Queen's Medical Review Issue 7.2- May 2014

8112019 Queens Medical Review Issue 72- May 2014

httpslidepdfcomreaderfullqueens-medical-review-issue-72-may-2014 128

QMRQUEENrsquoS MEDICAL REVIEW





4 Letter rom the Editors EDITORS983085IN983085CHIEF

5 Managing Uncertainty THOMAS KRAHN 7 Op-Ed Ethical Conversation and CAM MARK BROUSSENKO

8 ND vs MD LAURA BOSCO

10 Naturopathy vs Homeopathy LOUISA HO

11 raditional Aboriginal Healing in Canada An Overview JANE KOBYLIANSKII

14 Dietician vs Nutritionist LAURA BOSCO

Interview

16 ell Your Doctor ALLISON ROSEN

18 Interview with Dr Leung STEVEN TONG

20 Whatrsquos the big deal BRANDEN DESCHAMBAULT

Re-defining Naturopathic Doctorsrsquo Scope o Practice in Ontario

23 CAMIG Quick Facts THOMAS KRAHN

23 Student Survey Opinions about CAM AERA J UNG

24 Gross National Happiness in Bhutan ADAM MOSA 26 Has she been Vaccinated SARAH LUCKETT983085GATOPOULOS

CONTENTSRECENT EVENTS

FEATURES

Te Queenrsquos Medical Review grateully acknowledgesthe financial support o Queenrsquos Alma Mater Society

Cover art provided by Louisa Ho

INTERVIEWS

OPINION

CREATIVE




httpslidepdfcomreaderfullqueens-medical-review-issue-72-may-2014 528 5 Volume 7 Issue 2 | May 201

QMRFEATURE

THOMAS KRAHN CLASS OF 2017

Managing Uncertainty

What is the appropriate answer when a patient asks theirphysician i a treatment will cure them O course

the answer depends on the circumstance who is the patientwhat is the disease and what is the proposed interventionBut in answering this question we have to acknowledge oneundamental axiom we cannot predict the uture

As the proessional creed o physicians involves a fiduciary

duty to patients it is expected that physicians act with com-plete honesty in the best interests o their patients Howeverthis becomes complicated when what is best is unclear Asthe role o the physician in the therapeutic relationship haschanged so has the role o physician as educator Physiciansmust now incorporate into their practice evidence interpre-tation and the delivery o this interpretation to patients inorder to reach the best decision or the patient

Evidence-based medicine and the rise o patient autonomyhave certainly made this decision-making process easier inmany ways or the physician When patients can be groupedinto populations with specific risk actors and treatmenteffects are known and quantified weighing the options be-comes a question o probabilities Presenting this inorma-tion to the patient or the ultimate decision in some waysrelieves physicians o the burden o the decision

Yet despite the omnipresence o evidence every physiciandeals with uncertainty By a broad definition not all med-

ical interventions and practices are based on evidence andoutcomes are never 100 Studies based on populationscannot predict the particular outcomes o individuals andwide variations in treatment effect or side effects can occurresulting in markedly different outcomes

It is useul in some ways to consider approaches to patientcare offered by practitioners o Complementary and Alter-native Medicine (CAM) While it is difficult to encompassthe variety o perspectives included in the umbrella term

o lsquocomplementary and alternative medicinersquo a ew gener-al principles can be said to be universally applicable Fun-damentally there is the claim o practitioners that CAMmodalities treat the patient with a lsquoholisticrsquo approach tohealth attending to mental psychological spiritual andsocial aspects o overall patient well-being AdditionallyCAM therapies ofen draw on practices preceding the ap-plication o the scientific method to medical interventionsconsidered the prerequisite or acceptance within the conventional medical paradigm o evidence-based medicineAs CAM therapies and health care exist outside o conven-

tional health care systems and the pharmaceutical industriacomplex research unds and studies are scarcer applicationo CAM interventions are thereore based more on tradi-tion and the experiences o the practitioners who have beentrained in their application

Interestingly studies in Switzerland and Germany reportgreater patient satisaction when CAM is included in pri-mary care Tese findings are despite the levels o uncertain-ty that exist around the field o CAM as a whole especiallywhen viewed through the lens o evidence-based medicineTese findings speak volumes about the effectiveness o thephilosophy o lsquotreating the whole patientrsquo Te treatment osome chronic diseases such as bowel disorders or back paincould certainly benefit rom an increased ocus on the allaspects o the patientrsquos well-being as the causes o these dis

eases can be idiopathic and their effects debilitating As wellthis underlines the importance o engaging in the subjectiveand emotional aspects o the healing process something o-ten ignored when ocusing only on objective results

