I'm a professor of physiology and medicine at Georgetown University, which is in Washington, DC. My background is as a physiologist. I study the kidney. I teach about kidney function to medical students, but about 17 years ago, I began an interest in integrative medicine. As an educational initiative in our school, and it's broadened to include, not just education of students, but also the use of integrative therapies in education and in improving patient care. So, I would like to ask you today about issues of medical education, training, approaches of students' inclinations to integrative oncology, to treating with patients with cancer. We're talking about supportive and palliative care, and what are the challenges that medical students in the US or in other places in the world face, or residents, when they talk about this issue of integrative medicine? Integrative medicine has undergone a big change over the last 20 years. Initially, it began as a very peripheral activity, that is therapy's that were unconventional, were not accepted in academic health centers, not accepted in academic hospitals. It was really the purview of practitioners that went to China, learned Chinese medicine, learned acupuncture, and were working with their patients. The shift began in the mid '90s, where medical schools began to have individuals on the staff that wanted to bring additional therapies because the public was looking for answers. So, the real motivation began, and the real drive began in the United States at least with the public outcry that the quality of life could be improved by bringing in other therapies. That's, for example, an integrative oncology, not necessarily to shrink the tumor, but to improve the symptoms of cancer care, to improve the symptoms of nausea, to improve one's well-being, which would actually make them better to fight the disease, and the same with other chronic ailments. Western medicine is very good at acute problems and not so good at chronic ones. So, the challenge we faced over the last 20 years is the gradual acceptance of a number of therapies as the data began to build to become part of standardized care, and we continue to face that challenge, although now it's a lot easier than it was 20 years ago. Years ago, you were one of the people that just talked about a doctor-patient communication, and about how to educate students, and residents, physicians, about non-judgmental skeptic approach. Correct. So, what's the challenges today, in that sensing in the realm of doctor-patient communication and cancer cure? So, 20 years ago, when we began, this was outside the mainstream, and so the rationale was how do we begin? Why should we bring this element into the curriculum? And the answer was, if we're focused on patient-centered care, which was a goal of most academic centers, the argument was how can you talk about patient-centered care without incorporating patient preferences? If the patient is looking for approaches that are outside the mainstream, for example, someone has knee pain from osteoarthritis. Well, what are the options? With either surgery or drugs that have now been taken off the market because they're so dangerous, but they didn't even consider acupuncture. Well, now we know that acupuncture is as good, if not better, and less invasive. So, the idea was, we need to include the patient, and we need to have the student learn to ask the patient, and we need to trust and build trust, so that the patient tells us, what are they using? What else are they using besides conventional care? Because we knew from the '90s studies, that patients weren't telling their practitioner what they were using. So, as we build the trust and as we began to incorporate patient preferences into the paradigm of clinical care, it also put the onus on us to responsibility to educate our students in, so what is the evidence for many of these things? As well as what things do we find are not useful and should be taken out of the options for patients. Today, I think the challenge becomes more focused on determining what is the right therapy for the right patient. We don't know that yet. We haven't done those kinds of studies. We also need to know what is the most cost effective way to treat a patient, and we don't have real good cost-effectiveness data. So, we see things become effective, but is it very expensive if we're using three therapists? Or in the long run, is that actually going to save money because it'll keep a patient out of the hospital? And that actually incurs a bigger charge. Those are some of the issues that we're dealing with, but what I would say that a positive development, as research has increased the acceptability of many therapies in our academic centers. The good news is that we're having much more rational conversations about what is and isn't appropriate, as opposed to a blanket flat-out rejection of anything that was unconventional. That has not happened. In fact, the reverse has happened. Do you perceive any difference between the concept of patient-centered care and patient-tailored treatments? No. I think one flows from the other. So, patient-centered care would say the patient is in the center of the relationship. There's the patient preference, there's, the practitioner, there's the learning environment, there's the family, there's a psychosocial elements that bear on this. But, then tailoring the right therapy, well, that also requires data. That requires information, for whom, for which group of patients, is massage better than acupuncture? Does the cultural context matter? Because that's going to be a very important element of the belief system, and we all know that if a patient believes that our particular therapy will be helpful, that actually improves the