Pediatric Integrative Medicine in Residency (PIMR): Description of a New Online Educational Curriculum

Pediatric Hematology-Oncology Provider Attitudes and Beliefs About the Use of Integrative Modalities for Their Patients: A Cross-Sectional Survey

Purpose: Children with cancer suffer from physical and psychological symptoms. Integrative medicine modalities (IMMs) for symptom management are increasingly popular, but whether these are acceptable to pediatric hematology-oncology (PHO) providers remains unknown. To address this knowledge gap and guide integrative medicine (IM) program development, a needs assessment was conducted to understand PHO provider knowledge, attitudes, and beliefs regarding IMMs for symptom management in children with hematologic or oncologic disorders. Methods: A detailed survey instrument was crafted using primary literature and expert opinion, iteratively reviewed for validity, and piloted tested by health care providers (HCPs). The survey was distributed electronically to patient-facing staff and stratified by clinical role. Survey response data from physicians and advanced practice providers (APPs) underwent descriptive analysis using SAS v.9.4 (Cary, NC). Results: A total of 78 PHO physicians and APPs completed this survey (response rate 29.5%). While most PHO physicians and APPs do not feel confident discussing incorporation of IMMs into the care of PHO patients, they are willing to (1) receive additional education in IM and (2) refer to a trusted IM provider. Providers do not believe that families typically disclose use of IMM to HCPs, and many worry about the use of entities such as high-dose vitamins and chiropractic care. Conclusions: PHO providers are concerned about the use of specific IMMs in their patients' care but support massage and mindfulness almost universally. Most PHO clinicians are willing to engage trained IM providers and support strategies that may contribute to improved quality of life for their patients and families.

Evaluation of Integrative Medicine in Residency-Psychiatry Curriculum

OBJECTIVE

This study describes knowledge change, self-assessed confidence in providing integrative medicine approach, and respondents' perspective on value and feasibility for the Integrative Medicine in Residency-Psychiatry (IMR-Psychiatry) curriculum, a 100-h elective offered during psychiatry training.

METHODS

Residents/fellows completed pre-post Medical Knowledge tests and self-assessment instruments tracking self-rated confidence. Participants were also interviewed for feedback about their experience using a semi-structured design after completion of the program.

RESULTS

Thirty-five of 37 (94.6%) participants completed all elective requirements. Items on the self-assessment instrument with the greatest positive pre-post change (p < 0.001) included ability to identify authoritative sources about botanicals (Cohen d = 2.15), effectively respond to patients' questions regarding the use of herbs/supplements (Cohen d = 2.67), and interpret labels on nutraceuticals (Cohen d = 2.28). Mean score on the Medical Knowledge test (n = 30) increased from 64.7% correct at pretest to 81.6% at posttest. Responses tracking self-assessed confidence in providing an IM approach to address 18 common medical and psychiatric conditions all increased significantly pre to post (p < 0.001). Qualitative interviews provided important insights into challenges and recommendations for improvement, and all participants highly recommended the curriculum and found it feasible to complete during training.

CONCLUSION

The IMR-Psychiatry curriculum provides trainees skills that promote comprehensive person-centered care; as a tool to optimize patient care and safety while enhancing physician well-being, wider-spread incorporation of the curriculum into psychiatry residency programs would be beneficial.

A Positive Depression Screen Is Associated with Emergency Medicine Resident Burnout and Is not Affected by the Implementation of a Wellness Curriculum

Introduction

While burnout is occupation-specific, depression affects individuals comprehensively. Research on interventions for depression in emergency medicine (EM) residents is limited.

Objectives

We sought to obtain longitudinal data on positive depression screens in EM residents, assess their association with burnout, and determine whether implementation of a wellness curriculum affected the rate of positive screens.

Methods

In February 2017, we administered the Maslach Burnout Inventory and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire two-question depression screen at 10 EM residencies. At five intervention sites, a year-long wellness curriculum was then introduced while five control sites agreed not to introduce new wellness initiatives during the study period. Study instruments were re-administered in August 2017 and February 2018.

Results

Of 382 residents, 285 participated in February 2017; 40% screened positive for depression. In August 2017, 247/386 residents participated; 27.9% screened positive for depression. In February 2018, 228/386 residents participated; 36.2% screened positive. A positive depression screen was associated with higher burnout. There were similar rates of positive screens at the intervention and control sites.

Conclusion

Rates of positive depression screens in EM residents ranged between 27.9% and 40%. Residents with a positive screen reported higher levels of burnout. Rates of a positive screen were unaffected by introduction of a wellness curriculum.

