The Santa Rosa Integrative Medicine Curriculum and Fellowship

The Santa Rosa Integrative Medicine Curriculum and Fellowship Fasih Hameed, MD Ben Brown, MD (Wendy Kohatsu, MD) (Walt Mills, MD)

Sonoma County Population 500, 000 Santa Rosa ~150, 000 Significant Minority Populations: Latino, Laotian, Vietnamese, Cambodian, Native American, African

Residency, Misc Data • • • 36 Residents 176 Bed Hospital Clinic: FQHC status, 11/2007 54% Medi. Cal, 40% uninsured 9. 9 FTE core faculty members

Integrative Medicine Fellowship Timeline • Fall, 2006 - Fellowship & Curriculum Idea is Born • Winter 2006 -2007– Idea is postponed – Consortium Born Instead • Fall, 2007 -New Faculty Leadership – IM Task Force convened • Winter, 2007 - IM Clinic & Fellowship approved!!! • Aug, 2008 – Fellowship Begins

Mission Statement “In order to enhance the health of our patients and communities, The Santa Rosa Integrative Family Medicine Fellowship is committed to training physicians to incorporate holistic principles into the delivery of effective care to diverse and underserved populations. ”

Acknowledgments • Standing on the shoulders of Giants! – Victoria Maizes, MD – David Rakel, MD – Jeff Geller, MD – Pam Smith, MD – From Our Program: Sunjya Schweig; Colin Kopes-Kerr; Naomi Fuchs; Walt Mills; Scheduling Staff; Kevin Barrows; Ellen Barnett; Panna Lossy

What’s Different • 1 st West Coast Community-Based IM Fellowship!! – 2 nd Community-based IM Fellowship in Country with Underserved focus • 3 rd Non-Arizona IM Fellowship • IM Clinic Model – Consultation with Resident PMD present – Maximizes learning and relationship development • Extensive CME funding • Evolving model

Nuts and Bolts • • • Faculty Funding Curriculum Fellow (Napkin) Clinic (mini-fellow to Fellow)

Nuts and Bolts: Faculty Existing: Ben Brown, Walt Mills Local: Sunjya Schweig, Win Bertrand Distant: Wendy Kohatsu

Nuts and Bolts: $ Money from Work 0. 4 FTE clinic= $48, 000 0. 1 FTE precept FPC=$12, 000 0. 1 FTE precept IM= $12, 000 0. 4 Admin = $0 Money from Grant Kaiser faculty development = $30, 000/yr Money Spent Salary = $60, 000 Call = $3, 250 Benefits= ~$20, 000 CME funding = $12, 000 Money Left over

Fellowship Curriculum • Build While Flying • Principle Based and Skills-Based • 4 Goals: Learn, Apply, Be, Teach – Train Physicians in Integrative Medicine (Learn) – Apply Holism to Diverse Populations (Apply) – Live Self Care and Wellness (Be) – Build a Model: Local and National (Teach)

Principle Based Holism

Principle Based Treatment Pyramind Acute to Chronic Step or Stratified

Lifestyle Is the Foundation of Health Connection & Relationships Movement Sleep Hygiene Stress Management Habits Spirituality Food

Residency Curriculum • Didactic • Clinic • ‘Theme’ Months • Elective

Nuts and Bolts: Fellow • Fasih Hameed, MD – Motivated – Self Directed – Enthusiastic – Inspired Others – Visionary – Committed to Fellowship and Integrative medicine with Underserved Populations

Fellowship Acitivities: The ‘Napkin’

Fellowship Activities: The ‘Napkin’ • • • FPC clinics 4/week Precept Resident Clinic 1/week Precept IM clinic 1/week IM lectures ~ 1 -2/mo Website Development IM intake Form Development Research Project Low-cost EBM IM handbook Acupuncture Clinic Director Mindfulness-Based Stress Reduction (MBSR) Group

Fellow’s Regular Clinic Changes Typical Volume Schedule Full-spectrum Family Medicine • Patient Education Handout System • Functional lab tests started – Hunter Labs • Last two appointments held – acupuncture and body-work • Referral-based consultation

Fellow Skill-Building • • Acupuncture Heart. Math, Biofeedback OMT Functional Nutrition MBSR Herbal Medicine Qi Gong & Yoga

Educational Conferences Attended • American Board of Integrative and Holistic Medicine- Certification • HMI-Helm’s Acupuncture for Physicians. Certification • Food As Medicine • Mindfulness-Based Stress Reduction training workshop-Jon Kabat-Zinn • Healthy Kitchens- Harvard/CIA • California School of Herbal Studies-Course • Healing the Healer- Lee Lipsenthal, MD • OMT training workshop-Veronica Vuksich, DO

Additional Educational Resources • “Integrative Medicine” Textbook, David Rakel, MD • “Textbook of Functional Medicine” • PDR for Herbal Medicines • “Ultrametabolism” Dr. Mark Hyman • Chef MD • Natural Medicines Database • Natural Standard

Nuts and Bolts: IM Clinic • Purpose: – Deepen doctor-patient relationship – Uncover barriers to healing – Work towards a sustainable and realistic plan of action to achieve improved health

The IM Clinic • • • 2 residents 2 -3 patients 1 or 1. 5 hours per patient 1 Fellow or IM Faculty Preceptor ‘Appreciate Inquiry’ Model of Behavioral Change • Follow-up in PMD clinic