A deeper understanding o patient values could help bridgethis gap and provide a better experience or patients as awhole People have multiple worldviews and it is not o-ten that their lie decisions are made solely on the basis oavailable evidence Tough the scientific method has yield-

ldquowe have to acknowledge one fundamental

axiom we cannot predict the futurerdquo

ldquoFundamentally there is the claim of

practitioners that CAM modalities treat the

patient with a lsquoholisticrsquo approach to health

attending to mental psychological spiritual

and social aspects of overall patient well-beingrdquo

ldquodespite the omnipresence of evidence

every physician deals with uncertaintyrdquo





QMRFEATURE

MARK BROUSSENKO CLASS OF 2016

Op-Ed

Ethical Conversation and CAMhe issue o ethics within complimentary and alternative

medicine (CAM) is one that many medical proessionalsaddress with great trepidation or not at all Tere is a hesita-tion pervasive throughout the medical community towardsdictating a patientrsquos belies regarding alternative therapiesWe worry about paternalistic attitudes and o underminingour rapport with patients who may balk at a heavy-handeddismissal o a trusted remedy A specter o racism cultural

insensitivity and plain rudeness hangs in the background oeven the most well-intentioned critique o a traditional rem-edy amily cure-all or exotic herbal concoction We want tobe prescriptive with our patients ndash take this over the counterremedy avoid those other ones save your money vaccinateyour kids herbal remedies are mostly placebo ndash yet we tendnot to Instead we retaliate against ideologies grounded inear ignorance and misinormation by doubling down onour appeals to epidemiology and science Tere are appealsto risk reduction Herd immunity Quibbles and qualifica-tions about lsquoaveragersquo lsquotypicalrsquo lsquomost people most o the timersquoNods to the placebo nocebo and gazebo effects In our earto offend our reticence to judge and paternalize we insteaddeflect with science try to shif the issue away rom the in-dividual and towards the population Te issue is not withyour decision per se but with what it would mean i every-one else did as you do

Apologists or this approach ofen reply with a sad shakeo the head a plaintive supination o the hands and a sadknowing appeal to lsquopatient autonomyrsquo Afer all who are weto tell others how to live their lives However this line oreasoning is flawed and rankly offensive

We are not so naiumlve as to orget that autonomy needs to bebalanced against the other principles those o justice be-nevolence and non-maleficence Aspects o CAM have aclear and demonstrably be shown not to adhere to theseprinciples A parentrsquos reusal to vaccinate his or her childharms not only the child (a grievous injustice in its ownright) but also those other children who are unable to be vaccinated or one reason or another and rely on the pro-tective effect o mass vaccinations to eliminate the potential

reservoir o deadly and untreatable disease Hardly just orbenevolent A patient who makes a decision based on mis-inormation alse advertising or emotional appeal is hardlyinormed and is in no way helped by our turning a blind-

eye to these issues or risk o appearing insensitive Whereis the non-maleficence in this Te case o a child who diesbecause a common inection is treated with home remediesrather than antibiotics is not a morally ambiguous situationIt is a tragedy and we would be remiss or even consideringnot intervening

Te above examples are o course laced with too much nu-ance and subtext to explore here Te conversation is notabout the finer points o biomedical ethics with respect toconronting opposing belies What we are discussing is our

abject cowardice with respect to the conversation that someelements o CAM practices are not acceptable As practi-tioners the onus is on each o us to not only respond ap-propriately when a situation like the above arises but also toactively engage with CAM wherever possible Te messagerom the medical community should be clear and unequiv-ocal Certain behaviors are unacceptable and we are re-sponsible or addressing them as such Tese conversationswill be difficult and unpleasant Some might even go poorlybut we as medical proessionals are perhaps uniquely welprepared to address such uncomortable situations Difficultconversations is a course Breaking bad news is a way o lie

Other articles in this issue o the QMR address the contento the message Tis one intends to persuade you that theconversation about dangerous CAM practices should notand cannot be optional I telling a parent that his or herchild has died is an easier conversation than one about theneed or antibiotic therapy we have a problem oo ofenthat problem is that we end up having the easier conversa-tion rather than the difficult one And that dear reader is aproblem that we cannot afford to have

ldquoWhat we are discussing is our abject cowardice

with respect to the conversation that some

elements of CAM practices are not acceptablerdquo



QMR

Queenrsquos Medical Review | qmrqmedca 8

FEATURE

ND vs MD Curriculums

Wherersquos the differenceLAURA BOSCO CLASS OF 2017

he growing popularity o complementary and alterna-tive medicine has increased the demand or naturopath-

ic doctors (ND) and led to the requent comparison betweenNDs and medical doctors (MD) regarding their knowledgebase clinical application and role in patient care Tere aretwo accredited Naturopathic Medicine schools in Canadathe Canadian College o Naturopathic Medicine (CCNM)in oronto ON1 and the Boucher Institute o Naturopathic

Medicine (BINM) in Vancouver BC2 Te CCNM acceptsapproximately 140-160 in each class whereas BINM acceptsa maximum o 35 students12 Tis article aims to compareand contrast the curriculum o their 4-year undergraduateeducational programs

Both programs emphasize a strong science background intheir training Te first year courses common to both NDand MD degrees include anatomy embryology immunol-ogy biochemistry physiology ethics and research apprais-al13 In the ND program there are additional courses thatreflect the ldquoholistic nontoxic approachesrdquo to disease preven-tion and wellness Asian medicine botanical medicine ho-meopathic medicine clinical nutrition naturopathic histo-ry naturopathic medicine and massage and hydrotherapy 3

Te second year ND curriculum expands the knowledgebase acquired in first year and introduces clinical reason-ing and diagnosis similar to the MD program While thetypical MD second year consists o systems-based coursescovering pathophysiology diagnosis and treatment relevantto each body system ND programs typically ocus on howa symptom affects onersquos entire well-being3 Courses such

as microbiology naturopathic manipulation clinical med-icine physical and clinical diagnosis practicums and phar-macology are introduced homeopathic medicine botanicalmedicine Asian medicine and clinical nutrition are con-tinued to expand the breadth and depth o knowledge andclinical application3