outcomes. So, why would we want to use that and why wouldn't we build on that, as opposed to forcing a therapy on someone that really doesn't want it. Then we know that's not going to be a good outcome. So, there's a lot more to be gained by understanding this. There's also an element of the practitioner developing their empathy. It's a difficult field to be giving care all the time, because what happens is you give and you give, and unless you learn to replenish, unless you want to understand yourself and what you need, you're not going to be effective for your patients, and so there's a tension line here between giving giving and also receiving receiving. So, this is also where integrative medicine can help inform the process by allowing practitioners to use some of these tools for their own benefit which will make them much more effective to the patients. That's an element in medical education and I'm going to talk about later today in the plenary session, and I think that every medical school needs to adopt. I think there is more and more acknowledgements in the integrative medicine circles of the wall of cross-cultural medicine and cultural sensitivity especially regarding minority groups in the western world, and like what we have is a diversity in the Middle East of many traditions of health system and so on. How should this sensitive approach, cultural sensitive approach be developed? How do you perceive places like the Middle East, I mean, in regard to other activities in the integrative medicine all over the world. I mean, what's the unique aspects that can be learned or can be practiced in our area? You're raising a very important issue. The cultural diversity that exists in approaches to health and to disease inform how an individual will do. The more we understand about each other, it doesn't mean we adopt everybody's practice's, but by being culturally sensitive, the physician understands and can deliver better care, and so I'll give you an example from the United States and then I'll answer your question about the Middle East. My medical school is in Washington DC. It's in the east coast, it's in a very urban center, very governed. We send students everywhere. We have a course that addressed as cultural sensitivity and we deal with Native American healing. Now, what is the connection between Native American healing in Washington DC? Well, it's not very close. But when our students go to Arizona, and they begin to work in hospitals and clinics in Arizona where the Native American population is is very high, not knowing the culture of the Native American community, that will be a huge disadvantage. But on the other hand, having an awareness of where, say the Navajo Indian family, how they approach health, what are some of the key elements that impact on health. Our students need that information in order to deliver the appropriate cure. So, here's a radical example where understanding the cultural background is as important as understanding the physical history, its social history, it's the familial history, and it's the cultural history. Whole of that context is critical. Now, let's go to the Middle East. The Middle East has longstanding systems of care, and yet we have political divines, we have religious divines, we have cultural divines. By understanding each other's place of what motivates them, what herbs are used in cooking, what sort of traditions are involved in the care of the family. As we understand more about each other, we break down barriers, and we'll find that even though they're different, they're also similar. There are many things that are common even within that region, and so what I found in my own experience, as I've gone to different places around the world, is that the more we learn about each other, the one we find lines of contact, and lines of commonality, and lines of convergence not divergence. So, I think there's great hope in them believes as we share information about our cooking, our herbs, our families, our health systems, our view of how we heal. It's going to be a way that will connect us. For Medical Education and Research points of view, what kind of Middle East offer in terms of global integrative medicine or integrative oncology? So. Why to invest? Let's say [inaudible] Here's what's interesting. I was involved with the Middle East Cancer Consortium for a number of years. So, here's an initiative that was developed by a group of very forward thinking individuals in the Middle East. With the help of Bill Clinton when he was president and the U.S. government providing resources to bring together the Israelis, Palestinians, Jordanians, Egyptians, Lebanese, Turks, and Cypriote. So, you've got a mix of folks and others beyond that. And the goal was let's improve cancer care, cancer delivery. Share problems and provide common solutions, and learn from each other, and find out that we're all facing similar challenges, and now let's work together to improve it. What I found in those sessions that I participated in, the more we learn about each other, the more we found that we're not so different. We're actually a very common, and that together we built bonds, we built bridges, and so sometimes we have preconceived notions about this group or that group. When we work together on a problem, it brings us together. I think the future in the Middle East is very bright because there's much to learn. There is much history. We haven't really delved into the origin of many of the herbs that are used in different sectors and in different groups. There's a rich area to investigate, and to build on. I'm very hopeful that things are going to improve, and that actually studying the role of integrative medicine will actually serve to integrate the people as well.
