Foundation for Integrated Medicine Patient-Centered Diagnosis: a Cornerstone of Integrative Medicine...
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Foundation for Integrated Medicine Patient-Centered Diagnosis: a Cornerstone of Integrative Medicine Leo Galland M.D. Foundation for Integrated Medicine Slide 2 It is more important to know what person has the disease than what disease the person has. Sir William Osler Slide 3 Foundation for Integrated Medicine Diagnosis Greek for knowing through Underlies all human problem-solving activity Is goal-oriented; diagnosis is the basis of treatment Diagnostic systems are attempts to separate two kinds of information: signal and noise Slide 4 Foundation for Integrated Medicine The Disease Model of Illness People become sick because they contract diseases Each disease is a distinct entity with its own natural history Each disease can be coded and understood independently of the person who is sick or the context in which the illness occurs Slide 5 Foundation for Integrated Medicine Conventional Medicine The leading clinical question is, What disease does this person have? The treatment that results from answering this question is, first and foremost, the treatment of the disease Education, research, scientific evidence, health policy and insurance are all built on this model Slide 6 Foundation for Integrated Medicine Disease vs. Illness Disease is what the doctor observes Illness is what the patient experiences In conventional diagnosis, disease and illness are related but separate constructs with trajectories that may be totally independent of one another In conventional medicine, physiologic and psychosocial domains may barely overlap Slide 7 Foundation for Integrated Medicine The Biographical Model of Illness Illness is an event in the life of an individual Illness results from disharmony or imbalance Each persons illness is unique The healers job is to help the individual restore harmony and balance, not to suppress disease Slide 8 Foundation for Integrated Medicine Integrated Medicine Integrates modern science with the ancient biographical model of illness The foremost question is, What are the disharmonies and imbalances contributing to illness in this person? Uses the process of Person-Centered Diagnosis to answer that question and guide therapy Slide 9 Foundation for Integrated Medicine Modern Science and the Origins of Disease Etiologic agents: the infectious, toxic, or allergic triggers of illness Chemical and psychosocial mediators of tissue injury and distress Risk, the cornerstone of preventive medicine 1 Slide 10 Foundation for Integrated Medicine Science and the Biographical Model What we call a disease is a pattern of signs, symptoms, pathological changes in tissue, and behavioral changes that appears coherent to the observer. Clinical disease and illness result from the interaction of mediators, triggers and risk factors (antecedents). Slide 11 Foundation for Integrated Medicine Person-Centered Diagnosis The individuality of each patient is foremost. Disease and illness, physiologic and psychosocial functional domains are integrated. The fundamental diagnostic question is what are the mediators, antecedents, triggers and effects of sickness in this individual patient. Slide 12 Foundation for Integrated Medicine Mediators Biochemical: prostanoids, cytokines, neurotransmitters, reactive oxygen species, ions, electrons Psychological: fear, anger, denial, expectations, perceived self-efficacy, motivation, conditioning, personal beliefs Social: reinforcement, support, cultural beliefs, relationship with a healer 2 Slide 13 Foundation for Integrated Medicine Mediators are not Disease- Specific They are organized into circuits and cascades that sub-serve homeostasis and allostasis. Each mediator is multi-functional. Each function involves multiple mediators. Redundancy is the rule, not the exception. Biochemical, psychosocial and cultural mediators interact continuously. Slide 14 Foundation for Integrated Medicine Mediator Flow There is a natural flow of mediator activity which is strongly influenced by the common components of life: diet, sleep, exercise, hygiene, social interactions, solar and lunar cycles (circadian, menstrual, annual) and the effects of age and sex. Ripples, currents and maelstroms result from the effect of triggers. Slide 15 Foundation for Integrated Medicine Common Triggers of Illness Microbes Physical injury Allergens Chemical toxins Elemental toxins Radiation Social interactions Emotional injury Loss Anticipations of loss Memories Slide 16 Foundation for Integrated Medicine Antecedents, the Flip Side of Risk Those factors that predisposed this person to this illness Congenital: genetic or acquired in utero Developmental: the result of nutrition, trauma, stress, toxins, social learning or symbiosis Slide 17 Foundation for Integrated Medicine Symbiosis Greek for living with We live with our families. We share our bodies with microbes. There are as many microbial cells as