cell lymphoma in British Columbia. J Clin Oncol. 2005;23(22):5027–33.

5. Sparreboom A, Cox MC, Acharya MR, Figg WD. Herbal remedies in the United States: potential adverse interactions with anticancer agents. J Clin Oncol. 2004;22(12):2489– 503.

Based on the literature, it has been observed that as many as 88 % of lymphoma patients engage in some form of CAM therapy, the most common being vitamin/mineral supplements. Most patients employing CAM do so concurrently with allopathic treatments, although the rationale for employing CAM therapy is highly varied. Moreover, up to 10 % of patients do not recognize that CAM therapies may have side effects that could impact their clinical course. In particular, CAM therapies with antioxidant and immune modulatory properties have the potential to negatively interfere with allopathic treatments. As little is understood of the activities and potential contraindications of CAM therapies in the context of lymphoid cancer, these treatments should be assessed on an informed and unbiased case–by–case basis. In so doing, the primary focus can remain on the well–being of the patient with the concurrent development of a safe, agreeable, and efficacious lymphoma management plan that is established on sound scientific principles and clinical practice.

6. Michaud LB, Karpinski JP, Jones KL, Espirito J. Dietary supplements in patients with cancer : risks and key concepts, part 1. Am J Health Syst Pharm. 2007;64(4):369–81.

7. Boon H, Stewart M, Kennard MA, Gray R, Saw-ka C, Brown JB, et al. Use of complementary/alternative medicine by breast cancer survi-vors in Ontario: prevalence and perceptions. J Clin Oncol. 2000;18(13):2515–21.

8. Carboon I. Rethinking the evidence imper-ative: why patients choose complementary and alternative medicine. Leuk Lymphoma. 2008;49(2):181–2.

9. Jackson JL, Srinivasan M, Rea J, Fletcher KE, Kravitz RL. The validity of peer review in a general medicine journal. PLoS One. 2011;6(7):e22475.

10. Rausch Osian S, Leal AD, Allmer C, Maurer MJ, Nowakowski G, Inwards DJ, et al. Widespread use of complementary and alternative med-icine among non-Hodgkin lymphoma survi-vors. Leuk Lymphoma. 2015;56(2):434–9.

11. Richardson MA, Sanders T, Palmer JL, Greising-er A, Singletary SE. Complementary/alterna-tive medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol. 2000;18(13):2505–14.

12. Michaud LB, Karpinski JP, Jones KL, Espirito J. Dietary supplements in patients with cancer : risks and key concepts, part 2. Am J Health Syst Pharm. 2007;64(5):467–80.

13. Finniss DG, Kaptchuk TJ, Miller F, Benedetti F. Biological, clinical, and ethical advances of pla-cebo effects. Lancet. 2010;375(9715):686 –95.

14. Public safety advisory for clients of acupunc-ture and Chinese medicine centre in Abbots-ford. Fraser Health Newsroom [Internet]. 2014 Mar 1 [cited 2015 Jun 10]. Available from: http://news.fraserhealth.ca/News/No-vember-2014/Public-safety-advisory-for-cli-ents-of-acupuncture.aspx

15. Berman BM, Singh BB, Lao L, Langenberg P, Li H, Hadhazy V, et al. A randomized trial of acu-puncture as an adjunctive therapy in osteo-arthritis of the knee. Rheumatology (Oxford). 1999;38(4):346–54.

16. Irving KB. Cancer and quackery. Intern Med J. 2012;42(4):466–8.

17. Hamilton AS, Miller MF, Arora NK, Bellizzi KM, Rowland JH. Predictors of use of complemen-tary and alternative medicine by non-Hodgkin lymphoma survivors and relationship to quali-ty of life. Integr Cancer Ther. 2013;12(3):225–35.

18. Doroshow JH, Davies KJ. Redox cycling of anthracyclines by cardiac mitochondria. II. Formation of superoxide anion, hydrogen peroxide, and hydroxyl radical. J Biol Chem. 1986;261(7):3068–74.

19. Mendivil-Perez M, Velez-Pardo C, Jimenez-Del-Rio M. Doxorubicin induces apoptosis in Jurkat cells by mitochondria-dependent and mitochondria-independent mechanisms under normoxic and hypoxic conditions. Anticancer Drugs. 2015;26(6):583–98.

20. Nakano H, Yonekawa H, Shinohara K. Thresh-old level of p53 required for the induction of apoptosis in X-irradiated MOLT-4 cells. Int J Radiat Oncol Biol Phys. 2007;68(3):883–91.

21. Bairati I, Meyer F, Gélinas M, Fortin A, Nabid A, Brochet F, et al. Randomized trial of antioxi-dant vitamins to prevent acute adverse effects of radiation therapy in head and neck cancer patients. J Clin Oncol. 2005;23(24):5805–13.

22. Bairati I, Meyer F, Gélinas M, Fortin A, Nabid A, Brochet F, et al. A randomized trial of antioxi-dant vitamins to prevent second primary can-cers in head and neck cancer patients. J Natl Cancer Inst. 2005;97(7):481–8.