Te third and ourth years o the MD undergraduate pro-gram share some similarities in structure but differ in re-sponsibilities rom those o the ND program MD clerkship

involves clinical rotations in a variety o specialties andserves as an opportunity to explore and gain experience indifferent fields o medicine beore deciding on a specialtyAlthough clerks play an important role in patient care aspart o the medical team they are not directly responsibleor the patient In third year o an ND program there is anincreased proportion o clinical exposure and related cours-es pediatrics primary care emergency medicine maternal

and newborn care physical medicine radiology and menand womenrsquos health in addition to Asian medicine naturo-pathic manipulation botanical medicine and clinic hours3

In ourth year o an ND program the majority o the term iscomposed o clinic hours with courses in practice manage-ment ethics and integrated therapeutics as well3 Te clini-cal training in the third and ourth years o the ND programare ocused on preparing students to independently diag-nose and treat their own patients upon graduation3 whereasmedical student clerks are being prepared or residency

Upon graduation medical students are required to com-plete a residency program or urther training which ismandated and regulated by medical schools Naturopathicresidency programs are less common as they are not re-quired nor unded by the government Instead many na-turopathic graduates choose to shadow or practice with amore experienced naturopathic doctor to gain more clin-ical experience Te ND curriculum is designed to trainits graduates to become primary care providers and thusintroduces many specialty subjects without covering themin depth ND students are taught to recognize symptomso diseases that may all outside o their scope o practice

such as cancer in order to provide the appropriate reerralto an MD Overall both MDs and NDs aim to prevent dis-ease and improve the health and well-being o their patientsWhere MDs seek conventional modern medicine NDs seekholistic traditional approaches to treatment



QMRFEATURE

Te objectives o the ND and MD curriculums45 compare as ollows

Medical Doctor Naturopathic Doctor

History bull Elicit and interpret pertinent events rom the pa-tient amily or other sources

bull Manage the underlying spiritual social mental andphysical causes o disease

Physical Examination bull Perorm a physical examination appropriate to theage o the patient and nature o the clinical prob-lem(s) presented

No pertinent objectives listed

Investigations bull Select and interpret appropriate laboratory and oth-er diagnostic procedures that confirm the diagnosisexclude other important diagnoses or determine thedegree o dysunctionbull Perorm common procedures using the appropriateinstruments and materials

bull Integrate biomedical with clinical science knowl-edge in the assessment diagnosis and managemento patients

Clinical Judgementand Decision Making

bull Interpret pertinent data in order to1 List and prioritize a differential diagnosis or com-mon clinical problems

2 Diagnose specific common diseases3 Diagnose more rare but lie threatening diseasesbull Differentiate among acute emergency situationsacute exacerbations o chronic illnesses and seriousbut non-emergency situationsbull List the indications or specialized care andorconsultation

bull Utilize naturopathic therapeutics in the individual-ized care o patients including but not limited too Asian medicine

o Botanical medicineo Clinical nutritiono Health psychologycounselingo Homeopathic medicineo Liestyle modificationo Natural cureo Pharmaceuticals

Management Skills bull State the pharmacologic effects the clinical ap-plication including indications contraindicationsmajor side effects and interactions o commonly useddrugs

bull Collaborate effectively and work in partnershipwith other health care practitionersbull Demonstrate commitment to the advancement othe naturopathic proession

Critical Appraisal bull Evaluate scientific literature in order to assess the

benefits and risks o current and proposed methodso investigation treatment and prevention o illness

bull Appraise and apply research in treating patients

Law and Ethics bull Discuss the principles o law biomedical ethicsand other social aspects related to common practicesituations

bull Practice in a manner that exemplifies proessional-ism strong ethics and a commitment to the princi-ples o naturopathic medicine

Health Promotionand Maintenance

bull Formulate preventive measures into their manage-ment strategies ommunicate with the patient thepatientrsquos amily with regard to risk actors and theirmodification where appropriatebull Describe programs or the promotion o health in-cluding screening or and the prevention o illness

bull Manage chronic diseasebull Identiy the need or urgent and emergent healthcare and direct appropriate resolution

Please note that this list o objectives is adapted rom the Canadian College o Naturopathic Medicine (CCNM) and Medical College o Canada (MCC) websites to highligh

the similarities and differences between the proessions and is not comprehensive 45

References

1 Canadian College o Naturopathic Medicine [Accessed April 9th 2014] httpwwwccnmedu2 Boucher Institute o Naturopathic Medicine [Accessed April 9th 2014] httpwwwbinmorg3 Khalsa Guru SS Comparing ND and MD Curricula Association o Accredited Naturopathic Medical Colleges [Accessed April 9th2014] httpaanmcorgschoolscomparing_nd_md_curricula4 Program Objectives Canadian College o Naturopathic Medicine [Accessed April 9th 2014] httpwwwccnmeduprospective_studentsprogram_objectives

5 General Objectives Medical College o Canada [Accessed April 9th 2014] httpappsmcccaObjectives_Onlineobjectivespllang=englishamprole=expertampid=000



