I'm sitting here with Dr. Elad Schiff from Bnai-Zion Hospital in Haifa. We're sitting here in the ecological botanical garden in the Technion on Mount Carmel, Israel. I would like to discuss with you several aspects of integration. First of all to ask you, what is your attitude concerning the aspects or definitions of alternative medicine on one hand and integrative medicine on the other hand. So, I think in the past 50 years, we've seen an evolution, tremendous evolution from alternative through complimentary, into the integrative definitions where the alternative denotes the opposition, the barriers, the wars between the sides. When there's a war, there's no discussion, there is no understanding and the patient is in between the practitioner and the physicians who never speak and oppose each other. So, I don't think there's an alternative to conventional medicine and I don't think there's an alternative to complementary medicine, and that won't help anyone if there will be such an opposition. That I think is the cause where we saw a natural transition into complementary medicine, because no one likes battle for a long time. Complementary medicine, however, wasn't also a good model, although there was some acknowledgment of the parties and people who are tolerant to each other, they never really talked. Nobody really understood what happens in the practitioner's room. The practitioner didn't really understand what happens in the physician's room. So, it was side-by-side. It was side-by-side it, it was in the best way you can say multidisciplinary but without any reference to one another. So, there was some acknowledgment, however, there was still no open discussion, no real understanding, and no learning between the sides. During the time in the complementary medicine module, still the patient was alone. He would go to the complementary medicine practitioner and to the physician and they would not discuss between themselves what is actually happening with the patient. That, again, isn't a safe environment and isn't health promoting for the patient. Therefore, in the past 10-15 years, we've seen the evolution towards what we believe is the true and right medicine which is the integration of both worlds. I think there's also something that is synergistic between complementary medicine convention in the integrative medicine paradigm, where one plus one is actually not two but is three because the cross-cultural talk between both systems of healthcare creates a better medicine for every one of us. That is the future of integrative medicine which is better for patients and promotes good health. So, when you look at the continuum between alternative to complimentary to integrative, where do you place the concept of traditional medicine? Traditional medicine was more in the realm of complementary medicine, where there was no opposition to traditional medicine. It was always there, but there wasn't an understanding of what is happening in the traditional practitioner clinic. So, I would place it more on the complementary medicine realm where there is some acknowledgement but there is no true understanding of what is happening with the patient. Within complementary medicine, as you see the NCCAM, a distribution of different systems of care, and one of the five systems of complementary medicine is traditional medicine. Which can be ayurvedic medicine or traditional Chinese medicine or Islamic medicine, but it is still under the complementary medicine paradigm. But nowadays, we can integrate also the traditional medicine to the integrative medicine. So, I think there's some semantic aspects of the definitions but, of course, I see the evolution of complimentary and traditional medicine into the integrative medicine world. During the last decade, you created significant projects in integrative medicine within your hospital. Can you elaborate a little bit about what you did? How integrative medicine is practiced daily inside the hospital? So, a complementary medicine or integrative medicine is quite well established in the ambulatory setting, outpatient setting, not in the hospital. I think very few places in the world integrated complementary medicine for in-patients. Of course, you can see some studies with complementary medicine that has been assessed in the in-hospital setting, but there was no systematic integration of complementary medicine into in-patient care. Being a internal medicine physician and a hospitalist, I saw that there is a huge possibility to integrate complementary medicine for in-patients. Because in-patients experience similar symptoms and similar life-changing events during their hospitalization. They're anxious, they're painful, they are nauseous, they have a problem to rehabilitate after serious procedures or illness. Why not implement complementary medicine and support their healing and support their health during the process of being in-patients, being hospitalized? However, integration into hospitals is very challenging because in the hospital setting, patients are in acute situation. They are in a very hectic, energetic, and unhealthy situation and it's a risky environments. So, really to bring complementary medicine practitioners into the hospital is a risky endeavor. So, we had to prepare both the complementary medicine practitioners and the departments themselves; the physicians, the nurses, the paramedical teams to prepare themselves for the integration. It was a long process, I would say one, two years to do that and then we started the integrative service itself, where we provide complementary medicine, we integrate complementary medicine into departments where the patients are, where the physicians are, where the nurses are, there you will find also our practitioners. So, you just started with the staff and only then moved into real work, clinical work with the patients themselves. So, it was a tremendous work and some good stuff. I can talk about that a little bit but first what we did, we assessed the needs of the conventional medical team. We talked with the nurses, we talked with the head nurses, with