23. Bairati I, Meyer F, Jobin E, Gélinas M, Fortin A, Nabid A, et al. Antioxidant vitamins supple-mentation and mortality: a randomized trial in head and neck cancer patients. Int J Cancer. 2006;119(9):2221–4.

24. Ferreira PR, Fleck JF, Diehl A, Barletta D, Bra-ga-Filho A, Barletta A, et al. Protective effect of alpha-tocopherol in head and neck cancer ra-diation-induced mucositis: a double-blind ran-domized trial. Head Neck. 2004;26(4):313–21.

25. Meyer F, Bairati I, Fortin A, Gélinas M, Nabid A, Brochet F, et al. Interaction between anti-oxidant vitamin supplementation and cigarette smoking during radiation therapy in relation to long-term effects on recurrence and mortality: a randomized trial among head and neck can-cer patients. Int J Cancer. 2008;122(7):1679–83.

26. Steidl C, Lee T, Shah SP, Farinha P, Han G, Nayar T, et al. Tumor-associated macrophages and survival in classic Hodgkin’s lymphoma. N Engl J Med. 2010;362(10):875–85.

27. Kemp DE, Franco KN. Possible leukopenia associated with long-term use of echinacea. J Am Board Fam Pract. 2002;15(5):417–9.

28. Akkas BE, Kitapci MT, Arpaci F, Gurses MA, Unlu N. Complementary and alternative medical therapies can be potential pitfalls for PET/CT imaging: report of false-positive FDG PET/CT findings caused by Nerium oleander vaccine in a patient with lymphoma. J Altern Complement Med. 2013;19(11):916– 7.

29. Habermann TM, Thompson CA, LaPlant BR, Bauer BA, Janney CA, Clark MM, et al. Com-plementary and alternative medicine use among long-term lymphoma survivors: a pilot study. Am J Hematol. 2009;84(12):795–8.

30. Molassiotis A, Margulies A, Fernandez-Or-tega P, Pud D, Panteli V, Bruyns I, et al. Com-plementary and alternative medicine use in patients with haematological malignancies in Europe. Complement Ther Clin Pract. 2005;11(2):105–10.

31. Masteikova R, Muselik J, Bernatoniene J, Ber-natoniene R. Antioxidative activity of Ginkgo, Echinacea, and Ginseng tinctures. Medicina (Kaunas). 2007;43(4):306–9.

32. Abdul MI, Jiang X, Williams KM, Day RO, Rou-fogalis BD, Liauw WS, et al. Pharmacokinetic and pharmacodynamic interactions of echina-cea and policosanol with warfarin in healthy subjects. Br J Clin Pharmacol. 2010;69(5):508–15.

33. Wu ZR, Peng C, Yang L, Li JY, Xin W, Yong W, et al. Two cinnamoyloctopamine antioxidants from garlic skin attenuates oxidative stress and liver pathology in rats with non-alcoholic ste-atohepatitis. Phytomedicine. 2015;22(1):178–82.

conclusion

references

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disclosuresThe authors do not have any conflicts

of interest.

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Mindfulness: What It Is and How It Is Impacting Healthcare

Matias P. Raski, BSca,°Citation info: UBCMJ. 2015: 7.1 (56-59)° Corresponding author: mraski@sfu.caa Departments of Psychology and Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC

The following is a review of literature concerning the place of mindfulness, a non-judging present-moment awareness, and techniques by which to invoke it, in Canadian healthcare. Central to the discussion are the effects of mindfulness on personal and interpersonal well-being. A recent surge of research has found mindfulness to positively impact a wide range of measures of personal health including stress, anxiety, affect, and healthy lifestyle choices. At present, mindfulness-based interventions have been confirmed effective for the treatment of chronic pain, psoriasis, and a number of psychiatric illnesses, and are possibly helpful for the prevention of cognitive decline. Mindfulness also presents benefits to interpersonal relationships by promoting empathy, compassion and attentiveness reflected in the enhanced patient-centeredness with which mindful physicians conduct their clinical practice. As such, mindfulness training among healthcare providers is advocated for the improvement of quality of care as well as a means to mitigate work-related stress and burnout. The underlying mechanisms of the effects of mindfulness are also discussed, with emphasis on present-moment attentiveness and a disempowerment of one’s maladaptive cognitions allowing the individual to act with intention and care rather than out of habit and impulse. Given the potential for mindfulness to promote health and enrich the practice of medicine, its increased utilization among patients, physicians, and the population at large is encouraged.

abstract

Mindfulness is a concept derived from Buddhist tradition. It is a central

component of an ancient school of thought concerning human suffering and ways to bring about its cessation.1 It is characterized by Jon Kabat-Zinn2 – a foremost pioneer in introducing mindfulness to medicine – as a nonjudgmental, curious, and self-compassionate awareness of one’s moment-to-moment experience. It is an active and deliberate regulation of one’s attention so as to focus it on the many cognitive events – sensations, thoughts, emotions, and so on – that occur within the field of consciousness at any given moment. Further, it is to manifest a nonjudgmental orientation toward these cognitions, treating them not as things to be liked and disliked, or pursued and resisted, but rather as objects of observation to simply acknowledge and accept as they are.3