QMR


FEATURE

LOUISA HO CLASS OF 2017

he term natural medicine encompasses a number omodalities including mind-body therapies (eg art

therapy bioeedback) biologically-based therapies (egherbal products) manipulative methods (eg reflexologyosteopathy) and energy therapies (eg qi gong) As moreand more patients are becoming interested in exploringalternative medicines it is important or health care pro-essionals to amiliarize themselves with the terminologywhich can be conusing at times In particular naturopathyand homeopathy are two ofen mixed up terms while thetwo modalities are complimentary they are not the same

A naturopathic doctor (ND) is a general practitioner whohas undergone ormal training in school On the other handnaturopaths are sel-taught or were apprentice to anothernaturopath Other groups such as chiropractors massagetherapists and nutritionists may also include some naturo-pathic methods in their practice

It should be noted that a homeopath is a specific kind onaturopath with subspecialty training in in homeopathywithin naturopathic medicine Homeopathic remedies are

said to work by stimulating the intrinsic curative powerso the body Te term was coined by German doctor Sam-uel Hahnemann - ldquoAny substance which when given in astrong dose produces specific symptoms in a healthy per-son is likely i given in a homeopathic [ie infinitely smalldose to cause those same symptoms to disappear in a sickpersonrdquo

Te high dilutions characteristically used are ofen consid-ered to be the most controversial and implausible aspect ohomeopathy Comparative studies have demonstrated that

homeopathic effects are comparable to placebo effects1 inother words homeopathy simply does not work In actcurrently available scientific evidence does not support thanaturopathic medicine in general is an effective treatmentmodality or most health problems Although there is in-creased interest in integrating alternate method modalitiesor treatment o chronic conditions such as cancer mostclaims in the literature are based on individual case reportsmedical records and summaries o practitionersrsquo clinicalexperiences23

Natural Medicine Terminology

Naturopathic Medicine Homeopathic Medicine

Approach Primary care using natural medicine treatmentssupport and stimulate a personrsquos innate healingcapacity

rigger bodyrsquos natural system o healing using dilutedsubstances

Principle Vis Medicatrix Naturae(ldquoHealing power o naturerdquo)

Similia similibus curentur (ldquoLike cures likerdquo)

TreatmentModalities

Clinical Nutrition Hydrotherapy Herbal Med-icine raditional Chinese Medicine Physical

Medicine Homeopathy

ablets prepared by specialist pharmacies using aprocess o dilution and succession (a specific orm o

vigorous shaking)Regulation Regulated Health Proessions Act None

College Canadian College o Naturopathic Medicine(CCNM)

Canadian College o Homeopathic Medicine(CCHM)

Training 4 years o training at an accredited naturopathiccollege

Post-graduate specialty

Accreditation Naturopathic Physicians Licensing Examina-tions (NPLEX)

Accreditation Commission or Homeopathic Educa-tion in North America (ACHENA)

Designation Doctor o Naturopathic Medicine (ND)

A brie primer on key differientiating eatures o naturopathy and homeopathy



QMRFEATURE

JANE KOBYLIANSKII C LASS OF 2017

Traditional Aboriginal Healing in

Canada An Overview hose unamiliar with the practice o traditional Aborig-

inal healing will ofen envision a ceremony o spiritsand herbs taking place in Canadarsquos past on an Aboriginalreserve distinct rom the sphere o Western medicine In re-ality traditional healing has a sanctioned role within com-plimentary and alternative medicine and holds an import-ant position within the contemporary context o health andwellness o gain an understanding o traditional Aborigi-

nal healing and what it can offer one must first explore itshistory and progression towards the present

Traditional healing practices ndash past and present

Tere are generally three types o Aboriginal tradition-al healers herbalists medicine men and shamans Tesehealers differ mostly in the extent to which spirituality is involved in their treatment Herbalists use various plant-basedand herbal medications such as sweetgrass and sage to treatillness (and are thereore the most separated rom any spir-itualism)1 Medicine men are sanctioned to heal those thatseek their service by supernatural powers and they ollowsupernatural instructions in conducting healing rituals andceremonies1 A shaman alls into a deep trance or ecstaticstate and makes contact with spirits during healing sessionsTese healers were historically observed to perorm trickssuch as swallowing a bone and subsequently retrieving itrom the part o the patientrsquos body affected by an illness1

Tese practices clearly identiy shamans as the most spiritu-ally-guided Aboriginal healers

Prior to the landing o Europeans in Canada traditionalhealing was common and openly practiced among Aborig-inal culture2 Moreover consistent with the significant di- versity o the Aboriginal cultures with respect to geograph-ical areas languages liestyles and traditions the popularorms o healing varied significantly between groups Heal-ers living in certain cultures such as the Cree communities

demonstrated a greater understanding and propensity oruse o plants and herbs while others relied more on super-natural acts and belies during their healing services1

Afer colonial contact discouragement and ormal legisla-tion resulted in the prohibition o many Aboriginal tradi-tions including several healing practices In 1880 the Indi-an Act was amended to include the first o many regulations

that prohibited engaging in or acilitating certain healingapproaches especially those involving shamanistic acts anddances2 Fear o prosecution led to the gradual loss o thesepractices and the knowledge required to perorm them thehealing acts that endured were largely practiced in secret2

