Pain is considered by many to be the best entry point for integrating "alternative" medicine into hospitals and
healthcare organizations, and an important focus for improving the existing healthcare system.
Two prominent illustrations of this positive development are Dr. James Dillard's book, The Chronic Pain
Solution -- and the Columbia-Presbyterian Medical Center Integrative Pain Conference in New York,
which he co-directed.
A catalyst for this attention to pain, and the opportunities it offers, is The Joint Commission on Accreditation of
Hospitals Organization (JCAHO). The Commission issued new standards that make the
assessment and management of pain a priority in the nation's healthcare system.
Accredited institutions must now provide information on other pain management techniques' including,
"alternative and complementary interventions that may be used individually, in combinations of alternative
or complementary interventions, or in combination with medications."
In other words, information on Complementary Alternative Medicine (CAM) must be provided. Over 18,000
healthcare organizations were required to comply with these new pain management standards. The question is: have they?
Dr. Dillard is a vibrant and energetic man who gets things done with swift and friendly effectiveness.
In addition to being a board certified medical doctor, he is a doctor of chiropractic and a board certified
medical acupuncturist. His many responsibilities and roles to improve healthcare include: Assistant Clinical
Professor at Columbia University College of Physicians and Surgeons, on the of board the medical staff at the
New York-Presbyterian Hospitals Columbia Medical Center, Director of Complementary Medicine Services at
University Pain Center in Manhattan, Clinical Advisor to the Rosenthal Center for Complementary and Alternative
Medicine, and the founding Medical Director for the Oxford Health Plans Alternative Medicine program.
Despite a hectic schedule he found time, while multi-tasking, to be interviewed.
Lese Dunton: Tell me a bit about your book.
James Dillard: It's called The Chronic Pain Solution (Bantam Books) and will be released probably August, maybe September of 2002. Bantam is wild about this book. It's going to be one of their biggest titles for the Fall. We're hoping that -- as one of the bidders of my books, Broadway Books, said -- it will undoubtedly be the category killer for this particular field. That is, how do you combine the best of conventional and unconventional medicines for pain?
It's my contention that pain is probably one of the best areas for integrating or bringing together some of the unconventional therapies with conventional therapies.
With some of the other big diseases we have, there probably is not all that much you can do to really change the course of the illness -- and certainly not on a day-to-day basis. Pain, however, is something that lives in the mind, the nervous system, the brain, the person's personality; in the spirit, in the meaning of their life. It lives in many areas. It's a very complex, multi-dimensional, multi-system problem. It's a subtle problem.
A multi-dimensional approach would seem to be the most appropriate, rather than a reductionistic approach. In diabetes, for example, we clearly control the blood sugar to end organ system damage -- eyes, kidney, skin, nerves, etc. With pain, there's so much that can be done; with the person, with the way they feel about it, with their relaxation or stress level, and all the other therapies that can modulate pain.
LD: And these are things they can integrate into their day-to-day lifestyle.
JD: Yeah, a lot of self-care stuff.
LD: Or at a hospital...in various settings.
JD: Absolutely -- it can be done at the bedside, very appropriately, and it's not just my idea. It's part of the guidelines that the Joint Commission has, which I talked about in my opening remarks at the Integrative Pain Conference.
LD: Could you give an overview of the main goals of the conference?
It's about creating a conversation about what we know, what we don't know, and what we'd like to know. It's about starting the dialogue. We know
that an extraordinary number of our patients are using some of these complementary therapies for their pain, and the questions are:
What should we endorse? What should we not endorse? What do we think has some decent science? What has no science? What's potentially harmful?
What's going to be a distraction from another therapy that may actually work a lot better for the patient? These are the big questions.
All of us need to be better informed about this.
LD: Do you know where you're at in terms of integrating this into hospitals, particularly Columbia, as well as around the nation?
JD: Clearly, it's increasingly in academic medical centers, not just private hospitals. Academic medical centers are building and developing integrative centers that are affiliated with the hospital, though the amount of those services that are actually delivered in the in-patient setting is a bit sparse.
LD: At Columbia as well as all over.
LD: Do you know what it would take to move it along?
JD: Time. Gradual buy-in. I think, increasingly, physicians have to be convinced that some of these things have decent science.
LD: So, education...
JD: Education and familiarity, getting some of these practitioners actually in the hospital.
LD: Are you going to have more conferences such as this?