In recent decades, research interest in mindfulness has grown.4,5 While mindfulness practices are diverse – yoga, tai chi, and various prayer and chanting

exercises present a few examples – meditation has been the primary object of our scientific study. 6 Mindfulness meditation is the deliberate evocation of mindfulness, usually in a state of physical stillness, 7 and was first introduced to the Western medical lens with the establishment of Mindfulness-Based Stress Reduction (MBSR) therapy in American clinics and hospitals in the 1980s. 7 MBSR is a secular therapy that seeks to develop participants’ mindfulness skills through meditation practice. 7 MBSR’s success in the management of chronic pain spurred the development of a considerable body of literature exploring the impact of mindfulness training on human psychology and physiology. 6

This research has confirmed millennia-old reports 6 of mindfulness as a powerful promoter of personal and interpersonal health. First, it is now generally accepted that mindfulness training can promote

long-standing increases in positive affect and reductions in anxiety, negative affect, 8,9,10 emotional reactivity, 11 and stress. 12,13 Second, it is reported to increase empathy and compassion 14 and promote a sense of connectedness with others. 15 Third, it has emerged as a predictor of various health-determining lifestyle choices, including diet, 16 exercise, 16

and substance use. 17,18,19 Fourth, the act of meditation itself is associated with increased parasympathetic tone and related decreases in heart rate, blood pressure, blood cortisol, breathing rate, skin conductance, and muscle tension. 20

Finally, a number of mindfulness training studies 21,22,23 in patient populations report enhanced immune function as measured by cytokine expression, 21, 22, leukocyte quantities, 21, 22 and antibody titers in response to vaccination.23 Together, these findings suggest not only a capacity of mindfulness to promote subjective well-being, but also a preventive effect on stress- and hypertension-mediated pathologies, as well as the possibility of enhanced immunoprotection from viral and bacterial diseases.

introduction

the health benefits of mindfulness

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explain, becoming mindful represents a paradigm shift in the ‘mode of mind’ in which we operate: we disengage from a ruminative avoidant mode of processing and engage with an acceptance-based, approach-oriented mode anchored in present-moment awareness. In this mode we are better able to notice and reflect upon our thought processes, and, to an extent, deliberately let go of those we find maladaptive.

In considering the interpersonal effects of mindfulness, Bihari and Mullan27 come to important insights in their 2014 qualitative study of the effects of mindfulness training on participants’ relationships. These authors suggest that mindfulness incites an enhanced awareness of one’s tendencies to react automatically to internal and external cues in interpersonal situations. This allows one to act less out of habit and impulse, and more out of conscious purpose. They also report an enhanced ability to engage in constructive, fruitful arguments and to “be with” another without submitting to urges to “fix” or avoid that person. These findings indicate a capacity of mindfulness to promote constructive and fulfilling interpersonal interactions and help avoid destructive and taxing ones.

show promise as preventive strategies for cognitive impairment and Alzheimer’s disease. Kabat-Zinn et al35 report accelerated skin clearing among psoriasis patients who listened to a guided mindfulness meditation tape during their phototherapy sessions as compared to controls without the tape – a remarkable finding for psychosomatic medicine. Together, these findings make it clear that the clinical applicability of mindfulness is extensive and continued research in a variety of fields is warranted.

The potential clinical relevance of mindfulness training is not difficult to imagine, and its application to patients has grown considerably since the initial introduction of MBSR.4,5 In psychiatry and clinical psychology, mindfulness training has come to play a central role in a number of distinct therapies concerning mood,28,29 anxiety,4 personality,30 conduct31 and substance use disorders.32 MBSR itself has extended its reach from managing chronic pain to complementing a wide range of medical treatments as a means to reduce psychological comorbidities of illness.8,33 Larouche et al’s 2015 review34 suggests that mindfulness-based interventions, in their capacity to improve many of the risk factors for neurodegenerative cognitive decline (including stress, mood disturbance, and metabolic syndrome),

Numerous groups14,36,37,40 have turned their attention toward health care providers as a target population for mindfulness-based interventions to enhance stress resilience and overall well-being. Physicians, in particular, face many stressors in medical practice and thus many challenges in maintaining their own well-being.36 Stress, anxiety, burnout, and compassion fatigue are common ailments36 and they present substantial detriments to the quality of care a physician provides.14 Burnout, characterized by a reduced sense of accomplishment, emotional exhaustion, and depersonalization,37 is reported by as many as 30% to 40% of practicing

How is mindfulness doing all of this? The cognitive and neurobiological mechanisms underlying the benefits of mindfulness training are undoubtedly complex, and while a number of compelling models have been proposed (for review, see Hölzel et al 20), our understanding of these mechanisms remains rudimentary. Even so, because mindfulness is a conscious psychological process, 3 we stand to learn a great deal about it by reflecting upon the conscious experiences of mindful people. In one account of personal reflection, Krasner24

writes:“What mindfulness - based

interventions ask of the participants ... is to consciously shift [the] locus of control internally, acknowledge and accept whatever challenges arise, and apply wise attention to the challenges without judgment in the present moment ... It is through the cultivation of this awakened state that one begins to see the perceptual distortions of unexamined thoughts, feelings, and sensations. In doing so, one recognizes how these distortions drive the engine of behaviour and choices and how this results in movement toward states of greater disease.”