It was only in the early 1950s that the Indian Act was amend-ed to remove bans on traditional Aboriginal rituals2 In the1980s Aboriginal medicine and healing methods began tore-emerge reflecting a need or Aboriginal individuals toreclaim their lost culture1 Many writers on Aboriginal tra-ditional healing emphasize that this reclamation o spiritu-ality and culture through healing practices was necessitatedby the consequences o the suffering inflicted by residentialschools and other aspects o colonialism2 Several Aborig-inal communities plagued by alcoholism and addictionsuch as Alkali Lake in British Columbia revitalized certainpractices like the sweat lodge and healing circles in orderto successully address these issues by reintroducing cultureand spirituality into the lives o those affected1

Presently traditional Aboriginal healing services are uti-lized by both Aboriginal and non-Aboriginal people acrossCanada especially in urban settings Data collected by the2006 Aboriginal Peoples Survey indicates that about 35per cent o Metis people living in urban areas have accessto traditional medicines3 Similarly both Aboriginal and

ldquoThere are generally three types of

Aboriginal traditional healers herbalists

medicine men and shamansrdquo

ldquoPresently traditional Aboriginal healing

services are utilized by both Aboriginal and

non-Aboriginal people across Canadaespecially in urban settingsrdquo



QMR


FEATURE

non-Aboriginal patients seek out various types o customaryhealing services raditional Aboriginal treatment centersacross Canada now offer popular services like healing cir-cles smudging and certain spiritual ceremonies4-6 Healingcircles and smudging may be more amiliar than the latter

Healing circles are group therapeutic sessions occasionallyconducted by shamans who seek to address physical socialand spiritual concerns7 Smudging is a orm o ritual cleans-ing that involves burning a medicine plant and directing thesmoke to areas o the body that require healing8 Spiritual

ceremonies ofen include sweat lodges which are cleansingrituals held by medicine men in a ceremonial sauna7 andshaking tent ceremonies which involve the construction oa lodge that allows the entrance o spirits encouraged by theshaman leading the ceremony9 One o the most amiliar andwidely used tools in the treatment centers that offer tradi-tional Aboriginal healing is the medicine wheel a symbol oAboriginal healing that includes the ours directions ndash NorthEast South West ndash and represents the our aspects o healthand vitality ndash mental emotional physical and spiritual10 Tis concept is used as a tool to emphasize the need or bal-

ance between these valued dimensions o Aboriginal livingas well as the holistic approach used in traditional healing10

Presently Health Canada recognizes traditional Aboriginalhealing within the sphere o complimentary and alternativemedicine11 Tese practices are no longer discouraged andprohibited as they were during colonialism Indeed the 1994Aboriginal Health and Wellness Strategy or Ontario statesldquotraditional Aboriginal approaches to wellness includingthe use o traditional resources traditional healers medi-cine people mid-wives and elders are recognized respectedand protected rom government regulation Tey enhance

and complement healing as well as programs and servicesthroughout the health systemrdquo12 Te Regulated Health Pro-essionals Act in Ontario (1991) urther supports the specialplace o Aboriginal traditional healing within conventionalhealth care Tis Act provides an exemption to the clausethat no individual except a regulated health proessional mayprovide medical services thus allowing Aboriginal healersand midwives to provide traditional healing or midwieryservices to Aboriginal patients13

Te Canadian government and medical community especial-ly recognize the validity and effectiveness o Aboriginal tra-ditional healing within the realm o mental health In 1983a special report rom the department o National Health andWelare Canada stated ldquoWe have come to appreciate very

much the relevance and the utility o traditional approachesparticularly to mental health problems ndash approaches whichaddress the suicide rate approaches which address addictionproblems We believe that in areas such as those the applica-tion o traditional medicine and native culture perhaps canbe more successul than anything we could offer in terms ocontemporary psychiatric approachesrdquo14

Concurrent use of traditional Aboriginal and biomedica

health services

It has gradually become commonplace to see traditionahealing rituals and practices perormed in hospitals clinicsor other institutions1 More recently specialized Aboriginahealth centers providing traditional healing services havebecome established such as the Kingston local KatarokwiNative Friendship Centre ounded in 1992 which offers a

traditional healing and wellness program5

Te widespreadavailability o traditional Aboriginal healing modalities evenin urban environments creates a setting o medical plural-ism1 raditional healing services offered in this contextare ofen used concurrently with contemporary biomedicaservices by many Aboriginal and non-Aboriginal patientsWaldram suggests several explanations or patientsrsquo decisionto utilize both It is possible that Aboriginal patients use thebiomedical system or alleviation o symptoms o their ill-ness but then attempt to address its etiology through a holis-tic Aboriginal approach Alternatively patients may in des-peration seek any and all possible treatment or turn to one

system when the other has ailed them1

Ultimately in order to allow or these practices to occurwithin the context o sae patient care both the contem-porary biomedical health care provider and the traditionalhealer must be aware o the medical pluralism taking placeDue to the paucity o evidence or the efficacy o traditionalAboriginal healing in the treatment o physical illness phy-sicians may be tempted to dismiss use o these services asludicrous creating a situation that threatens the saety o the



non-Aboriginal people across Canada

especially in urban settingsrdquo

ldquoIt has gradually become commonplace to see

traditional healing rituals and practices

performed in hospitals clinics or other

institutionsrdquo



QMRFEATURE

patient1 On the other hand some traditional healers mayrequire that patients discontinue any prescription medica-tions prior to taking part in a ceremony or ritual1 In 2001Jane Maiangowi an elder in the Wikwemikong communityin Ontario died during a three-day spiritual ceremony led

by a visiting shaman who instructed her to discontinue heroral hypoglycemic diabetes medication prior to engaging inthe service15 Moreover certain herbal medicines may neg-atively interact with conventional medications resulting inpotential harm or the patient i not recognized1 Finally dueto the recent increase in popularity o alternative medicineamong the general population there have been New Ageadaptations o traditional Aboriginal healing practices thathave resulted in harm to those seeking their services1 Forexample in 2009 three individuals died during a sweat lodgeconducted improperly in Sedona Arizona as part o a com-mercial retreat16 Due to the unregulated nature o Aborigi-

nal traditional healing ensuring that patients are reerred tocommunity-validated healers is crucial or avoiding poten-tially dangerous New Age services and subsequent compli-cations1 Te use o traditional healing services poses certainissues that may compromise patient wellness within the con-temporary context