the matrons. We talked with the physicians and asked them where they see themselves providing less than effective treatments. Where they feel their hands tied. In those areas, we sought to see if we can provide better health. So, for instance, pain management it's not a secret, isn't good in the hospital settings. Patients are very anxious before they go through procedures, through surgery and the convention medicine is quite limited in the help they can provide patients and we assess those needs through conversations with the conventional team and also with patients. After understanding where the limitations are of the convention medicine, there then we research if complementary medicine can provide some benefits. In which departments you integrate this service? We started seven years ago in the general surgery department. It was the pilot department for integrating complementary medicine in the hospital setting and we selected the surgery department because we knew that the needs of the patients are quite repetitive. So, patients are anxious before surgery, they're painful after surgery, they are nauseous after surgery and they need rehabilitation process after recuperate from the surgery. So, it was quite a clear understanding where we need to step in and we could educate the complementary medicine practitioners on building protocols or to address these common symptoms in the hospital setting. Therefore, the general surgery department was seen as the best place to begin with. If you take that and compare it to an internal medicine department, in the internal medicine department, every patient is so different. The reasons for admissions, the symptoms they experience, it would be quite problematic to start there with implementing complementary medicine into the in-patient setting and therefore that's why we started in the general surgery department. So, which departments are currently included in the integrative service? Currently, so the service grew during the seven years into 12 departments. Now we're opening the 13th department, oncology department. But we grew from the general surgery to the anesthesia care then pediatric surgery, hematology, gastroenterology, maxillofacial surgery, urology then into the OBGYN department mostly in the delivery room. In the past two years, there's a huge activity in the internal medicine department and nowadays we are opening the Oncology Department into integrative Oncology Department. So, I would like to talk with you specifically with patients with cancer admitted in the hospital and know that you currently work with patients in the Haemato-oncology department and maybe in other departments like surgery or maybe internal medicine in acute admissions. So, can you describes in which conditions or symptoms or concerns integrative medicine can amplify supportive or palliative care? Maybe it will be best to talk about women who are diagnosed or in the process of diagnosing a breast lump. So, there's a potential of having cancer there and those women are going to have surgery and they will have to recuperate from the surgery. Not only from the surgery, but from what will be found in the surgery which is going to be a life-changing possibly, a life-changing experience because they're going to now have the diagnosis of cancer. So, we know from the literature that if we prepare women mentally towards the surgery, then there will be less complications of the surgery. There will be better recuperation from the surgery. So, on our team, we have a hypnotherapist, the mind-body therapist, Dr. Zahi Arnon who has developed during the years in strong collaboration with the nurses that are in charge of the breast unit and the physician that is in charge, the surgeon that is in charge of the breast unit, he has developed through understanding, meeting women with a new diagnosis of cancer or undergoing surgery for breast cancer. What are really the needs of the system and of the women that are undergoing these procedures? He developed scripts, generic scripts for each situation of preparing towards the surgery and what will be found in the surgery and how to cope with that. So, this is a very important aspect of oncological integrative care in the surgery department of preparing women or patients in general, towards surgery that may reveal cancer. So, this is a mind-body preparation which usually the women have the CD recorded for them with a generic suggestions of how the body is prepared better for the surgery and how the body will recuperate from the surgery and they listen to those CDs every day. Our experience is that women come calmer, they are less anxious significantly. We know that from qualitative analysis that we did with those patients and also in the surgery arena, we have trained the physicians, the surgeons how to talk with patients differently so that they will be less aroused by the anxiety. All the suggestions- Put more emphasis on positive suggestions and less on triggering Nocebo effects which are negative suggestions. Now I think we have an integrated team of nurses, and surgeons, and anesthesiologist who actually provide this integrative surgery theater where the patients are being in a better state of mind due to this environment. So, if we focus about patients with cancer, you talked about the contribution of integrative care in the pre-operation phase, basically regarding anxiety and maybe coping and is there any contribution in the postoperative phase as well? So, for every surgery, they are the postoperative symptoms, for instance, for women undergoing breast surgery, there's pain and there's nausea. For some reason this type of surgery causes nausea which is not all the time alleviated or best taken care of with anti-nausea medication such as promin or zofran. So, we have seen that acupuncture can significantly reduce these symptoms. So, providing acupuncture in the post-operative setting, women are relieved from their pain, they can better move their hands. Okay. So, they return to full function of the upper limbs, and the pain is addressed and the nausea is addressed and they