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International Congress for Integrative Health & MedicineStuttgart, 9. 11. June 2016Integrative Medicine:Medicine of the FutureGustav Dobos, MD.Professor of Internal MedicineDirector Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, Academic Teaching Hospital, University ofDuisburg-Essen, GermanyChair of Complementary and Integrative Medicine, Faculty of Medicine, University of Duisburg-Essen, Germany

Physicians give medicine about which they know little against diseases they know even less to patients they don t know at all!Ärzte geben Medikamentevon denen sie wenig wissenwegen Krankheitenüber die sie noch weniger wissenan Patientenüber die sie gar nichts wissen!Voltaire 1694 - 1778

Traditional model of a physician„Wissenschaft und christliche Nächstenliebe“Picasso 1897, age 15, Barcelona„Science and humanitarian altruism“ (Ciencia y caridad)

And physicians? A significant number of young physicians(up to 30%) will not work in medicine! Up to 80% of female doctors are planningto work parttime! As a consequence we are running into adramatic shortage of qualified doctors!

The current situation :Physicians and patients are dissatisfied!Ärzte und Patienten sind unzufrieden!

GO!We have lost our goal, but doubled the speed!Wir haben unser Ziel aus den Augen verloren, aberdie Geschwindigkeit verdoppelt!

What is the official definition forIntegrative Medicine?Integrative Medicine is a way of looking at ahuman being as a whole and consider theemotional and spiritual condition as muchas the function of the organs.It will not reduce a human being to a canceror a disfunctional organ.

What is the official definition forIntegrative Medicine?Integrative Medicine is a way of looking at ahuman being as a whole and consider the itemotionalcombines as muchCAM therapiesfor whichoftheresome highas the functionthe isorgans.quality scientific evidence of safety andeffectivenessIt will not reducea human being to a cancerDefinition organ.of the NCCAM, NIHor a disfunctional

What is the official definition forIntegrative Medicine?Integrative Medicine is a way of looking at ahuman being as a whole and consider the itemotionalcombines as muchCAM therapiesfor whichoftheresome highas the functionthe isorgans.quality scientific evidence of safety andeffectivenessIt will not reducea human being to a cancerDefinition organ.of the NCCAM, NIHor a disfunctionalBy courtesy of Stefan Willich

Integrative MedicineIntegrative Medicine is a way of looking at ahuman being as a whole and consider theemotional and spiritual condition as muchas the function of the organs.It will not reduce a human being to a canceror a disfunctional organ.

„Mind-Body Medicine“ Anti-Stress Medicine Resilience trainingKLINIKEN ESSEN-MITTE,Dpt. for Internal and Integrative Medicine

Mind-Body Medicine the aim is to increase the perceived self-efficacynutrition„Mind-Body Medicineare interventions,that use a variety of techniquesdesigned to faciliatethe mind s capacityto affect bodily functionand ciserelaxationmindfulness(MBSR)stressmanagement

What are the significant problems of thewestern health systems? Aging society with increase of chronic diseases!Increasing rate of side-effects of therapiesExplosion of costs in the health-care systemLoss of humanity in medicine!Physicians lose fun and motivation in the profession Shortage of doctors! Alternde Gesellschaft mit zunehmender Anzahl chronischerErkrankungen!Konsequenzen durch Nebenwirkungen moderner Therapien!Ökonomisierung der Medizin mit der Folge einer Kostenexplosionim Gesundheitswesen! Verlust der Menschlichkeit!Ärzte verlieren die Freude am Beruf! Ärztemangel

One solution for an aging society People are getting older!It s a blessing of modern medicine,but also a threat!Fountain of youth 1546, Lucas Cranach the ElderlyJungbrunnen

What are frequent illnesses of anAging Society? Osteoarthritis Depression Cancer Heart diseases

What are frequent illnesses of anAging Society? Osteoarthritis Depression Cancer Heart diseases

What are frequent illnesses of anAging Society? Osteoarthritis of the knee

Every 2nd woman and every 3rd man above 60 issuffering under osteoarthritis of the knee.

