1. “Using Integrative Medicine to Enhance Student Experience in Family Medicine and the PCMH” Armaity Vaghaiwalla Austin, MD, MPH, FAAFP Keck School of Medicine of USC Kim Peck, MD Texas Tech University Health Sciences Center School of Medicine Roberta J Weintraut MD Medical Center of Central Georgia/Mercer University School of Medicine

2. Disclosures Armaity Vaghaiwalla Austin, MD, MPH, FAAFP –No Disclosures Kim Peck, MD –No Disclosures Roberta J Weintraut MD –No Disclosures

3. Roberta J Weintraut, MD Director, Integrative Medicine Division Asst. Director, Family Medicine Residency Medical Center of Central Georgia/Mercer University School of Medicine

4. Why Teach Integrative Medicine? Self Defense? –42% of patients use it –629 million “visits” in 1997 –$21.2 billion 1997

5. Or – a natural part of the Patient- Centered Medical Home Integrative Medicine –Combines tools from many different toolboxes –Uses Evidence to assess risk/benefit ratios, safety profiles, and cost-effectiveness –Focus on Wellness and Prevention –Recognizes the fundamental interrelation of the Body, Mind and Spirit –Accepts and ENCOURAGES Patient Empowerment

6. To set the stage: What is the Patient-Centered Medical Home? patient-centered comprehensive team-based coordinated accessible focused on quality and safety a philosophy of care that meets patients where they are where patients are treated with respect, dignity, and compassion enable strong and trusting relationships with providers and staff. care is received in the right place, at the right time, and in the manner that best suits a patient's needs.

7. And what is Integrative Medicine? The practice of medicine that reaffirms the importance of the relationship between the practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing Consortium of Academic Health Centers of Integrative Medicine May 2004 ( 2009) 7

8. How does Integrative Medicine facilitate care in the PCMH? Fundamental approach is the Integrative patient- centered encounter which differs from conventional care in the following: –Chief complaint –History –Plan of Care –Resources AND addresses the needs of the PCMH in doing so… 8

9. The Patient-Centered Integrative Intake Patient-oriented, not system or disease- oriented: –“Patient concerns” vs “chief complaint” –history is patient-centered, and includes patient experience/perception Uses lifestyle assessment and motivational interviewing –Diet,Exercise,Sleep,Interpersonal relationships, –Supplement use,Alcohol, tobacco, recreational/prescription drug use 9

10. Patient- Centered Integrative Therapeutic Plans Reflect patient-centered goals and interdisciplinary resources Goals – set by the patient, not provider –Prevention, Wellness, Chronic Illness care Resources – with evidence –Includes nutrition, mind-body therapies, exercise, dietary supplements, spiritual therapy, manual therapy –Team-based Care - Dietician, psychologists, MFTs, chiropracters, OMT, massage therapists, acupuncturists, chaplain –Group visits, community resources

11. Patient-centered integrative plan “I’ll take the stairs at work and walk around the building during my breaks. I liked the guided imagery I used for my surgery – can I use it to help me with the weight and food craving? I can take the metformin at night but it makes me go to the bathroom at work so I’ll use the cinnamon in the morning and metformin at night. I’ll use my pedometer to measure my steps so I can see how I’m doing. My goal is to improve my energy and my sugar” 11

12. The Mercer Experience IM in Residency IM in clerkship

13. The Medical Center of Central Georgia Family Medicine Residency –8/8/8/program –Full hospital/ICU experience –65% rural or underserved –30% complete fellowships –ALL do IMR curriculum –Integrative level 3 PCMH FM clinic

14. MCCG/Mercer University School of Medicine affiliation- 1982

15. Integrative Medicine in Clerkship Orientation Day –Routine approach to patient is motivational interviewing –EBM - Integrative Therapeutics overview OMT Nutrition ( anti-inflammatory diet) Top 10 dietary supplements used by patients: –Risks/benefits/costs Guided Imagery and Biofeedback

16. In clinic and on wards Each encounter reviews principles of integrative care with IMR-trained physician Extended intakes : Integrative Clinic opportunity to do 1 hour assessments On wards: extended assessments of interest and needs to prepare for outpatient follow-up Hospital-home bridge – phone call, office visit