can recover faster and go back home and have full capacity in the locomotor system, just move and feel better with themselves. So, in your settings, when you talk about acupuncture, you are talking, I understand, about TCM, Traditional Chinese Medicine practitioners, who are working as part of the integrative team and provide this acupuncture, well-trained acupuncturist. Yeah. So, I would like to ask you about the interrelation between Traditional Chinese Medicine and integrative medicine in your hospital. Is it merely acupuncture if there are any other modalities which are based on TCM movement or touch modalities? Is there any role for herbal medicine as well as part of the treatment? So, I'll start in response to your question about acupuncture itself and then discuss movement therapy such Tai Chi and herbal medicine. So, first of all, acupuncture is a large basket of approaches. So, some practice traditional chinese medicine, traditional chinese acupuncture and that may be according to the five elements or according to syndromal diagnosis, stems and branches. There are different approaches. We also have one Japanese acupuncturist in our group. Our morals, in terms of how to provide the acupuncture treatments, we say we don't have a protocol for paris symptom. We don't have a protocol, we don't have a kitchen book acupuncture with a set of points for nausea or pain. We want the practitioner to diagnose the patients according to their traditional system of diagnosis and provide the care, provide the acupuncture itself according to the tradition diagnosis of treatment. So, each practitioner does it his way, their way. However, they must document the diagnosis, they must document the treatment. So, at the end of the day, we can mirror to ourselves what was effective and in what should we improve. Maybe this set of points per diagnosis isn't relevant for some reason for the hospital settings and then we need to change our approach to the patient. Maybe this patient doesn't benefit from the five-element approach and we need something that is according to Yamamoto scalp acupuncture for instance. We've seen that and we've struggled with that, and for instance, for post laparoscopic shoulder pain, some 20 percent of patients, when they have laparoscopic surgery of the abdomen, they experience severe shoulder pain after the surgery. That is barely relieved by pain medication and at the beginning, the acupuncturist in our team couldn't alleviate such pain. Post laparoscopic pain was also a stubborn pain that we couldn't relieve with acupuncture. So, the acupuncture is set together after they have this mirroring that they're not effective in the treatment and they came back to the ancient texts, where the saw-. Chinese texts. The ancient Chinese texts and they were surprised to find that such a diagnosis of a flame, can be in an acute setting. Patients can have a tremendous energetic change in terms of Chinese medicine which the energies phlegmatic and they started treating patients according to this diagnosis of acute flame, stagnation in the upper area of the body and lo and, behold, they were very surprised to see that the patients responded very well to the treatments. So, we are serving all the times, which is the best approach? So it's like patient tailored Patient-centered care but we changed the system of care and we're flexible with them as long as we provide care to the patients. We relieve their symptoms and we look for different approaches according to what is there in the traditional Chinese medicine takes. So, what is the role of herbs in that? Regarding- yeah. So, regarding herbs, herbs is a tricky business because, think of all the medications that patients are receiving during their hospitalization. I can show you in the internal medicine, patients are prescribed 14, 15 different drugs and that is taken twice, three times a day. This is a typical patient in the internal medicine department and there are very intense and harmful drug-drug interactions. Just plug into that a complex Chinese herbal formula. How would I know if it's safe for the patient if there is no drug-herb interaction or herb-herb interaction? Yes. So, maybe interaction with anesthesia. Maybe interaction with the drug. Maybe interaction with the patient. So, maybe the patient is delirious. Okay, has delirium, is confused that maybe this type of herbal formula can aggravate the delirium. So, this is a huge area of uncertainty and therefore we decided, at least in the first year of our integrative service, not to go risky, to be very safe in our approach, incorporate Chinese medicine terms of acupuncture, movement therapy, Tai Chi and Qi Gong, mind-body therapies, reflexology and not beyond that, not incorporated these years until we have more data regarding herbal safety and drug-herb interaction, we will not incorporate Chinese herbal medicine. For herbal medicine at all. So, I understand that you don't initiate herbal medicine treatment but still as I understand, about half of the patients admitted to your hospital already use all kinds of supplement. Some of them are herbal supplements. So, what's the way to diagnose that? How would you discover if they use herbal or non-herbal supplements? What's the approach? I'll go one step just to say something about movement therapies before I address your question on assisting herbal use by patients. We have a Tai Chi and Qi Gong experiences every day in each of the 12 departments where we have integrated medicine. So every day at 11 AM, patients rise from their beds, go to the center room of the department and start to practice Tai Chi. This is an amazing experience to see patients with tubes with IV lines, with open scars, going and changing their mode of thoughts from being patients who were passive into people who are taking active care of themselves. This is a beautiful picture where not only the patients participate but also their family and also the hospital staff joins. So, there is a role model there. I want to just to highlight this aspect of the important role of movement therapy in the hospital