Despite such concerns the philosophy that underlies manytraditional Aboriginal healing practices has much to offerto practitioners o contemporary biomedical medicine Asdemonstrated by the medicine wheel and the inusion oemotion and spirit into each healing ceremony traditionalAboriginal healers use the notion o holistic healing and re-use to treat the body and mind separately Tis philosophyspeaks to the whole patient approach commonly soughtwithin contemporary medicine Further although physi-

cians practicing Western medicine must be skeptical o treat-ments not validated by biomedical research it is importantto not become cynical o other therapies and to remain opento recognizing their benefits Especially when working withan Aboriginal patient population within the psychosocial ormental health context contemporary medicine could trulystand to benefit by encouraging physicians to reer to a com-munity-validated Aboriginal traditional healer or healingcenter where available1

References

1 Waldram James B Herring Ann and Young Kue Aboriginal health in Canada historical cultural and epidemiologicalperspectives 2nd ed oronto [Ont] University o oronto Press2006 Print2 Robbins Julian Dewar Jonathan ldquoraditional Indigenous Approaches to Healing and the modern welare o raditional Knowledge Spirituality and Lands A critical reflection on practices andpolicies taken rom the Canadian Indigenous Examplerdquo Te International Indigenous Policy Journal 24 (2011) 23 Janz eresa urner Annie Seto Joyce ldquoAboriginal PeoplesSurvey 2006 An overview o the health o the Meacutetis populationrdquoStatistics Canada Social and Aboriginal Statistics Division 20094 ldquoServicesrdquo Anishnawbe Health oronto (AH) lthttpwwwahtcaservices-and-programsservices-offeredgt5 ldquoKatarokwi Native Friendship Center - Aboriginal Healing andWellnessrdquo South East Health Line lthttpwwwsoutheasthealth-linecadisplayServiceaspxid=72390gt

6 ldquoCultural Activitiesrdquo Nenqayni Wellness Centre lthttpwwwnenqaynicomprogramscultural-activitiesgt7 ldquoraditional Aboriginal Medicinerdquo University o Ottawa Aboriginal Health 2009 lthttpwwwmeduottawacasimdataAboriginal_Medicine_ehtmgt8 ldquoGifs rom the Creator or manrsquos use - Te smudging ceremonyrdquoAMMSA 1998 lthttpwwwammsacomnode12407gt9 Robbins Julia ldquoGathering echnical Report GEGENOAAOLIMG Sharing the Knowledge Elsipogtog First Nationrdquo Na-tional Aboriginal Health Organization 200810 Dapice Ann N ldquoTe medicine wheelrdquo Journal o ransculturaNursing 173 (2006) 251-26011 ldquoComplementary and Alternative Healthrdquo Public Health Agen

cy o Canada 2008 lthttpwwwphac-aspcgccachn-rcscah-acps-engphpgt12 Crouch Robert et al ldquoComplementaryAlternative HealthCare and HIVAIDSrdquo Canadian Strategy on HIVAIDS 200113 Regulated Health Proessions Act 1991 SO 1991 c 18lthttpswwwe-lawsgovoncahtmlstatutesenglishelaws_statutes_91r18_ehtmBK35gt14 Penner Keith Indian Sel-Government in Canada Report othe Special Committee on Indian Sel-Government Ottawa Houseo Commons 198315 Dub Francine ldquoWoman dies in healing ritual shaman guiltyrdquoReligion News Blog 25 Apr 2003 Web lthttpwwwreligionnewsblogcom3132woman-dies-in-healing-ritual-shaman-guiltygt

16 Dougherty John ldquoSweat Lodge Deaths Bring Soul-Searchingto Area Deep in Seekersrdquo Te New York imes 11 Oct 2009 Weblthttpwwwnytimescom20091012us12lodgehtml_r=0gt

ldquoDue to the unregulated nature of Aboriginal

traditional healing ensuring that patients are

referred to community-validated healers is cru-

cial for avoiding potentially dangerous New Age

services and subsequent complicationsrdquo



QMR


FEATURE

LAURA BOSCO CLASS OF 2017

Confusing Terminology

Dietician vs Nutritionist

Dietician

ldquoDietitianrdquo is a protected title indicated by RD PDt or DPtafer onersquos name Becoming a dietitian requires a bachelorrsquosdegree in ood and nutrition rom a university program ac-credited by Dieticians o Canada1 Tese programs ocuson basic sciences social sciences and communications aswell as proession-related courses such as ood science dis-ease-specific courses community nutrition and ood service management2 Following the undergraduate programone must apply or a post-degree internship or a masterrsquospracticum both o which are highly competitive Te in-ternships are sponsored by hospitals or other care acilitiesand typically last 35ndash40 weeks1 Te masterrsquos practicum pro-grams are run through the accredited university programand can be thesis or non-thesis based Te practicum expe-

rience is incorporated into the curriculum design where theuniversity organizes the placements1 In addition there areprograms that integrate the undergraduate program and theinternship where some or all o the admitted students areprovided placements