What is the regular treatment forosteaoarthritis of the knee?o Non Steroidal Anti-Inflammatory Drugs(NSAID)oro Arthroscopic operation

1. Possible consequences of NSAIDtreatment„number needed to kill“On average 1 in 1.200 patients taking NSAIDsfor at least 2 months will die from gastroduodenalcomplications who would not have died, had theynot taken NSAIDs.Tramer MR et al. Pain 2000KLINIKEN ESSEN-MITTE,Department for Internal and Integrative Medicine

GASTROINTESTINAL TOXICITY OFNONSTEROIDAL ANTI-INFLAMMATORY DRUGSWolfe et al., NEJM 1999

2. Arthroscopic operationA controlled trial of arthroscopic surgery forosteoarthritis of the knee.Moseley et al. 2002, N Engl J MedKLINIKEN ESSEN-MITTE,Department for Internal and Integrative Medicine

2. Arthroscopic operationA controlled trial of arthroscopic surgery forosteoarthritis of the knee.Moseley et al. 2002, N Engl J MedKLINIKEN ESSEN-MITTE,Department for Internal and Integrative Medicine

Joint lavage for osteoarthritis of the knee.Reichenbach et al., Cochrane Database Syst Rev. 2010.Joint lavage does not result in a relevant benefit forpatients with knee osteoarthritis in terms of painrelief or improvement of function.Die Lavage des Kniegelenks führt bei Patienten mitKniegelenksarthrose weder zu einer Schmerzreduktionnoch zu einer Funktionsbesserung.KLINIKEN ESSEN-MITTE,Department for Internal and Integrative Medicine

Evidence for complementary therapiesin osteoarthritis of the kneeMeta-Analysis AcupunctureLeech therapyExerciseTai ChiKLINIKEN ESSEN-MITTE,Department for Internal and Integrative Medicinepos (Manheimer et al. 2010)pos (Lauche et al. 2014)pos (Tanaka et al. 2015)pos (Kang et al. 2011)

What are frequent illnesses of anAging Society? Depression

Prozac

Why would an integrative treatment in depressionpossibly make sense?Antidepressive drug therapy officially works inapproximately 50% of the patients, but:There is a large number of “selective publications” (31%)!(Turner et al. NEJM, 2008)Medikamentöse antidepressive Therapien wirken offiziellbei ca. 50% aller Patienten,aber es gibt einen hohen Anteil (31%) an “selectivepublications”!(Turner et al., NEJM, 2008)

Initial severity and antidepressant benefits: a meta-analysisof data submitted to the Food and Drug Administration.Antidepressives (SSRI) only workin very depressed patients!Kirsch et al. PLoS Med., 2008Kirsch et al. PLoS Med., 2008Fluoxetin,ParoxetinVenlafaxinNefazodon

Complementary antidepressivetherapies with positive evidenceTherapies with positive Meta-Analyses:EvidenceSt. John s wort2. Daily Yoga and/or exercise3. Daily Meditation4. Omega-3 FA-rich nutrition or capsules5. Acupuncture as a monotherapy or6. In combination with SSRI7. Fascia massage therapy***************1.

Patient: 43 years, maleI IIMBSR1AI IIIAcupuncture1AIII:LeechTherapy1AI IIYogaLevel of evidence:1AI.II.III.IV.Low back painDepressionOsteoarthritis of kneeObesityIV.Nutritioncouncellingenhanced care & skills-training5

What are frequent illnesses of anAging Society? Cancer as an adjunct treatment to treatside effects and improve quality oflife in cancer patients!