A number of interesting changes are thought to occur with this sort of insight. One such change, as Krasner alludes to, is that maladaptive cognitions tend to lose their power in guiding behaviour. Brewer et al 25 illustrate this notion with the example of fictional Joe Smoker, who, upon experiencing a craving for a cigarette, might bring mindful awareness to the sensations and perceptions that comprise his craving and just observe them from moment to moment. The craving itself and any judgments surrounding it become merely objects of curious and wide-eyed observation, and in this process lose their salience as driving forces for behaviour.

A similar principle applies not only to overt behaviour, but to our maladaptive cognitions themselves. As Crane et al26

principles and mechanisms of mindfulness

clinical applications of mindfulness

mindfulness, physician distress and quality of care

MBSR’s success in the management of chronic pain spurred the development of a considerable body of literature exploring the impact of mindfulness training on human psychology and physiology.

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Although most studies have shown encouraging results, mindfulness training sometimes fails to help participants and can potentially even do harm.46 Reported adverse responses include panic attacks and intensified perceptions of pain, particularly among new practitioners.46

Some authors46,47 understand these responses as a result of encountering and attending – perhaps more fully than ever before – to certain burdensome mental events (e.g., traumatic memories or pain).46 In addition, while no specific populations for whom mindfulness training is contraindicated have yet been uncovered, case reports of manic and psychotic episodes precipitated by meditation advise caution for certain psychiatric populations. 48

Crane et al26 emphasize teacher competence as a critical factor in allowing participants to respond adaptively to the arisal of unpleasant perceptions. By offering strategies for open acceptance of perceptions in real time and by themselves embodying the practice,46 teachers may allow otherwise aversive experiences to become intense but

physicians at a given time38 and by up to 60% as having been experienced at some point in their careers.37, 39 Burnout is related to a less patient-centered approach to care,37 reduced empathy and compassion,36 and leads to increased medical errors.36 As a result, burnout influences patients’ recovery times,14 compliance with therapies, confidence in their physicians,36 and overall satisfaction with their care.36

Fortney et al40 suggest that mindfulness presents a particularly suitable and appealing option for physicians as a means to deal with distress in that it directly addresses meaning in life and work but is entirely secular and firmly founded in empiricism. Indeed, a growing body of evidence40-43 suggests that mindfulness training is effective in reducing indicators of burnout, depression, anxiety, and stress and improving indicators of well-being, vigor, empathy, and stress-resilience among physicians, other health care professionals, and medical students. Although this field of research is young and much of the data is only quasi-experimental,44 these findings indicate the promise of mindfulness training as a means to mitigate distress among healthcare providers and improve quality of care.

How might we understand these changes in healthcare providers’ well-being and proficiency? In his reflections upon mindful physicians, Epstein45 suggests

that the critical self-reflection essential to mindfulness enables physicians to listen attentively and presently to their patients’ distress; recognize their own errors; make evidence-based decisions; and act with technical competence, insight, and compassion. Beach et al42 find that mindfulness among physicians is associated with patient-centered communication and an increased likelihood to consider a range of possible explanations in stressful situations. Further, Beach et al report an enhanced approach attitude among mindful physicians – a capacity to respond consciously and engage with distressing situations rather than react automatically and withdraw from them. Together, these considerations lend us fur ther indication that mindfulness may have an important role to play in promoting an effective, fulfilling, and human-centered practice of medicine.

limitations of mindfulness training

conclusionThe therapeutic applications of

mindfulness are considerable and its impact on clinical practice itself appears to be profound. Indeed, several commentators4,23,45,49 characterize mindfulness as inciting nothing short of a revolution in the way we conduct our mental lives both within the clinic and without. By continuing to encourage and teach mindfulness meditation and expand mindfulness training programs, we stand to enhance the health of patients and healthcare professionals alike, enrich the practice of medicine, and empower people to navigate their lives with skill, wisdom, and meaning. Given these findings, the continued investigation and realization of potential roles for mindfulness in healthcare is strongly encouraged.

1. Bhikkhu, T. Satipatthana Sutta: Frames of refer-ence [Internet]. 2008 [updated Nov 30 2013]. Available from: http://www.accesstoinsight.org/tipitaka/mn/mn.010.than.html

2. Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clinical Psychology: Science and Practice. 2003;10:144-156.

