[MUSIC] My name is Heather Boon. I am a professor, and I'm the Dean of the Leslie Dan Faculty of Pharmacy at the University of Toronto in Canada. >> And your main research is with? >> Most of my research focuses on health systems or models of care. And so I'm very interested in the regulation and policy around the practice of complimentary and alternative medicine. As well as with respect to how we regulate products. >> What we would like to know more from your expertise and research about your point of view of the doctor-patient communication. And especially regarding patients with cancer that encounter with the medical oncology institution. How do you approach that, I mean, what are the main questions? When patients come and to think about complementary versus alternative versus herbal medicine and find an oncologist who is more receptive or less receptive. I mean, what are the key questions in this dialogue? >> I think two things come to mind right away. One, the question I get asked the most is, can you help me find an oncologist who would be willing talk about these thing with me? And the other thing, I think the other piece of information is that we know that most patients, especially those with diagnoses of cancer, are using complimentary and traditional medicines. And I'm lucky because I've never actually had cancer. But I can imagine you're given that diagnosis, you want to try everything. You want to do everything possible to help yourself get better. And so, I think it's only natural that people are looking for a wide range of therapies. The challenge in this whole field is there's so much we don't know. And so, I think what's really important is to keep in mind if we know that there's evidence that something might work. If we know there's evidence something won't work or be harmful. Or if it's in the middle of bucket and that is we just don't know. And a lot of complimentary alternative therapies are in the middle. And I think it's very important for both patients and for clinicians not to pretend they know when we don't know. Be honest when we don't know and help patients on that journey to either participate in trials, if they're available. Or to help them to gauge whether it is working for them, even if there's not a study to say if it works in general. I think that's really important. >> So what were patients' expectations when they seek complementary medicine? >> One of the things that the patients in our studies talked a lot about was that when they go to see a traditional practitioner or a practitioner of integrative medicine, that person often spends a lot more time with them. And they feel supported in ways that unfortunately, our conventional western style medicine doesn't support them. And they tell stories about having seven minutes with the physician. And an hour or two with their naturopathic doctor or their traditional Chinese medicine practitioner. And that very human contact and support is something that's very important to them, over and above whatever therapies the practitioner may recommend. >> And can it compare patients expectations with the care provider versus the oncologist? >> They have different expectations with the two realms? >> They do have different expectations. They do expect more personalized care with the integrative medicine provider. I think though, if you talk to patients, they'd actually like all of their providers to have that kind of perspective. And it's our healthcare systems, which mean that oncologists often don't have the time. They would love to be able to spend an hour with a patient. But the way the system is designed, the way they're reimbursed, it's impossible for them to spend that much time. And I really think we need to think about how we organize healthcare as a whole. To think about the good things that are part of integrative medicine that should be available to all patients. And then oncologists should be able to deliver, ultimately. >> So would you say that in Canada, in cancer care for example, it's more complementary? Or rather, integrative conceptualization of care? >> I would say it's not integrative for most patients. I would say that most patients see their oncologist and then also see their complementary or integrative healthcare providers. And if anyone integrates the treatments, it's often the patient. It's the patient that's sharing information between these two different worlds. We don't unfortunately have a system where the traditional Chinese medicine practitioner, or the acupuncturist, or the naturopath talks very much to the oncologist. We have a couple of centers that are focusing on that kind of integrated care, and studying it. And I think that's a nidus of something really important. But in the health care system as a whole, you don't see much of that yet. >> So who should be the integrator? >> Who should be the integrator? >> Mm-hm. >> It will be really nice if our different types of health care providers truly work together as a team. But frankly we have enough trouble getting doctors and nurses and pharmacists to talk together. It's even harder when you want a traditional Chinese medicine practitioner to also be part of that conversation. Our medical records don't facilitate that. And so again, it's about systematic barriers that make it very difficult, even if the practitioners want to work together as a team. The payment systems, the medical records systems, none of those make it easy. >> Well, how would you envision, practically, an integrative model of care? If a patient, for example, has a has breast cancer diagnosis and she's