17. Make it just part of the routine Intrinsically woven into all patient encounters and experiences Integrative care plans reviewed at all patient case conferences and as part of routine care management didactics. Web-based EBM Integrative databases for clinical questions ‘on the fly’ 3 of 8 supervision attendings trained in IMR and/or fellowship trained in Integrative Medicine

18. Senior electives Integrative Women’s health –8-10/year –2-4 weeks –Nutrition, prenatal care, lactation, menopause Integrative Medicine –1-2/year –Botanical boot camp – salves, tinctures, teas –Guided imagery, biofeedback –Integrative clinic

19. Armaity Vaghaiwalla Austin, MD, MPH FAAFP Associate Clinical Professor of Clinical Family Medicine Residency Medical Director Keck School of Medicine of USC

20. Professionalism and the Practice of Medicine (PPM) PPM/ Integrative Medicine Selective MS 2 6 sessions Case based learning Experiential

21. PPM/ IM Curriculum Healing modalities and healing enclaves Acupuncture Herbals and Botanical Medicine Mindfulness (MBSR) and Guided Imagery Yoga and Qi Gong Ayurveda Traditional Chinese Medicine (TCM) Homeopathy

22. Integrative Medicine Elective MS 4 Prevention and Wellness Clinical Experiential Integrative Medicine Clinic East West Medicine Mindfulness Acupuncture/ TCM Homeopathy

23. Case Based Learning Fibromyalgia Women’s Health/ Menopause Anxiety and Depression Chronic Disease: MSK (Back pain) Diabetes Headache

24. Kim Peck, MD Associate Professor of Family and Community Medicine Assistant Director, Division of Integrative Medicine Texas Tech University Health Sciences Center School of Medicine

25. Integrative Medicine Education TTUHSC Family Medicine ICAM (Integrative, Complementary, Alternative Medicine) Student Interest Group Educational lunch meeting speakers Experiential Workshops IM Elective - course and workshops Herbal Preparation Workshop Acupuncture Workshop Acupuncture Elective Division of IM Lunch Series - inter-professional

26. IM can assist schools of medicine in meeting some of the LCME Standards Standard 6: Competencies, Curricular Objectives, and Curricular Design Elements: 6.3, 6.5, 6.7 Standard 7: Curricular Content Elements: 7.1, 7.2, 7.4, 7.5, 7.6, 7.7, 7.8, 7.9 Standard 8: Curricular Management Elements: 8.2, 8.3, 8.4 Standard 9: Teaching, Supervision, Assessment, and Student and Patient Safety Elements: 9.3 Standard 11: Medical Student Academic Support, Career Advising, and Educational Records Elements: 11.2 26 Integrative Medicine and the LCME

27. Integrative Medicine and the AAMC Core Entrustable Professional Activities (EPAs) for entering Residency The Core EPAs for Entering Residency are designed to be a subset of all of the graduation requirements of a medical school. Individual schools may have additional mission-specific graduation requirements, and specialties may have specific EPAs that would be required after the student has made the specialty decision but before residency matriculation. The Core EPAs may also be foundational to an EPA for any practicing physician or for specialty-specific EPAs. AAMC 2014

28. Entrustable Professional Activities (EPA) EPA 1: Gather a history and perform a physical examination EPA 4: Enter and discuss orders and prescriptions EPA 5: Document a clinical encounter in the patient record EPA 6: Provide an oral presentation of a clinical encounter EPA 7: Form clinical questions and retrieve evidence to advance patient care EPA 9: Collaborate as a member of an inter-professional team EPA 13: Identify system failures and contribute to a culture of safety and improvement 28

29. Questions and Discussion

30. Armaity Vaghaiwalla Austin, MD, MPH, FAAFP Associate Professor of Clinical Family Medicine Residency Medical Director Keck School of Medicine of USC avaustin@med.usc.edu Kim Peck, MD Associate Professor of Family and Community Medicine Assistant Director, Division of Integrative Medicine Texas Tech University Health Sciences Center School of Medicine Lubbock, Texas kim.peck@ttuhsc.edu Roberta J Weintraut, MD Director, Integrative Medicine Division Asst. Director, Family Medicine Residency Medical Center of Central Georgia/Mercer University School of Medicine Macon, GA weintraut.roberta@mccg.org Yan Zhang, L.Ac. Associate Professor, Department of Family and Community Medicine Director, Division of Integrative Medicine Texas Tech University Health Sciences Center School of Medicine Lubbock, Texas yan.zhang@ttuhsc.edu

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