3. Bishop SR, Lau M, Shapiro S, Carlson L, Ander-son ND, Carmody J, Segal ZV, Abbey S, Speca M, Velting D, Devins G. Mindfulness: A pro-posed operational definition. Clinical Psychol-ogy: Science and Practice. 2004;11:230-241.

4. Jennings JL, Apsche JA. The evolution of a funda-mentally mindfulness-based treatment meth-odology: From DBT and ACT to MDT and beyond. International Journal of Behavioural Consultation and Therapy. 2014;9(2):1-3.

5. Baer RA. Mindfulness training as a clinical in-tervention: A conceptual and empirical review.

referencesIn psychiatry and clinical psychology, mindfulness training has come to play a central role in a number of distinct therapies concerning mood, anxiety, personality, conduct and substance use disorders.

valuable learning opportunities. Dobkin et al46 also offer a set of guidelines for reducing the risks and maximizing the benefits of mindfulness training. These include pre-screening for psychiatric problems and ‘priming’ participants before training begins by informing them of potential challenges and ways to approach disconcerting perceptions if and when they arise.

reviews

disclosuresThe author does not have any conflicts

of interest.

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Clinical Psychology: Science and Practice. 2003;10:125-143.

6. Boyce B. The mindfulness revolution: Leading psychologists, scientists, artists, and meditation teachers on the power of mindfulness in daily life. Boston: Shambhala Sun; 2011.

7. Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-reg-ulation of chronic pain. Journal of Behavioural Medicine. 1985;8:163-190.

8. Shapiro SL, Carlson LE. The art and science of mindfulness: Integrating mindfulness into psy-chology and the helping professions. Washing-ton, DC: American Psychological Association; 2009.

9. Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxi-ety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology. 2010;78(2):169-183.

10. Hill CL, Updegraff JA. Mindfulness and its re-lationship to emotional regulation. Emotion. 2012;12(1):81-90.

11. Keng S, Smoski MJ, Robins CJ. Effects of mind-fulness on psychological health: A review of empirical studies. Clinical Psychology Review. 2011;31:1041-1056.

12. Laurent HK, Laurent SM, Nelson B, Wright DB, De Araujo Sanchez M. Dispositional mindful-ness moderates the effect of a brief mindful-ness induction on physiological stress respons-es. Mindfulness. 2014 Dec.

13. Bränström R, Kvillemo P, Åkerstedt T. Effects of Mindfulness Training on Levels of Cortisol in Cancer Patients. Psychosomatics. 2013;54:158-164.

14. Raab K. Mindfulness, self-compassion, and em-pathy among health care professionals: A re-view of the literature. Journal of Health Care Chaplaincy. 2014;20:95-108.

15. Trautwein F, Naranjo JR, Schmidt S, Walach H. Meditation: Neuroscientific approaches and philosophical implications. Cham, Switzerland: Springer International Publishing; 2014. Chap-ter 10, Meditation effects in the social domain: Self-other connectedness as a general mecha-nism?; p.175-198.

16. Gilbert D, Waltz J. Mindfulness and health be-haviours. Mindfulness. 2010;1:227-234.

17. Vidrine JI, Businelle MS, Cinciripini P, Li Y, Mar-cus MT, Waters AJ, Reitzel LR, Wetter DW. Associations of mindfulness with nicotine de-pendence, withdrawal, and agency. Substance Abuse. 2009;30:318-327.

18. Brewer JA, Mallik S, Babuscio TA, Nich C, John-son HE, Deleone CM, Minnix-Cotton CA, Byrne SA, Kober H, Weinstein AJ, Carroll KM, Rounsaville BJ. Mindfulness training for smok-ing cessation: Results from a randomized con-trolled trial. Drug and Alcohol Dependence. 2011;119:72-80.

19. Karyadi KA, Cyders MA. Elucidating the asso-ciation between trait mindfulness and alcohol use behaviours among college students. Mind-fulness. 2015 Jan.

20. Hölzel BK, Lazar SW, Gard T, Schuman-Olivi-er Z, Vago DR, Ott U. How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspec-

tive. Perspectives on Psychological Science. 2011;6(6):537-559.

21. Carlson LE, Speca M, Faris P, Patel KD. One year pre–post intervention follow-up of psy-chological, immune, endocrine and blood pres-sure outcomes of mindfulness-based stress reduction (MBSR) in breast and prostate can-cer outpatients. Brain, Behaviour, and Immunity. 2007;21:1038-1049.

22. Witek-Janusek L, Albuquerque K, Chroniak KR, Chroniak C, Durazo-Arvizu R, Mathews HL. Effects of mindfulness-based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer. Brain, Behaviour, and Immunity. 2008;22:969-981.

23. Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SK, Ur-banowski F, Harrington A, Bonus K, Sheridan JF. Alterations in brain and immune function produced by mindfulness meditation. Psycho-somatic Medicine. 2003;65:564-570.