The Contribution of Complementary and Alternative Medicine to Reduce Antibiotic Use: A Narrative Review of Health Concepts, Prevention, and Treatment Strategies

AIM

The aim of this narrative review was to explore the potential contributions of CAM to reduce antibiotic use.

METHODS

We searched PubMed, Embase, and Cochrane Database of Systematic Reviews with a specific, limited set of search terms and collected input from a group of expert CAM researchers to answer the question: What is known about the contribution of CAM health and health promotion concepts, infection prevention, and infection treatment strategies to reduce antibiotic use? Results. The worldview-related CAM health concepts enable health promotion oriented infection prevention and treatment aimed at strengthening or supporting the self-regulating ability of the human organism to cope with diseases. There is some evidence that the CAM concepts of health (promotion) are in agreement with current conceptualization of health and that doctors who practice both CAM and conventional medicine prescribe less antibiotics, although selection bias of the presented studies cannot be ruled out. There is some evidence that prevention and some treatment strategies are effective and safe. Many CAM treatment strategies are promising but overall lack high quality evidence.

CONCLUSIONS

CAM prevention and treatment strategies may contribute to reducing antibiotic use, but more rigorous research is necessary to provide high quality evidence of (cost-)effectiveness.

Assessing Integrative Psychiatry Curriculum Needs

BACKGROUND

Research on incorporating integrative medicine (IM) into medical training is increasing. Programs and organizations around IM have been established, but there has not previously been a needs assessment focused on integrating IM into psychiatry training.

OBJECTIVES

The results of a needs assessment of training directors and faculty, focused on interest and priorities for developing an IM curriculum for psychiatry training programs, are described.

METHODS

Psychiatry Training Directors and faculty were invited to participate in a detailed electronic survey. Areas of inquiry included (a) IM content areas to include in training; (b) IM approaches to specific medical conditions; (c) existing IM content; (d) importance, interest, and strategies for IM training; and (e) availability of wellness programs for trainees.

RESULTS

Thirty-six respondents from psychiatry training programs completed the survey. Of the training programs represented by the respondents, 50% indicated that they currently had IM content in their curriculum; only 11.8% of them rated their programs' existing IM content as sufficient. Content areas rated most highly for inclusion in a psychiatry IM curriculum included sleep health, motivational interviewing, and self-care. Respondents indicated incorporating IM into the psychiatry training curriculum (47%) or as an elective (44%) as the desired implementation strategy, with experiential onsite activities demonstrating IM topics (67%) and online modules supplemented by local faculty (58%) as the 2 most desirable learning formats. Significant barriers identified were time constraints, lack of faculty expertise in IM, current lack of curricular requirements for IM competencies, and budgetary limitations.

CONCLUSION

Responses to the survey suggest that faculty need support and additional education in implementing IM training. A standardized, online curriculum could help meet that need. Our results also indicate that wellness programs for residents are currently inadequate; bolstering them could help address burnout and increase the knowledge psychiatrists have of IM modalities. The types of institutions represented by faculty interested in further developing IM offerings vary considerably, as do their current efforts to integrate IM into training programs.

Pediatric Integrative Medicine in Academia: Stanford Children's Experience

Pediatric integrative medicine is an emerging field which, to date, has not been described in detail in academic medical centers in the United States. Early research of pediatric integrative medicine modalities shows promise for the treatment of common pediatric conditions such as irritable bowel syndrome, acute and chronic pain, headache, and allergy, among others. In light of the growing prevalence of pediatric illnesses and patient complexity, it is crucial to emphasize the patient's overall well-being. As academic centers around the world start to develop pediatric integrative medicine programs, the aim of this manuscript is to briefly highlight evidence of effective integrative treatments in pediatric subspecialties, to describe the establishment of our integrative medicine program, to summarize its early efforts, and to discuss potential barriers and keys to success.