setting. So, we have moved under the corrupt tree here aimng to ask you about herbal medicine in your practice inside the hospital. Understand that you don't prescribe actively herbs but still about half of the patients that are admitted to the hospital are practically using herbal medicine or non-herbal products. So, how do you find out if patients are using herbs? What's your approach? How do you communicate with patients regarding herbs? So, we have used data from our studies that have revealed the percentage that almost half of the patients are using herbal medicine or supplements around their hospitalizations. We didn't know that before the studies, we had some indications and we know that people in the community have this level of use. We had some studies showing that people in the hospital, one-third also are using dietary supplements or herbs around the hospitalizations and we wanted to find out actually if that happens also at our center, [inaudible] Medical Center. So, I used, originally, the questionnaires that were used in other studies to assess the rate of use of data in herbal supplements in our medical centers. So, I provided those questionnaires to patients in the different departments, and there was almost a zero percentage of patients declaring, or telling us through those questionnaires that they're using herbal supplements. I was very surprised, how can that be? So, after receiving questionnaires for patients, I approached the patient who said that they are not using herbal supplements, and starting to have a free chat with them about that in herbal supplements in different ways, and I found out that patients are actually using herbal supplements, but they responded to the questions in the questionnaires in a negative answer. Why is that? That is how we found out that patients when you ask them, ''Do you use herbal supplements?'' Most of them won't understand the question, and will respond with the nay. However, when you start asking them about, ''Do you use some grandmother herbs for your health?'' Or ''Do you use vitamin C with the specification of the type of the vitamin?'' Or ''What natural products do you use for your health?'' Then patients will respond and reveal the use of a herb of [inaudible] in herbal supplements. We went systematic on this concept, and ask not in teuropathic physician students, to go into different departments, and start asking the patients in a very open way, ''Do you use herbal supplements?'' Then if the patients respond with a negative response, then they start to asking them in a culturally sensitive open way about herbal remedies from grandmother, or things they pick in the garden for their health, or natural products, or specific names of vitamins and minerals. Actually, we found out that almost 50 percent as you said, of patients are using herbal supplements during their hospitalization. We need to use those codes, those specific terms in the history taking from patients to reveal such use. Why is it so important to ask patients? Because as we said earlier, the use of herbal medicine during hospitalizations may cause interaction between the drugs, and the herbs, or the supplements. We actually found out that there is some 50, or 40 to 50 percent of patients having potential interaction, which is a bad interaction. Let's say, if you take some herb, it may potentiate the blood thinning effect of a medication. Therefore, it is very important to understand if a patient is or is not using a herbal medications. So, you have to ask it sensitively, you have to be proactive in that, you have to document such use. We found out also that one in 55, 40 hospitalizations, is actually caused from an herb-herb, or a drug-herb interaction. So, although the Ministry of Health strongly recommends to ask patients if they use drug and herbal supplements, you need to know how to ask that question, and then what to do with the response of the patient when they tell you what type of herb, or supplement they use, and to check if they have any drug herb interaction. So, you're talking about an open non-judgemental communication between patients and physicians, or healthcare provider, how do you produce this atmosphere of non-judgemental communication? What are the benefits of that? So, many studies have shown that the patients are fearful to reveal a herbal use to their physicians. They think that physicians will oppose, but they still want to do that because that's the way the health philosophy goes. So, if physicians understand that this is for patient safety, if they will ask the patient in a judgmental way about herbal supplements, and the patients will not reveal that, then they are endangering the patient's. Therefore, we have to educate physicians, and we have shown that in a one hour educational sessions, we can educate physicians how to ask a question non-judgmentally regarding drug and herb used, supplement use. Physicians understand that morally, it is their role to ask in a non-judgmental way, and that way they will keep the patient safe. So, this is the atmosphere we create. Create a natural atmosphere, a safe atmosphere for the patient to reveal, otherwise you're in danger as a physician in your patients. So, you perceive that in ethical context, I understand. It's not only practical, but there are some ethical context to this approach, this open approach to communication. Yeah. I think that when you talk evidence-based about complementary medicine, or herbal medicine with physicians, they will oppose most of the things that you will say. But physicians are ethical human beings, they chose to be physicians, they chose to help patients. When you bring it to the realm, the discussion to the realm of ethics, and morals, then physicians will find themselves willing to participate in the moral, and ethical way with patients regarding complementary medicine. They will be willing to reduce their judgment in order to keep the patient safe. I want to thank you for coming here to the garden, and sharing your knowledge and approach with us. Many thanks. Thank you thank you very much. It was a pleasure.