JD: Yes. This one was seen as being a really rousing success. I think we hit the ball out of the park on this one, as far as I can tell. I think all the faculty was thrilled with what they heard. I think we did a good job, despite the fact that I don't think we made any money on it. I think we're probably in the red because, for one thing, I was looking for corporate sponsorship and most corporations are not interested. Maybe if they hear how successful it was they might want to ante up next time. But I talked to lots of pharmaceutical companies who make products for pain, and lots of equipment manufacturers; acupuncture needles, chiropractic tables, equipment, you know, Chattanooga, Leeander. They all just went, "Get out of my face." They just couldn't be bothered.
LD: I heard the conference was a sellout.
JD: Oh, it was past a sellout. Two weeks before we actually put it on, we had to close registration. It was a nice mix. We had a lot of physicians, of course, and a lot of nurses and psychologists, some CAM practitioners, acupuncturists, massages therapists, physical trainers, a fair number of academics and researchers.
LD: So you'll be having other ones in the future.
JD: Yes. This is the first annual.
LD: Will you be collaborating with, and are you in touch with other academic institutions or hospitals?
JD: In as much as our faculty comes from a number of powerful institutions, including Memorial Sloan-Kettering, Beth Israel, Harvard, University of Maryland, University of New Mexico, University of Arizona -- a number of different powerful institutions -- we will continue to collaborate with them. I don't think that there's any more formal collaboration that needs to be done. Essentially, medical conferences are done by the parent organization. They aren't necessarily...I mean they can be done in collaboration with other institutions, that certainly is not necessary.
LD: But sometimes you share information or strategies that work?
JD: I'd be happy to share that with whomever. I don't think we're in a position right now where we need to find strategies that will work for this course. I don't mean to sound smug, but I've been to lots of medical courses that were poorly attended. I've been to lots of sessions at major pain courses -- such as the APS meeting in Baltimore in March, which was a great session on Complementary Alternative Medicine -- but they were certainly not terrifically well attended, and not as well-rounded as ours. I think that this was a smash success. I don't think we're really going to need to get any help from any other institutions to make it be a success next year.
LD: You guys might end up being role models for others in the future.
JD: I welcome that. I have no proprietary stamp on this. The only thing I have a proprietary stamp on is my book. Other than that, I would like to see an equivalent of this course started on the west coast. There are a lot of people that don't want to fly across the country. I think the more we do education about pain, about the JCAHO standards, about what works and what doesn't work, how are all the different medications used, how are all the different injections used, and what else we can use from the complementary world. I support all of it.
LD: In colleges and universities, are people studying Complementary Alternative Medicine (CAM ) more and more? Is it offered in the core curriculum?
JD: About three quarters of U.S. medical schools now do an elective on Complementary Alternative Medicine, but this is still not a time where
you want to sort of cheer and throw your hands up and say, "Yeah, we won," because electives are electives. We want to see this as part of the core curriculum.
LD: So, not quite yet at Columbia nor other places.
JD: Nope. I think it's going to be a little while longer. And Dr. Weill's attitude towards this is that until you have questions on the board exams, specifically about Complementary Alternative methods, they ain't gonna to budge. They're not going to make any time. Sure, they'll do electives. They'll give you a little of this and a little of that, but they're really not going to bother to give you anything more than that, which is undoubtedly true, unfortunately.
So I think any strategy of trying to put board questions in the face of the people who make the core curriculum, I think that would be the way to go. I would support that.
LD: What's happening these days in terms of health coverage for CAM?
JD: It's kind of sleepy right now because health insurance companies have had increasing pressure on the bottom line. None of them are really making boat loads of cash right now. So, I think a lot of them are reticent to move forward with more aggressive benefits structures for complementary therapies.
The company that I work for, Oxford Health Plans, was one of the first to have, and continues to have, a terrific multi-dimensional CAM program. They actually set the standard for a lot of what you see in the marketplace today. But I don't see companies significantly strengthening their benefits right now.
There's so much pressure on the bottom line -- for all of healthcare; for all third-party payers, and for health consumers -- that I can't see a lot of companies being too aggressive with this right now.
LD: Do you know what it would take for all involved to feel that they were financially good with it?
JD: Research that shows cost-benefit offset. That's what it requires. People are working on that. We're involved in a project, along with Jery Whitworth's and John Week's group( thecollaboration.org), to try to gather some of that data, but it's tough to do and it's long-term and it's difficult. It's not easy.
LD: In your talk, you gave an example of a woman in the hospital with cancer who received a reflexology treatment and finally got a good night's sleep -- and that something as "simple" as that was very powerful.
JD: That was a story of something that I have done myself, at the bedside, with dying patients, multiple times. I've also taught family members to do this. Granted, they're not registered or trained reflexologists, but just some simple work on the feet can sometimes be so soothing.
