REINE DUBOIS – NATUROPATH DR ANTHONY SOLOMON DR FRANK GOLIK DR SUZANNE GRANT DR NICOLE AVARD Expectations of the relationship between doctors and CAM practitioners

Outline Requirements of a working relationship Forging the relationship Responsibilities Common pitfalls Patient group selection Pathology requesting Beauty of combining modalities Patient perspectives

Requirements of a integrative relationship Faith in the relationship Mutual respect Trust Equality Open communication between practitioners Sharing a common language/being a team member Understanding limitations Understanding other practitioners’ area of expertise Patient centred care as opposed to an ownership approach to the patient – power to the patient

Forging the relationship Make initial contact Be approachable and respectful Meet with the other practitioner Offer free session Develop a clear working contract & clear understanding of expectations Suggest a combined consultation with established shared care patient Common ground – eg. CDSA

Responsibilities Know your limitations and know when to refer “I have to trust that they (CAM practitioner) know where the medical boundaries lie and they are able to identify a serious issue that becomes essential to address within the mainstream medical realm” Reference –research project – the place of osteopathy within the integrated medical model – Bimbi Gray unpublished research

Responsibilities Realistic assessment of efficacy of naturopathic treatments  Using pathology as a guideline Know when to suggest the inclusion of medication by the doctor – naturopaths well placed for these discussions

Responsibilities Keeping accurate records Using the common language that the team members understand Patient – financial awareness

Common Pitfalls Undeveloped relationship & lack of understanding of another practitioner’s therapeutic approach  May lead to misunderstandings regarding chosen pathology tests and treatment strategy  Lack of trust Undermining another practitioner’s therapeutic approach  Prevents creation of a single, comprehensive care plan  Forces patient to play mediator One practitioner becomes overly dominant  Loss of equality Over Servicing – diversity of opinions

Integrative medicine ACAM – American College for Advancement in Medicine

Patient group selection Patient is open to integrated care Nature of the case  Complex chronic health conditions  IBS, fibromyalgia, anxiety, mood disorders, CFS, addictions, chronic pain, pre and post cancer treatment  Work cover Patient values  How the patient views medical and alternative therapies  Commitment to wellness Finances

Pathology requesting Governed by Medicare  benefit for patients but issue for GPs Requests need to be reasonable You need a common language Responsibility for results  Results need to be reviewed together A GP may not know why your pathology request is needed  Communication needed to forge understanding Different understanding of “normal range” – TSH

Beauty of combining modalities Inter collegiality - Connecting with other professionals - “not one or the other but both” Interesting patient mix Positive patient outcomes New approach to health care – future pathways Work satisfaction – challenge of the chronic/complex patient Giving the patient confidence to follow their belief system Attracts patients that want to get better – dedicated to wellness – committed

Patient Perspective It has been enormously helpful working with an integrative health practice for the treatment and care of my father. There is no doubt that medical, naturopathic, homeopathic, and other treatments can work symbiotically together to produce a better result. However, its very, very difficult to find a team of people with each of these specialties that get along and respect each other to coordinate treatment and care. The fact that we've been able to work with one team in one office that is set up to coordinate all of these treatments very well, has been literally a life- saver.

Patient Perspective I had suffered from mouth ulcers from childhood, as well as headaches & digestion discomforts ( I thought it was normal for me) & didn't seek professional help until i was in my mid thirties. Doctors after doctors said not much could be done but offered a variety of suggestions re various vitamin supplements. Nothing worked. All my symptoms were getting worse as i entered my forties. A girl i had been dating over three years ago, became concerned about my condition, & quite frankly, she became fed up with my constant whinging so she made an appointment for me to see Reine Dubois. I had my reservations in going but proceeded to do so anyway. What was i to loose, I thought. The rest is history! After a few consults, in conjunction with Dr Anthony Solomon, we got to the bottom of my condition. I felt totally comfortable in working with the both of them almost immediately & reached a level of trust i had not experienced with doctors & specialists before. Today i live a perfectly normal life, free of pain & discomfort, thanks to the team efforts of Reine Dubois & Dr Anthony Solomon, of which i am immensely grateful. Michael De Domizio

Patient Perspective " What I like about consulting a naturopath and a GP together is that I feel I get the caring for the whole person from the naturopath, rather than feeling more like a collection of symptoms in a more normal medical consultation, and the evidence based more scientific approach from the GP. I seem to get the good traits from both people. And, as they discuss what could be best for me, I am right there and can enter the discussion, so I feel more engaged in my own treatment and thereby quite empowered."