The specific situation for cancer patients the diagnosis of CANCER can be compared to an earthquake at the levelof 8 on the Richterscale, only – it happens onthe one m² you are standing on!Quotation of a cancer patientKLINIKEN ESSEN-MITTE,Department for Internal and Integrative Medicine

Treatment goals of Integrative Oncology is thereduction of side effects of conventional therapyImproved management of side effects of chemotherapy andmainstream treatment(pain, nausea, vomitting, polyneuropathy, hot flashes,aromatase-induced joint pain, fatigue ) physical and psychological fitness quality of life (reduction of depression, stress-perceptionand anxiety) compliance Reduction of use of quack methods!! Improvement of prognosis?!

11x/1 day per week 6 hours (incl. lunch)Covered by all health insurance companiesProvided by an interdisciplinary team4 different group settings:––––after treatmentduring chemotherapyduring antihormonal therapyfor patients with metastasisNutrition, exercise, relaxation, weekly reviewPsychoneuro- RelaxationStressimmuno- techniques ocialsupportCopingwith cancerComplementary medicine self care strategiesPhysician group consultationsMind-Body Medicine Day Care Groups for Cancer Patients

11x/1 day per week 6 hours (incl. lunch)Covered by all health insurance companiesProvided by an interdisciplinary team4 different groupsettings„Therapyfor: a thicker skin!“– after treatment „I became whole again!“– during chemotherapy„I got my soul back!“– during antihormonal therapy– for patients with metastasisNutrition, exercise, relaxation, weekly reviewPsychoneuro- RelaxationStressimmuno- techniques ocialsupportCopingwith cancerComplementary medicine self care strategiesPhysician group consultationsMind-Body Medicine Day Care Groups for Cancer Patients

compassion and mindfulness arerelevant also to the physician‘s healthand should be taken into consideration! Mitgefühl und Achtsamkeit sind auch wichtigfür die Gesundheit des Arztes und sollteberücksichtigt werden!

the physician s attitude is important for healing!The physician-patient relationship has a bigger effect size onthe 5-year risk of a cardiovascular event than smokingcessation, taking aspirin or primary prevention with statins!By courtesy of Robin Youngson

Economic situation A 6-year comparative economic evaluation of healthcare costs andmortality rates of Dutch patients of conventional and CAM GPsBaars and Kooreman, BMJ Open 2014Dutch patients whose GP additionallycompleted training in CAMon average have 192 (10.1%) lower annualtotal compulsory and supplementaryhealthcare costs and do not live longer orshorter than CON patients.

Economic situation Relaxation Response and Resiliency Training andIts Effect on Healthcare Resource UtilizationStahl Herbert Benson, Plos one 2015Mind body interventions such as Relaxation ResponseResiliency Program (3RP) have the potential tosubstantially reduce healthcare utilization at relatively lowcost to up to 40%.

Economic situation Relaxation Response and Resiliency Training andIts Effect on Healthcare Resource UtilizationStahl Herbert Benson, Plos one 2015

What is special about Integrative Medicine?1. Positive evidence of therapies in relevantchronic diseases in different areas!2. Physician-patient relationship is different! different attitude!3. Systematic use of Mind-Body Medicine forpatients and physicians leads to moreempowerment and improved resilience.4. It has the potential to reduce costs!

and if what would be necessary?

Integrative MedicineStandardization of education and Board certification Two years of additional systematic training in integrative medicine Development of medical guidelines to guide decisionsResearch program In addition to randomized-controlled trials (RCT) new researchmethodologies will be required to evaluate healing processes.Integration into the reimbursement system! Mixed model reimbursement

Integrative Medicine:The Medicine of the Future not only has totake care of the patients, but alsoof the physicians!

KLINIKEN ESSEN-MITTE,Department for Internal and Integrative Medicine

Dpt. for Internal and Integrative Medicine „Mind-Body Medicine" Anti-Stress Medicine Resiliencetraining. nutrition exercise relaxation mindfulness (MBSR) stress-management cognitive restructuring social support Mind-Body Medicine „Mind-Body Medicine areinterventions, thatusea varietyoftechniques designedtofaciliate themind scapacity