Integrative Pediatrics: Successful Implementation of Integrative Medicine in a German Hospital Setting-Concept and Realization

Complementary and Alternative Medicine (CAM) has not been systematically institutionalized in pediatric hospital care in Germany so far. For the responsible implementation and systematic evaluation of CAM in pediatric care, a model project was initialized in three different pediatric hospitals in Germany, one of them being the “Kinderkrankenhaus St. Marien” in Landshut, Germany. During this project, a concept of the implementation process was developed based on clinical care, teaching, and scientific evaluation. A project group was formed in St. Marien, which included leaders of the hospital, physicians, nurses, and physiotherapists. Over a period of three years, pediatric treatment modalities of the CAM-spectrum were systematically integrated into routine pediatric care and a new integrative medicine department was established. CAM is now being applied in an inpatient as well as outpatient setting, in addition to conventional medical treatments. The modalities now applied include Traditional Chinese Medicine (TCM), relaxation, hypnosis, reflexology, wraps and poultices, aromatherapy, homeopathy, yoga, and herbal medicine. Studies were initiated in some areas. The process and concept leading up to this successful implementation will be described in this article. We show that with motivated team players and structured proceedings, implementation of integrative medicine in a children’s hospital can be successful.

Pediatric Integrative Medicine: Vision for the Future

Pediatric integrative medicine (PIM) is of significant interest to patients, with 12% of the general pediatric population and up to 80% of children with chronic conditions using PIM approaches. The field of PIM has evolved over the past 25 years, approaching child health with a number of guiding principles: preventive, context-centered, relationship-based, personalized, participatory, and ecologically sustainable. This manuscript reviews important time points for the field of PIM and reports on a series of meetings of PIM leaders, aimed at assessing the state of the field and planning for its future. Efforts in the first decade of the 2000s led to increased visibility in academic and professional pediatric organizations and through international listservs, designed to link those interested in and practicing PIM, all of which continue to flourish. The PIM leadership summits in recent years resulted in specific goals to advance PIM further in the following key areas: research, clinical practice, professional education, patient and family education, and advocacy and partnerships. Additionally, goals were developed for greater expansion of PIM professional education, broader support for pediatric PIM research, and an expanded role for PIM approaches in the provision of pediatric care.

Integrating Pediatric Hypnosis with Complementary Modalities: Clinical Perspectives on Personalized Treatment

While pediatric integrative medicine (PIM) emphasizes an "evidence-based practice using multiple therapeutic modalities"; paradoxically, literature reviews examining the prevalence and/or efficacy of such mind⁻body approaches often address PIM modalities separately. Such contributions are relevant, yet documentation of how to deliver combined complementary approaches in children and youth are scarce. Nevertheless, integrative practitioners in clinical practice routinely mix approaches to meet the individual needs of each patient. Best practices are flexible, and include blending and augmenting services within the same session, and/or connecting modalities sequentially for an incremental effect, and/or referring to outside resources for additional interventions. Resonating with integrative medicine's definition, this article's goal is to demonstrate paradigms that "bring together complementary approaches in a coordinated way within clinical practice" by linking clinical hypnosis, the trail-blazer modality in PIM's history, with mindfulness, biofeedback, acupuncture, and yoga. Following the consideration of the overlap of guided imagery with hypnosis and an abridged literature report, this clinical perspective considers the selection of modalities within a collaborative relationship with the child/teen and parents, emphasizing goodness-of-fit with patients' contexts, e.g., symptoms, resources, interests, goals, and developmental stage. Case vignettes illustrate practical strategies for mixing approaches.

Integrative Medicine as a Vital Component of Patient Care

The landscape of medicine in the United States has been slowly progressing toward a more holistic and individualized approach to healing. Part of this progress has been the integration between western and alternative forms of medicine, a concept that has been described as “integrative medicine.” This approach to healthcare incorporates a patient’s mind, spirituality, and sense of community into the healing process. Integrative medicine has been typically well received and the demand has been steadily increasing in primary US hospitals. Here we cover a number of topics that include the definition of integrative medicine, its potential benefits, current examples of successful implementations, and potential barriers to its expansion. The aim was to give a primary on integrative medicine and its current state for healthcare providers.

Applied Pediatric Integrative Medicine: What We Can Learn from the Ancient Teachings of Sebastian Kneipp in a Kindergarten Setting

Pediatric integrative medicine focuses on the whole child and the environment in which the child grows up during the treatment of a child’s illness. Nowadays, many different treatment modalities are applied even in children, and doctors need to know about them and, ideally, be able to apply different approaches in the process of treating a child themselves. The program Pediatric Integrative Medicine in Residency (PIMR) already provides residents with several tools to provide this kind of service for the child. In our PIMR pilot program in Germany, we chose to diversify our knowledge about treatment and prevention options by visiting a Kneipp-certified kindergarten in Germany. The philosophy of Sebastian Kneipp focuses on five pillars of health, which incorporate aspects of prevention, self-awareness, self-responsibility, and consciousness of health by means of hydrotherapy, herbal medicine, exercise, nutrition, and lifestyle-medicine. These are being taught to the children during the early years they spend in kindergarten, and represent integral parts of integrative medicine. Integration of Kneipp-based health programs within a kindergarten setting can work well and provides an effective means of early prevention education in childhood.