Afer training is completed dieticians must register withProvincial Regulatory Bodies and are the only proessionalswho can use the protected titles ldquoRegistered Dieticianrdquo ldquoPro-essional Dietitianrdquo and ldquoDietitianrdquo1 Registrants must passthe national Canadian Dietetic Registration Examinationadministered by the provincial regulatory body 3 In Ontario

the regulatory body is the College o Dieticians o Ontario3Afer registration dietitians are accountable to their provin-cial body or proessional conduct the quality o their careand ethical practice3

Te responsibilities o a dietitian include providing advicearound diet ood and nutrition2 Dietitians help peoplemake healthier ood choices and establish healthy eatingplans to promote health and prevent chronic illness such ahypertension cardiovascular disease and diabetes2 Teyalso advise the government on population-wide strategies tochange the type o advertising to children and the status oschool nutrition guidelines and to implement policies andguidelines in processed ood production and marketing2

Nutritionist

In contrast the term ldquonutritionistrdquo is not protected by any lawor governing body Anyone may reer to him or hersel as anutritionist as no ormal training or certification is requiredNutritionists may support or promote any eating plans o

habits to their clients and they are not bound by the ethicaand proessional practices o dietitians

Te term ldquonutritionistrdquo has been commonly associatedwith holistic medicine where there is less ocus on evidence-based diets and eating plans and a greater ocus on

natural alive and good-quality oods or physical emotional and spiritual well-being4 Tere are educational programin Natural Nutrition and Holistic Nutrition however theseare unregulated and lack governmental accreditation4 Nutritionists are ofen sought afer when conventional medicines ail to yield the desired results or when the patienwould preer to put off conventional medicines until otheravenues have been explored1 However dietitians also utilizholistic approaches in treatment as they are trained to take

he terms ldquodietitianrdquo and ldquonutritionistrdquo are ofen and incorrectly used interchangeably It is however important or healthcare proessionals to understand the difference between these terms when reerring patients or nutritional consultations

ldquoThe responsibilities of a dietitian

include providing advice around diet

food and nutritionrdquo

ldquoNutritionists may support or promote any

eating plans or habits to their clients and

they are not bound by the ethical and

professional practices of dietitiansrdquo



QMRFEATURE

a nutrition-based approach to illness disease prevention andhealth promotion Tey communicate with the medical teamand they are part o government-regulated health services2

In conclusion choosing between a dietitian and nutrition-ist is a personal choice however dietitiansrsquo provincial reg-ulation establishment in the medical community and evi-dence-based plans make them the better choice or mostnutritional consultations

References

1 Difference between Dietitian and Nutritionist Dietitiano Canada [Accessed April 9th 2014 Updated 2013]httpwwwdietitianscaind-a-dietitiandierence-between-dietitian-and-nutritionistaspx

2 What does a dietitian do Dietitians o Canada [AccessedApril 9th 2014 Updated 2013]httpwwwdietitianscaFind-A-DietitianWhat-does-a-Dietitian-doaspx3 About Registered Dietitians College o Dietitians o On-tario [Accessed April 9th 2014 Updated March 26th 2014]httpwwwcollegeodietitiansorg4 What is a holistic nutritionist Canadian School o NaturaNutrition [Accessed April 9th 2014 Updated 2013]httpwwwcsnncaaboutwhat-is-a-holistic-nutritionist-holistic-nutrition

ldquoNutritionists are often sought after when

conventional medicines fail to yield the desired

results or when the patient would prefer to put

off conventional medicines until other avenues

have been exploredrdquo



QMR


INTERVIEW

ALLISON ROSEN CLASS OF 2016

Tell Your Doctor

Faculty Perspectives ndash Dr Reid

Dr Robert Reid an Obstetrician at Queenrsquos lectures studentsabout menopause In this class he outlines hormone therapiesand other treatments to minimize the symptoms o meno-

pause He emphasizes that apart rom hormone therapy anyeffect o other methods is at most placebo effect

Dr Reid does not believe the topic o CAM has been welladdressed in the Queenrsquos curriculum He expanded on histhoughts about CAM regulation ldquoMy view is that alterna-tive therapies should be held to the same standards o sci-entific proo that other therapies are held to Unortunate-

ly the Canadian government let many o these [alternativetherapies] into the system under the designation o lsquooodproductsrsquo instead o lsquomedicinesrsquo Te government has madea recent effort to correct this but those products already onthe shelves are lsquograndatheredrsquo meaning they donrsquot have tomeet any scientific standards Tis is why there are counters

ull o alternative therapies in every drug storerdquo Most med-ical students are unaware o this regulatory process I wewere better aware o regulatory mechanisms then we couldeducate patients that just because something is in the aisleor ldquocolds and flusrdquo it does not mean that the product wastested and shown to be effective or that purpose But beorewe can educate patients on selecting the best treatment we

must first have better oundational knowledge about regula-tory bodies and procedures