LD: You said reflexology should be in all hospitals. Are nurses allowed to do it?
JD: Are they legally allowed? Yes. Are they fiscally allowed? Absolutely not. Nursing staffs are cut way back. There's a nursing shortage. It's hard enough just to find the basically state law mandated staff for nursing just to barely push the pills at everybody and just run the floor, much less actually doing healing.
Again, we have a crisis in healthcare which many people are talking about and acknowledging, and one of the fallouts from that is that we can barely get the bones of conventional medicine done, much less have teams of people come in to do humanitarian-type treatments to people. In our dreams, you know? Sorry.
LD: Well, dreams can come true sometimes.
JD: Absolutely, and the other point that I would make in terms of pain medicine: I think integrating some of these things into the in-patient units to help people in severe pain -- particularly in orthopedics, neurology, neurosurgery, oncology floors and rehab floors -- is a tremendous thing. But I'm still having a hard enough time getting decent conventional pain medicine instituted in hospitals, that is, getting appropriate prescribing of pain medicine to the bedside.
Getting patient-controlled anesthesia pumps, getting house staff to stop writing orders for Q4 hours IM Demerol. Horrible things are still going on that represent really Neolithic conventional pain medicine.
So, if I had a choice between having a whole bunch of great, you know sort of groovy CAM therapies in there, or tuning up conventional pain medicine -- obviously I'd go for tuning up conventional pain medicine first.
LD: There's just so much time in a day.
JD: There's just so much time in a day and there's just so much institutional effort you can make. So I would say my first priority for institutional effort would be: bare bones compliance with JCAHO Guidelines, that is, assess pain, treat pain, treat pain as the fifth vital sign. Just that. If we can do that much then we've come a long way.
LD: And the JCAHO guidelines also go on to say that educational material on CAM for pain must be offered.
JD: Offer education. There has to be educational material on pain available. There is a number of things that are sited in the JCAHO guidelines, but let's just say if I had a choice between getting good conventional pain medicine instituted on the all the floors at U.S. hospitals as opposed to getting Reiki people, I would go for the conventional medicine stuff first. I'm sorry, that's just my bias. Not everyone would agree with me, but that's just my little opinion.
LD: With your specialty of acupuncture and chiropractic -- they're thought to be a little further along in terms of getting coverage. Is that true?
JD: Well, chiropractic is further along in getting coverage than any other CAM profession, perhaps besides psychological services that are billed under conventional psychology codes.
LD: And how about reflexology?
JD: No, unfortunately. Unless you have somebody who's a cross-trained person, like a physical therapist who can go in and bill under PD codes and do some sort of massage or reflexology. Some people might argue it's being fraudulent -- cross-coding -- but I think that most people would be able to get away with that without too much trouble. Unless you can do that, it just ain't going to happen.
LD: What are your basic personal and professional goals for the future? What would you like to see happen in the next 6 months to a year?
JD: I'd like to see hospitals come into relatively complete compliance with the JCAHO Guidelines, and take pain seriously. I'd like to see
hospitals and practitioners learn more about some of the complementary therapies that can be helpful for pain -- not embracing long laundry lists of therapies.
One of the biggest mistakes that's made in the CAM arena is how everyone loves laundry lists. You talk with most CAM gurus and you say, "So what about Dr. Atkins? What do you think about Fribromyalga?" By the time Bob Atkins is done, he has given you 14 things that he thinks are helpful for Fribromyalga. You can't do that. It leaves the consumer with nothing. So, what do I do? Do I go ahead and buy all 14 things and start taking them all at once?
LD: And if it's confusing to the consumer, it's confusing to the doctor.
JD: Completely confusing. I think that this area, and complementary medicine in general, is in tremendous need of wise guidance. Not laundry lists, but wise guidance.
LD: And consolidation.
JD: Consolidation, like, what are your best bets here and why? So, I'd like to see hospitals and practitioners, perhaps going to a course such as ours, come away with a sense of, well, where's the beef? What do we really have to think about? I run a 400-bed hospital in rural Pennsylvania. I'm thinking about bringing some of these therapies in. We're trying to improve our pain teaching and pharmacatherapy in the hospital, but, what do I want to bring in?
I hope that an administrator or a chief of the medical staff coming away from our conference will be able to say, "Well, I think there are two or three things we really need to focus on right now." That for me would be marvelous. Rather than coming away with 16-17 different things that all sound marvelous and you still have no idea what to do with it.
LD: So bring it into clear focus, into doable steps.
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Copyright © 2002 The New Sun.