Pediatric Integrative Medicine in Residency Program: Relationship between Lifestyle Behaviors and Burnout and Wellbeing Measures in First-Year Residents

It is widely recognized that burnout is prevalent in medical culture and begins early in training. Studies show pediatricians and pediatric trainees experience burnout rates comparable to other specialties. Newly developed Accreditation Council for Graduate Medical Education (ACGME) core competencies in professionalism and personal development recognize the unacceptably high resident burnout rates and present an important opportunity for programs to improve residents experience throughout training. These competencies encourage healthy lifestyle practices and cultivation of self-awareness, self-regulation, empathy, mindfulness, and compassion—a paradigm shift from traditional medical training underpinned by a culture of unrealistic endurance and self-sacrifice. To date, few successful and sustainable programs in resident burnout prevention and wellness promotion have been described. The University of Arizona Center for Integrative Medicine Pediatric Integrative Medicine in Residency (PIMR) curriculum, developed in 2011, was designed in part to help pediatric programs meet new resident wellbeing requirements. The purpose of this paper is to detail levels of lifestyle behaviors, burnout, and wellbeing for the PIMR program’s first-year residents (N = 203), and to examine the impact of lifestyle behaviors on burnout and wellbeing. The potential of the PIMR to provide interventions addressing gaps in lifestyle behaviors with recognized association to burnout is discussed.

Addressing Adverse Childhood Experiences Through the Affordable Care Act: Promising Advances and Missed Opportunities

Adverse childhood experiences (ACEs) occur when children are exposed to trauma and/or toxic stress and may have a lifelong effect. Studies have shown that ACEs are linked with poor adult health outcomes and could eventually raise already high health care costs. National policy interest in ACEs has recently increased, as many key players are engaged in community-, state-, and hospital-based efforts to reduce factors that contribute to childhood trauma and/or toxic stress in children. The Affordable Care Act (ACA) has provided a promising foundation for advancing the prevention, diagnosis, and management of ACEs and their consequences. Although the ACA's future is unclear and it does not adequately address the needs of the pediatric population, many of the changes it spurred will continue regardless of legislative action (or inaction), and it therefore remains an important component of our health care system and national strategy to reduce ACEs. We review ways in which some of the current health care policy initiatives launched as part of the implementation of the ACA could accelerate progress in addressing ACEs by fully engaging and aligning various health care stakeholders while recognizing limitations in the law that may cause challenges in our attempts to improve child health and well-being. Specifically, we discuss coverage expansion, investments in the health workforce, a family-centered care approach, increased access to care, emphasis on preventive services, new population models, and improved provider payment models.

Mind-Body Medicine in Pediatrics

The primary goals of this Special Issue are to encourage readers to become more familiar with the range of mind-body therapies and to explore their application in the pediatric clinical setting. The Special Issue includes a deliberate mix of case studies and practical clinical guidance, with the dual goals of piquing curiosity and providing resources for clinicians interested in pursuing further training.

Interprofessional Competencies in Integrative Primary Healthcare

In October 2014, the National Center for Integrative Primary Healthcare (NCIPH) was launched as a collaboration between the University of Arizona Center for Integrative Medicine and the Academic Consortium for Integrative Health and Medicine and supported by a grant from the Health Resources and Services Administration. A primary goal of the NCIPH is to develop a core set of integrative healthcare (IH) competencies and educational programs that will span the interprofessional primary care training and practice spectra and ultimately become a required part of primary care education. This article reports on the first phase of the NCIPH effort, which focused on the development of a shared set of competencies in IH for primary care disciplines. The process of development, refinement, and adoption of 10 "meta-competencies" through a collaborative process involving a diverse interprofessional team is described. Team members represent nursing, the primary care medicine professions, pharmacy, public health, acupuncture, naturopathy, chiropractic, nutrition, and behavioral medicine. Examples of the discipline-specific sub-competencies being developed within each of the participating professions are provided, along with initial results of an assessment of potential barriers and facilitators of adoption within each discipline. The competencies presented here will form the basis of a 45-hour online curriculum produced by the NCIPH for use in primary care training programs that will be piloted in a wide range of programs in early 2016 and then revised for wider use over the following year.