24. Krasner M. Mindfulness-based interventions: A coming of age? Families, Systems, & Health. 2004;22(2):207-212.

25. Brewer JA, Elwafi HM, Davis JH. Craving to quit: Psychological models and neurobiological mechanisms of mindfulness training as treat-ment for addictions. Psychology of Addictive Behaviours. 2013;27(2):366-379.

26. Crane RS, Kuyken W, Hastings RP, Rothwell N, Williams JM. Training teachers to deliver mind-fulness-based interventions: Learning from the UK experience. Mindfulness. 2010;1:74-86.

27. Bihari JL, Mullan EJ. Relating mindfully: A qual-itative exploration of changes in relationships through mindfulness-based cognitive therapy. Mindfulness. 2014;5:46-59.

28. Sipe WE, Eisendrath SJ. Mindfulness-based cog-nitive therapy: Theory and practice. Canadian Journal of Psychiatry. 2012;57(2):63-69.

29. Green SM, Bieling PJ. Expanding the scope of mindfulness-based cognitive therapy: Evidence for effectiveness in a heterogeneous psychiat-ric sample. Cognitive and Behavioural Practice. 2011;10:174-180.

30. O’Connell B, Dowling M. Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder. Journal of Psychiatric and Mental Health Nursing. 2014;21:518-525.

31. Swart J, Apsche J. Mindfulness, mode deacti-vation, and family therapy: A winning combi-nation for treating adolescents with complex trauma and behavioural problems. Interna-tional Journal of Behavioural Consultation and Therapy. 2014;9(2):9-13.

32. Penberthy JK, Konig A, Gioia CJ, Rodríguez VM, Starr JA, Meese W, Worthington-Stoneman D, Kersting K, Natanya E. Mindfulness-based re-lapse prevention: History, mechanisms of ac-tion, and effects. Mindfulness. 2013 Aug.

33. Reibel DK, Greeson JM, Brainard GC, Rosenz-weig S. Mindfulness-based stress reduction and health-related quality of life in a hetero-geneous patient population. General Hospital Psychiatry. 2001 July;23(4):183.

34. Larouche E, Hudon C, Goulet S. Potential benefits of mindfulness-based interventions in mild cognitive impairment and Alzheimer’s

disease: An interdisciplinary perspective. Be-havioural Brain Research. 2015;276:199-212.

35. Kabat-Zinn J, Wheeler E, Light T, Skillings A, Scharf MJ, Cropley TG, Hosmer D, Bernhard JD. Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychosomatic Medicine. 1998;60:625-632.

36. Shanafelt TD. Enhancing meaning in work: A prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009;302(12):1338-1340.

37. Geller R, Krasner M, Korones D. Clinician self-care: The applications of mindfulness-based approaches in preventing professional burnout and compassion fatigue. Journal of Pain and Symptom Management. 2010;39(2):366.

38. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. The Lancet. 2009;374(9702):1714-1721.

39. McCray LW, Cronholm PF, Bogner HR, Gallo JJ, Neill RA. Resident physician burnout: is there hope? Family Medicine. 2008;40(9):626-632.

40. Fortney L, Luchterhand C, Zakletskaia L, Agi-erska A, Rakel D. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clini-cians: A pilot study. Annals of Family Medicine. 2013;11(5)412-420.

41. Goodman MJ, Schorling JB. A mindfulness course decreases burnout and improves well-being among healthcare providers. In-ternational Journal of Psychiatry in Medicine. 2013;43(2):119-128.

42. Beach CM, Roter D, Korthuis PT, Epstein RM, Sharp V, Ratanawongsa N, Cohn J, Eggly S, San-kar A, Moore RD, Saha S. A multicenter study of physician mindfulness and health care qual-ity. Annals of Family Medicine. 2013;11(5)421-428.

43. Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, Quill TE. Asso-ciation of an educational program in mindful communication with burnout, empathy, and at-titudes among primary care physicians. JAMA. 2009;302(12):1284-1293.

44. Regehr C, Glancy D, Pitts A, LeBlanc VR. In-terventions to reduce the consequences of stress in physicians: A review and meta-analysis. The Journal of Nervous and Mental Disease. 2014;202(5):353-359.

45. Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839.

46. Dobkin PL, Irving JA, Amar S. For whom may participation in a mindfulness-based stress re-duction program be contraindicated? Mindful-ness. 2012;3:44-50.

47. Germer CK, Siegel RD, Fulton PR. Mindfulness and psychotherapy. New York, NY: Guilford Press; 2005.

48. Yorston GA. Mania precipitated by meditation: A case report and literature review. Mental Health, Religion & Culture. 2001;4:209-213.