going to undergo chemotherapy, how would you envision the path that she would lead? Where should the integration take place? Within the oncology department? Or- >> Well- >> Another place? >> I think that obviously, some cancer care needs to be delivered in a tertiary care center. There are certain tests and diagnostics and things that everybody may need and that's best delivered there. But I think we know that with cancer much of the care is after the surgery or throughout chemotherapy those kinds of things. These are longer termed treatments, which are often and usually provided on an outpatient basis. I think that's the site where integration is probably best delivered and survivorship and in the outpatient treatment of cancer. As well as, frankly in prevention. I think that integration could occur there as well. And it's really about creating settings, where the patients perhaps are going for their chemotherapy regimens, that also involve, perhaps there's an acupuncturist there working on the nausea from the chemotherapy. That kind of thing I think would be a logical place to start with integration. >> And maybe focusing more about herbal medicine out of all of this huge basket of complimentary therapies. >> Right, herbal medicine is such a challenge. And that's because we still don't fully understand how many of these herbs work. So we may know for example that they do impact the free radicals in the body. So normally that's a good thing, except when you're having some chemotherapies, which actually generate these free radicals as the way that they work. And so then the concern is, are we actually giving herbs which may decrease the effectiveness of the chemotherapy. So I think that this is an area where we need a lot more research. Because we don't actually know whether some herbals should be taken together and they mitigate side effects, but they don't impact the efficacy. Or whether they may impact the efficacy, they may have no effect at all. There's more questions than answer in this area. And so I think many people at this point recommend them having chemotherapy, you don't take herbal medicines at the same time. And that's really a recommendation based on best guesses and fear of the unknown. And we really do need to do the research to find out, because it's quite possible that some combinations may be beneficial. Unfortunately right now, we don't have good evidence to know which ones. >> But going back to the patient's perspective, the patient's narrative. Why do patients in Canada seek herbal medicine? I mean, comparing to what oncologists can just offer, it's. >> So most patients in Canada don't seek herbal medicine instead of conventional therapy. >> I understand. >> So they take it as well as. And when you ask patients they are hedging their bets. They're trying everything. Anything that might help, they'll try it. And they usually try it altogether at the same time, which actually makes doing studies hard. Because if we want to do a study, I don't want them to take five things at the same time. I would like them just to take the chemotherapy and the one herb that I'm studying, and not to take all their extra vitamins. And do acupuncture, and yoga, and everything else. And to find patients that are willing to say, I'll just do these two things so you can study me, is actually really hard. Because they want to try everything, and I perfectly understand that reasoning from a patient individual perspective. But what we really do need is to try different combinations and compare them, it's the best way to build the evidence base. >> But what's the reason? Why do patients use it? I understand that they use it in a complementary manner, not as an alternative to chemotherapy, but still why do they use it? They expect the quality of life improvement, they expect to be cured, they expect. >> It depends on the patient. For many people it's an added bonus, it's an extra thing that they can do. They often say things like, well it can't hurt, which isn't completely true. >> Yeah. >> But many people believe it's natural so it can't hurt me. And if it has a benefit, then that's a bonus. Some people do hope for a cure and believe it may be helpful in a curative way. Many people hope for added quality of life. It differs slightly depending on obviously the cancer diagnoses and the individual. But I think when people are doing a risk benefit analysis of what to try when you believe there are no risks, it makes it the barrier to try this that is very low because you might as well try it if it can't hurt you if that's what you believe. >> I wanted to ask you where usually we somehow minimize or underestimate the medical dialogue, focusing more on the patient and the doctor. Who are the additional players in the game, in terms of who should be also considered in developing an agenda that resonates with the patient health relief model? >> I think, from our research it's very, very clear that patients' families, and it may not be just blood families, but the significant others within their circle are very important players in all of this they are the ones. It's their loved one who's ill. So they may be the ones that have the energy to do the research on the Internet and find out about the herb or find out about the other products that the patient could be taking. And so, it's often their family and friends that are suggesting things for them. And so, I think it's really important for all of those people to be involved in the dialogue when we're talking about pros and cons and risks and benefits. They need to be engaged in that conversation