mammalian cells in the average human body. Beneficial symbiosis is eusymbiosis or mutualism. Harmful symbiosis is called dysbiosis. Slide 18 Foundation for Integrated Medicine Precipitating Events Lie between antecedents and triggers Initiate a change in health habits Common events include severe psychosocial distress, acute injury or infection, large toxic exposure or a period of nutritional deprivation Slide 19 Foundation for Integrated Medicine The Effects of Illness Symptoms Pathological and chemical changes in tissue Laboratory and physical signs Changes in behavior and social relationships Altered susceptibility to future illness through mechanisms that are disease- related, iatrogenic, cognitive or social 3 Slide 20 Foundation for Integrated Medicine The Anatomy of an Illness Antecedents influence exposure and sensitivity to triggers and the nature of the mediator response. Precipitating events initiate a change in health. Triggers maintain mediator activation. Mediators produce the effects of illness. The effects become antecedents for further illness. Slide 21 Foundation for Integrated Medicine Causation of Disease/Illness Disease/illness is not caused by mediators, antecedents, triggers or their effects but rather by the dynamic interaction of all four. Slide 22 Foundation for Integrated Medicine Practical Approach to Patients with Chronic Illness Describe the effects of illness, especially functional and social disabilities. Investigate the antecedents of illness. What was this person like before? Search for a precipitating event. When is the last time you felt really well? may yield a different answer than How long have you had this problem? 4 Slide 23 Foundation for Integrated Medicine Practical Approach, continued Inquire about the possible triggers of symptoms: food, drugs, supplements, environment, activity, sleep, social interaction. Think about the possible mediators: metabolic, neuro-endocrine, inflammatory, psychological, social, cultural and spiritual. 5 Slide 24 Foundation for Integrated Medicine Medical History: Key Points When is the last time you felt completely well? What was your health/life like during the years before that time? What happened in your life during the six months before that time? What treatments have you received? How have you responded to each? Slide 25 Foundation for Integrated Medicine Medical History, continued How are your symptoms affected by...sleep, food, activity, work, stress, supplements, medication, seasons, etc. How has this illness affected your life? What do you most fear about this illness? How much control do you believe you have over your symptoms? What kind of treatment are you looking for? Slide 26 Foundation for Integrated Medicine Functional Bowel Disorders: Effects Pain Diarrhea, constipation, urgent bowel movements Distension, flatulence, eructation Fatigue and symptoms of co-morbidity Anxiety Health care seeking behaviors Slide 27 Foundation for Integrated Medicine Functional Bowel Disorders: Mediators Neurotransmitters: Ach, DA, 5-HT Neuropeptides: CCK, VIP Prostanoids: PGE2 Anxiety, fear, appraisal Fermentation by-products Slide 28 Foundation for Integrated Medicine Functional Bowel Disorders: Antecedents Familial predisposition Trait anxiety predisposes to seeking medical evaluation and treatment Co-morbidity is common: migraine, fibromyalgia, pelvic pain, vulvodynia, asthma, atopy, latent tetany GI infection, antibiotic use Slide 29 Foundation for Integrated Medicine Functional Bowel Disorders: Precipitating Events Foreign travel Wilderness activities Antibiotic exposure Acute psychosocial distress Change in diet Slide 30 Foundation for Integrated Medicine Functional Bowel Disorders: Triggers Food Microbes Psychosocial distress Slide 31 Foundation for Integrated Medicine BACTERIAL OVERGROWTH IS MORE COMMON THAN SUSPECTED 202 patients with IBS underwent hydrogen breath testing 157 (78%) had SBBO and were treated with antibiotics 25/47 patients had normal breath tests at follow-up Diarrhea and abdominal pain were significantly improved by treatment Slide 32 Foundation for Integrated Medicine SBBO AND IBS: CONCLUSIONS Elimination of SBBO eliminated IBS in 12/25 of patients: 48 % of patients with IBS and abnormal breath tests who responded to antibiotics with normal breath tests no longer met Rome criteria for IBS Pimentel M et al, AM J Gastroenterol 2000 Slide 33 Foundation for Integrated Medicine MANAGEMENT OF UGI BACTERIAL OVERGROWTH INVOLVES DIET, ANTIBIOTICS Low fermentation diet -restrict sugar, starch, soluble fiber Antimicrobials (in select cases): Metronidazole (anaerobes) Tetracyclines (anaerobes) Ciprofloxacin (aerobes) Bismuth Bentonite Slide 34 Foundation for Integrated Medicine Low Fermentation Diet Basic diet: no wheat, sucrose, lactose Additional restrictions -no glutinous grains -no cereal grains, potatoes -restrict fruits, juices, honey -avoid legumes -cook all vegetables Slide 35 Foundation for Integrated Medicine IRRITABLE BOWEL SYNDROME IS ASSOCIATED WITH SPECIFIC FO