49. Siegel DJ. Mindful awareness, mindsight, and neural integration. The Humanistic Psycholo-gist. 2009;37(2):137-158.

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Peru’s northeastern province, Loreto, is geographically remote and in many

ways disconnected from the rest of the country. The population density here is only 2.4 people per square kilometre.1 In this region, deep within the Amazon, on the shore of the Napo River, lies the village of Santa Clotilde. The Centro de Salud de Santa Clotilde (CSSC) is a health center that serves the population of twenty thousand living along the Napo River. The CSSC provides inpatient and outpatient medical care, dental, obstetrical and basic surgical services, and coordinates public health campaigns up– and down–river. In February of 2015, two fourth–year medical students completed a clinical elective at the CSSC, following in the footsteps of many other UBC medical students who for years have been making the journey to the Amazon to enrich their tropical medicine knowledge, practice their medical Spanish, and experience the provision of medical care in a low–resource setting.

Peru is rapidly developing, but the improving healthcare system has yet to reach the remote areas where resources such as essential medicines are in short supply. Infections, primarily diarrheal disease, parasites, malaria, and tuberculosis, as well as trauma are the major causes of morbidity and mortality in the region.2 It is

on this frontier, where access to allopathic medicine is limited, that traditional forms of medicine intersect with biomedicine.

One Santa Clotilde physician estimated that 90  % of patients sought care by a local healer prior to presenting at the health centre. Consistent with this, a healthcare access study conducted in the region found that 80 % of the study population had consulted a shaman in the previous year, while only 43  % of the population said they had access to a Western physician.3 Furthermore, the majority of the study participants stated they believe traditional medicine to be better than or equal to Western medicine.3

However, there is some disagreement in the literature, as a recent study in the region by Williamson et al. found that the local population “preferred modern over traditional medicine, predominantly because of mistrust or lack of belief in traditional medicine.”4 With small sample sizes and selection bias, these studies have flaws, and better quality research should be conducted to further understand healthcare–seeking behaviours in this region.

Vegetalismo, the most common form of traditional medicine encountered in Santa Clotilde, is a syncretic healing tradition that borrows from both

The Intersection of Biomedicine and Traditional Medicine in the Peruvian Amazon

global health

Melanie van Soerena,°,BSc MD; Melissa Aragona,BA MA MDCitation info: UBCMJ. 2015: 7.1 (60-61)° Corresponding author: melvansoeren@alumni.ubc.caa Family Medicine PGY1, Faculty of Medicine, Memorial University, St. John’s, NLb Family Medicine PGY1, Faculty of Medicine, University of British Columbia, Vancouver, BC

In Northeastern Peru, in the Amazonian district of Loreto, one million Peruvians, mostly Indigenous and Mestizo, live isolated from the rest of the rapidly developing country. This region has a rich history of traditional medicine, and with financial, geographical, and cultural barriers to biomedical care, there exists a unique interaction between allopathic and alternative treatment models. During a clinical elective in the village of Santa Clotilde, in a hospital serving a population of twenty thousand people, two University of British Columbia medical students encountered this integrative system and witnessed health–seeking behaviours that at times were positive, and at others led to tragedy.

abstract

indigenous and Catholic beliefs. It is mainly practiced by members of the Mestizo population. Vegetalistas, those who practice Vegetalismo, gain their healing powers from the spirits of forest plants.5 They use diverse plant species as treatments for various ailments and make teas that purge “impurities.”6 There is pharmaceutical activity in many of these plants, and in one study 23 of 31 samples of plants used in traditional medicine had antibiotic activity.7 They also perform healing ceremonies involving chupando (sucking) and the use of tobacco smoke.

While access to Vegetalistas is easy for the local population, access to Western medicine is more complicated. Thus, we wondered how people made decisions about how and when to access allopathic medical care. Factors we perceived as being important in preventing access to Western medicine were cost, distance, time, and accessibility. These were recurring themes in the stories we heard from patients and their families, and are consistent with the findings of the healthcare access study.3 For example, the journey for families living up– or down–river can be up to eight hours by peke–peke, a canoe with an outboard motor. Families need to have access to a boat, gasoline, time, good weather, and stable enough health to manage the

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journey. Layer onto that potential mistrust and disbelief that Western treatments will work and occasional dissatisfaction with care due to long wait times and lack of resources, and it is shocking how many patients actually make it to Santa Clotilde.

Two patient encounters in Santa Clotilde illustrate this intersection of Western and traditional medicine — Roberto and Lette. Both patients’ stories provide a commentary on health–seeking behaviour in the remote Amazon. Roberto was a 50–year–old man with cirrhosis and hepatocellular carcinoma, a common presentation in this region due to the paucity of immunization against Hepatitis B. In planning for his care, it became evident that while we understood him to be palliative and were hoping only to limit his suffering, he was hoping for a cure. We managed his symptoms as best we could, although without access to morphine adequate pain control was challenging. He chose to pursue care with a local healer simultaneously, a choice that some of the hospital staff disapproved of and attempted to restrict. Depending on a patient’s illness, this health–seeking behaviour may be deemed acceptable by the hospital staff; at other times, however, these actions are viewed as irresponsible and ignorant, and are a major source of discord. If the patient’s prognosis is particularly grave, nursing staff are critical and create more barriers to the patient utilizing traditional medicine. Roberto ultimately discontinued his treatment at the health centre to pursue what he believed to be curative treatment with the shaman. In conversation he expressed that the traditional practices brought him hope and made him feel supported. He died several days after leaving our care. Lette presented to CSSC one afternoon. Her husband gave a brief history: the 34–year–old woman had been well until the day before, but had started to complain of a headache and chills that morning. She subsequently became obtunded. Physical exam revealed multiple patches consistent with purpura across her chest and back. Immediately a hemorrhagic fever or meningococcemia topped our differential.