as well. >> And from the healthcare perspective, are there additional healthcare practitioners that should be involved? >> Absolutely. We know that team-based care is the best way to go, especially in an illness such as cancer. So it should be the nurse, and the social worker, and the pharmacist. As well as the traditional Chinese medicine practitioner, and the doctor, and the patient. It's really a team based approach that is going to be the best. And I think perhaps one of the most crucial people in all of this is a nutritionist or someone that can give dietary advice. They're often forgotten in this circle of care as well. >> And what about the primary current physicians, family physicians? >> Absolutely, when I say physicians, I'm not just thinking about Oncologists. Because again, much chemotherapy is given outpatient. And certainly in North America now, chemotherapy is not always something you have to go into a center to have IV for. Now we have oral chemotherapeutic agents. And so patients are really managing their cancer at home, in the community setting. And so, it's pharmacists that they're interacting with, it's the primary care physician that they're interacting with, and their family. Those are the people that are their circle of care when they're in the community. And so helping all of those people understand the roles they can play, and the realistic expectations that one should have around complimentary and traditional medicine is really important. >> So if you design an integrative process where complimentary therapies or physicians, trained physicians in complimentary medicine are really integrated within the oncology ward. Who would be the best available healthcare practitioners from the conventional side that would be the, the gatekeeper that can open a little bit the door for this integration process? Should it be the oncologist, the nurse, or someone else? >> It's interesting, in North America often the nurse is the, they call them a care manager. So they're the ones that help the patients navigate through the different practitioners. It doesn't make sense for to be the oncologists, because they're very specialized. And there aren't many of them. So we need them to focus on what they do best. But to help the patient navigate the journey, which may entail visiting and speaking with, and engaging with many different specialists. Either a nurse or a primary care physician. Some groups have suggested that naturapathic doctors, which I know are a little bit different in different countries, how they're regulated. But in the west, they even even an option someone. And other people have an educated ley person actually the patient's coach as they as they navigate through all these different health care professions in this journey. >> So it depends partially on how the health care system is set up. But in many cases we find nurses have the right balance between knowledge of western care, openness to other different models of care. And they can be really good coaches for patients to navigate this >> So these are the case managers actually. If we would design a training in complementary medicine or integrative oncology training, you would suggest to focus on the nurses first? >> Something like a nurse because, first of all, they spend a lot of time with patients. They probably spend more time with patients than any of the other care providers. They come from, in most cultures, nurses are trained from a caring perspective. And that's not to say that doctors and pharmacists are not trained from a caring perspective. But, it's the core of what they do. They care for patients in a very personal way. And so, many nurses we found some of the philosophies and underlying worldviews of complimentary and traditional medicine are much more familiar. Or easy for them to understand than it would be perhaps for some of our other conventional therapist. And so, we find that they actually are pretty good at navigating between these two different worlds, and guiding patients. But they are also usually trained from an evidence-based scientific perspective. And so, they can help patients question when a claim seems too good to be true. Or help them realize that just because it's natural doesn't necessarily mean it's safe and there could be negative interactions. And so we find that nurses can be good coaches for patients as they're going through this and trying to integrate things from different paradigms. >> So in conclusion, how would you summarize the barriers and the options to bridge the barriers. Of integrating, let's say, herbal medicine in supportive cancer care? >> For me, the number-one barriers are systemic. They're how we organize our healthcare systems, how we pay people, who can write in the charts, who's allowed to come into the hospital. It's these systemic barriers which are the biggest challenge to integrated care. And so I think we need to think about how to work, and it's going to be different in different systems. But how do we work around those barriers, eventually we need to knock them down. But in the short term, what are the easy roads in and around those things? And for example in many Canadian hospitals, the only people that can write in the chart is the physician. And so slowly we're saying well what if nurses can write in the chart, pharmacists can write in the chart, then maybe we'll get to the traditional Chinese medicine practitioner down the road. But we need to be slowly knocking down those barriers if we're going to create fundamental change. 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