IM Clinic Data Overview • 76 Patient visits 2/1/08 -3/20/09 • N=45 for chart analysis • Age range 8 -77

Ethnicity

Language

Funding

Top Dx’s • • • • HTN: 11 Pain: 7 Depression: 7 HA/migraine: 7 Hepatitis: 7 Obesity: 6 Bipolar: 6 Hypothyroid: 5 PTSD: 5 DM: 4 GERD: 3 Asthma: 3 Fatigue: 3 Hyperlipidemia: 3 • • • • OCD: 2 Insomnia: 2 Seizure: 2 Methamphetamine use: 2 Smoking: 2 IBS Fibromyalgia CHF Breech Presentation Trichotilomania CRPS Sinusitis Allergic Rhinitis Fibroids

Magic Wand • • • Pain: 12 Weight: 9 Fatigue/energy: 7 Stress: 4 HA/migraine: 4 Relationship: 2 • N=27

Top Recommendations • Functional Nutritional Advice – Low GI, Anti-Inflammatory, Balanced Meals, Eat Breakfast, Gluten Free, Quinoa, Reduce Caffeine • Sleep Hygiene • Heart. Math • Breathwork/Relaxation – 4 -7 -8, 6 cycle/min, Mindfulness • • Movement Qi Gong Acupuncture Basic Supplements – EFA’s, Vit D, Mg, Probiotics, DGL

CASES

CASES

Case #1 • 9 y/o female with chronic abdominal pain • Conventional w/u negative • ROS: + diarrhea/constipation • Seen in IM clinic with Grandmother

Case #1: 9 y/o w/ abd pain • Stress-related, possibly food allergy • Heart. Math used in clinic w/ excellent results – 95% High Coherence @ level 1 – “That was fun. Can we do that again? ” • IM recs: – – f/u apt for Heart. Math biofeedback Labs: Food allergy panel, Celiac panel Probiotics Letter to school asking for private BM space

Case #1: 9 y/o w/ abd pain • Immediately after leaving IM consult, patient confided to her GM that GM’s partner had been sexually assaulting her. • CPS/police notified • Abd pain resolved

Case #2 • 55 y/o Obese female with trichotilomania • Long history of struggle with weight & Self. Esteem • Enrolled in Wellness Group x 3 years • Visits with PMD ~ Q 2 months • Usually refuses weight check • Wt 286#, BP 142/88 at IM f/u 10/17/08

Case #2: Obese 55 y/o • IM recs – d/c refined sugar/carbs – Increase fiber – Daily physical activity – Creative Outlet: Writing Workshop, Journal – Gardening – Guided Imagery CD – Vit D, EFA

Case #2: Obese 55 y/o • 5 month f/u – Wt 270# (- 16#) – BP 124/80 (SBP -18, DBP -8) – Per MD notes: Still ‘dieting’ and feels good

Case #3 • 48 y/o undocumented migrant worker with chronic daily HA, HTN, hyperlipidemia • Magic wand: – Leg Pain – HA – Anger

Case #3: 48 y/o with daily HA • IM recs: – Deep belly breathing exercises w/mindfulness – Wean Tylenol & Tramadol – EFA’s – Thought journaling with night wakening

Case #3: 48 y/o with daily HA • F/U @ 1 wk – – HA’s resolved Weaning pain meds Using relaxation techniques Amitriptyline started for neck/shoulder pain • F/U @ 1 mo – HA’s returned with complete d/c of tramadol but MUCH less intense – Pt. refused med tx of HA’s due to decreased intensity – OMT referral for myofascial pain, neck

IM for the Underserved: IM 4 U • Unique Barriers Patients – Financial, Financial – Lower educational level – Less Internet Access Clinic – Administration Buy in • Unique Strengths Patients – Focus on Lifestyle and Cost Effective Options – Cultural Diversity – Beginner’s Mind Clinic – Relationship-Based

Accomplishments, Activities and Curriculum • • • Chronic Pain Group Wellness Group Stress Management Group (MBSR) Centering Pregnancy Group Free Community Yoga Core Curriculum Series (monthly lectures) Weekly IM lunchtime lectures Acupuncture clinic for residents & fellow (distinct) Osteopathic training and clinics “Theme” Months in Clinic Resident Elective

Future Projects • • • Group Wellness Clinic Cooking Classes Formalize Consult Clinic Resident Leadership Projects Integrative Pharmacy Patient Education

Quotes from our Director • “It’s the best thing we have done for the residency. ” • “This is the best money spent dollar for dollar. ” • "Half of the incoming class has demonstrated a strong interest in integrative medicine. ”

Summary • • Do’able Fun Serves those that really need it Expands the role of outpatient Family Medicine

Final Tips for Success • • Start Small Build on Existing Resources Set Reachable Goals Find your Champions – Geese vs Buffalo – Critical Mass (internal, local, national) • Real Barriers Need Real Motivation and Determination • OK to build while flying

THANK YOU!

Santa Rosa Residency History • 1900’s Interns brought to hospital • 1938 Formal 2 -year residency • 1968 Alliance with UCSF • 1972 Formal “Family Medicine” Residency • 1996 Community Hospital becomes Sutter • 2007 -2009? Consortium Founded