As the nursing staff gained IV access, we quickly shared with our attending

Health Organization’s Traditional Medicine Strategy provides an approach by which this may be accomplished.8 This approach encourages allopathic and traditional medicine practitioners to learn about each other’s methods and scope of practice. It also calls for improved communication between patients and allopathic health practitioners regarding traditional medicine and shared care models.8

the concern regarding the purpura. The attending turned to the husband and asked: “Fue al vegetalista? Chupando?” (Did she go to the traditional healer? Sucking?). The husband answered “Ayer” (yesterday). Our attending turned to us and explained, “it’s not purpura, she went to a traditional healer yesterday who did chupando, sucking, to try and remove the sickness. They use their mouth on the skin.” Peripheral blood smears later revealed that Lette had Plasmodium falciparum malaria. With appropriate anti–malarials she made a full recovery. Lette initially chose to attend the traditional healer over the health center due to her strong belief in traditional medicine, and, logistically, due to the healer’s close proximity and the minimal resources involved in visiting him.

The cases of Roberto and Lette highlight the intersection of traditional healing practices with allopathic medicine. Both patients chose, at different times in their illnesses, to pursue different forms of treatment. Neither patient overtly viewed the forms of medicine as competing, but rather, employed them depending on a variety of factors including immediate needs, cost, distance, and accessibility. Roberto initially presented to the health centre, but, in the face of his terminal illness, turned to the local shaman when biomedicine could not meet his needs. Lette presented to the health centre after her conditioned worsened, however, her initial consult had been to a Vegetalista within her community.

This brief discussion of the intersection of allopathic and traditional medicine in the Peruvian Amazon invokes more questions than answers. What is clear is that traditional and allopathic medicine should not be seen as dichotomous, particularly due to the widespread use of and belief in traditional medicine. It is only through understanding the cultural influences and logistical barriers that access to healthcare can be improved. There is need for improved understanding and trust–building between traditional healers and allopathic clinicians. Further, health education and increased availability of both the evidence–based treatments and those that fall within the patient’s particular belief system are imperative. The World

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references1. Algunos datos importantes para la gestión en

la Amazonia peruana [Internet]. Peru:Instituto de Investigaciones de la Amazonia Peru [cited 2015 Mar 22]. Available from: http://www.iiap.org.pe/promamazonia/SGAmbiental/pambien-tales/datos_importantes.html

2. Principales causas de mortalidad por sexo: De-partamento de Loreto [Internet]. Lima: Ministe-rio de Salud – Oficina General de Estadística e Informática [cited 2015 Mar 13] Available from http://www.minsa.gob.pe/estadisticas/estadisti-cas/Mortalidad/Macros.asp?16.

3. Brierley CK, Suarez N, Arora G, Graham D. Healthcare Access and Health Beliefs of the In-digenous Peoples in Remote Amazonian Peru. Am J Trop Med Hyg. 2014 Jan 8; (90):1180–183.

4. Williamson J, Ramirez R, Wingfield T. Health, Healthcare Access, and Use of Traditional versus modern medicine in Remote Peruvian Amazon Communities: A Descriptive Study of Knowledge, attitudes, and Practices. Am J Trop Med Hyg. 2015 Feb; (92):857–864.

5. Luna LE. Vegetalismo - Shamanism Among the Mestizo Population of the Peruvian Amazon. [dissertation]. Stockholm: University of Stock-holm; 1986. Available from http://www.scribd.com/doc/26541421/Vegetalismo-Shaman-ism-Among-the-Mestizo-Population-of-the-Pe-ruvian-Amazon#scribd. [Accessed March 13, 2015

6. Ceuterick M, Vandebroek I, Pieroni A. Resilience of Andean urban ethnobotanies: a comparison of medicinal plant use among Bolivian and Pe-ruvian migrants in the United Kingdom and in their countries of origin. J Ethnopharmacol. 2011;136:27–54.

7. Jovel EM, Cabanillas J, Towers GH. An ethnobo-tanical study of the traditional medicine of the Mestizo people of Suni Mirano, Loreto, Peru. J Ethnopharmacol. 1996; 53:149–156.

8. WHO traditional medicine strategy 2002-2005 [Internet]. World Health Organiza-tion [cited 2015 Apr 24]. Available from http://herbalnet.healthrepositor y.org/bit-stream/123456789/2028/1/WHO_tradition-al_medicine_strategy_2002-2005.pdf.

disclosuresThe authors do not have any conflicts

of interest.

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