Patient Perspective My oldest son Josh attended North Coast Medical Centre when he was about 13. He was going through a difficult time. He was struggling with his school work and his relationship with his Dad was antagonistic at best The tension and arguing was impacting the whole family. Josh was in a dark place - and no amount of my nagging or encouragement could get him to exercise. Josh's first visit to the Centre was to meet with the Counsellor, Simon. Simon suggested an integrative approach with josh. Josh met with a GP, the naturopath and had weekly cranio sacral sessions. We found the integrative approach and the care of the 4 practitioners incredibly supportive and successful. Personally, I loved that all bases were covered so to speak. Generally Josh would meet with each person individually but they would all communicate and occasionally we would all meet and discuss the progress and give feedback. After one particular cranio sacral session, the practitioner called me at home to ask if I had noticed any difference in Josh over the last week as she had definitely felt something shift in him. Things did shift. It was subtle and gradual but when I think back to that time, i realise how far josh has come. He is now studying his HSC and is confident and happy (most of the time.) I can't speak highly enough of this approach in my son's case and I am very quick to recommend this holistic approach to healthcare.

Patient Perspective When I was diagnosed with Prostate cancer in 2008 a consultation directly with yourself and also Gareth your resident Naturopath at the time I was better able to understand firstly how Prostate cancer develops and then how it should be treated. The dual consultation gave me a real choice on how to proceed. Specialists just wanted the Prostate removed wherein by discussing with two forms of advice at the one time my decisions were made with a good foundation of knowledge and confidence. Dual consultation with blood tests were discussed to recognise the “Real “ cause of differing blood test results

Great Expectations DR SUZANNE GRANT, CHINESE HERBALIST & ACUPUNCTURIST POST DOCTORAL RESEARCH FELLOW, UWS DR NICOLE AVARD GENERAL PRACTITIONER

Research has shown that those patients consulting a CAM practitioner were more likely to have a regular GP than those who didn’t, to have seen a specialist in the past year and to have visited their physician more than 5 times in the past year Source: Soklaridis et al, Integrative health care in a hospital setting: Communication patterns between CAM and biomedical practitioners, Journal of Interprofessional Care 2009, 23(6):

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Lessons learnt Conflicting advice on nutrition, supplements and exercise  This could be formalised but need to allow for individualised needs of patients and practitioners. Acknowledge limitations Communicating the pathology and the diagnosis of the patient effectively within the practice especially when there are significant changes Much better when treating the problem initially if Chinese medicine is considered and where appropriate utilised into the patients treatment plan at the early stages as an option or integrative treatment Too many “cooks” to manage unless integrative or communicated.

Challenges The chronic, “thick noted” patient Availability of actual time to interact Financial models – what works, what doesn’t - to be able to meet without jeopardising patient practice or income; The best way to share patient charting; Deciding who is the case manager Tend to be GP led models What should we expect from each other with acute care patients?

IVF acupuncture Clearly documented The level of intervention is readily available for the patient, the specialist and any other practitioner to view

Medico-legal aspects AIMA Conference Melbourne Discuss the medico-legal aspects of the doctor/naturopath integrative model When do we become concerned about abnormal results How they are managed When and how should we intervene - when serious Who is responsible medico-legally – if things go bad

Creating Guidelines for an Integrative Approach: AIMA Conference Melbourne Respect for each other’s professional skill and experience. 2. Create a foundation for doctors and naturopaths to work together integratively. 3. Look at issues preventing this from taking place 4. Having clear boundaries relating to requests (including adequate and essential shared information): when, where, how (format), fees, patient information and clear procedures.

Creating Guidelines for an Integrative Approach: AIMA Conference Melbourne How to address seriously abnormal results; and when to intervene in critical situations. 6. How results are sent to the Naturopath +/- commentaries. 7. Liaise over the management approaches for the common medical problems; and how to discuss the unusual results or health issues.

Conclusion Marriage of IM has great potential – particularly for the patient Cost saving for the patient So few specialists – especially in niche areas – to share the burden – accessibility Develop more formal model of communicating and co-ordinating patient care Beware of the legal issues