Study afer study has highlighted just how widespread the use o complementary and alternative medicine (CAM) is amongpatients Yet the same studies emphasize that very ew patients disclose these practices to physicians12 Tis poses an evi

dent problem since it is critical or physicians to know all substances a patient is ingesting in order to provide good care asome substances may have adverse interactions

As medical students we are told by our amilies patients and proessors the importance o compassion and communicationSo why do patients eel the need to hide so much rom us

When among colleagues many medical practitioners scoff at the notion o CAM - rolling their eyes at stories o patients whohave tried Reiki or a lsquodetox dietrsquo beore seeking the medical care we know in our hearts and minds to be the right course oaction

Terein lies the problem

As medical practitioners we see the dangers o delays in seeking treatment We see the harms caused by alse hope We seethe desperation to do something anything to try and help a loved one Trough exposure to these scenarios we may becomeangry But does this response really help our patients Te more important question to ask may be the one o preventing thicommunication gap in the uture Te QMR turned to the Queenrsquos aculty to learn more about the place or CAM in medicaeducation

ldquobefore we can educate patients on selecting

the best treatment we must first have better

foundational knowledge about regulatory

bodies and proceduresrdquo ldquoalternative therapies should be held to the

same standards of scientific proof that other

therapies are held tordquo

ldquojust because something is in the aisle

for ldquocolds and flusrdquo it does not mean thatthe product was tested and shown to be

effective for that purposerdquo



QMRINTERVIEW

Faculty Perspectives ndash Dr Racz

Dr William Racz delivers a lecture on herbal medicine to med-ical students each year

ldquoMedical students as uture practitioners need to be awarethat a significant portion o the Canadian population are[sic] using herbal medicines and do not disclose this act totheir health care providersrdquo Dr Racz states echoing the sen-timent o the medical practice as a whole In his lecture hehopes to emphasize that just because something is lsquonaturalrsquoit doesnrsquot mean that the substance is not toxic ldquoWe need toacknowledge that the patient has the right to be involved inthe decision as to the nature o their treatmentrdquo he pointsout Dr Racz urther suggests that medical students discussthe evidence o a particular herbal medicine with patients

Tis is particularly important since many herbal medicationscan interact with traditional allopathic medicine

ldquoTe medical student should be aware that these productsexist are being used by the general population and use o

herbals can have significant impact on the patientrsquos manage-mentrdquo Dr Racz emphasizes

ldquoSome medical practitioners may elect to use herbals or thetreatment o mild orms o certain disease states Tis is aproessional choice but as a pharmacologist I still want toteach evidence-based therapeuticsrdquo

Dr Racz has advice or medical students grappling with thisissue ldquoTe uture physician should seek and find evidenceor the efficacy and toxicity o herbal products and decidewhether to use or recommend these products based on ariskbenefit analysisrdquo Dr Racz points out that this is no di-erent than what we should do or drugs o all categories

While scientifically sound studies o CAM were hard to findin the past recent interest has spurred many studies ldquoTesestudies and review articles are key to any discussion o therole o these agents in therapeuticsrdquo Dr Racz points out

Itrsquos Time You Had the Talk

It is worrying to think that such a large number o patientsbelieve that not disclosing CAM use is the best choice o ac-tion However steps can be taken to improve patient trust

and to educate patients While most patients may believedoctors to scorn CAM and judge those who turn to thesemodalities a more accurate statement may be that doctorsrightully mistrust unproven treatment modalities and thatthis mistrust is in the patientrsquos best interest

Medical proessionals must be educated on how medicationsand other treatments are regulated and must communicateour intentions and biases clearly and openly to patients Onlythen can one can hope or a more open patient-physician interaction and more harmonious and evidence-based deci-sions regarding treatment options We just may find that weattract more flies with honey than with homeopathic vinegar

References

1 Tomson P Jones J Evans JM Leslie SL 2012 Factors influencing the use o complementary and alternativemedicine and whether patients inorm their primary careposition Complementary Terapies in Medicine 20 45-532 Davis EL Oh B Butow PN Mullan BA Clarke S2012 Cancer patient disclosure and patient-doctor commu-nication o complementary and alternative medicine use asystematic review Te Oncologist 17 1475-1481

ldquoMedical students as future practitioners

need to be aware that a significant portion of

the Canadian population are [sic] using

herbal medicines and do not disclose this

fact to their health care providersrdquo

ldquoWhile most patients may believe doctors to

scorn CAM and judge those who turn to these

modalities a more accurate statement may be

that doctors rightfully mistrust unproven

treatment modalities and that this mistrust is

in the patientrsquos best interestrdquo



QMR


INTERVIEW

STEVEN TONG CLASS OF 2017

Interview with Dr Leung

QMR Why did you choose to study traditional medicine

Dr Leung Like every clinician you get kind o sel-revela-tion once in a while Afer practicing in Hong Kong I elt very rustrated that there were so many gaps in Western

medicine such as in the areas o chronic pain headacheinsomnia and depression I elt mysel repeating the samething to patients ldquothis is the most I can help you therersquos nobetter treatmentrdquo so being Chinese I asked mysel ldquohmmmChinese medicine has been around or 4-5 thousand yearsthere must be something thererdquo Beore we knew it bothmy wie and I signed up or a course and posted to Guang-zhou or first raditional Chinese Medicine hospital

QMR Was it difficult to learn traditional medicine afertraining in western medicine

Dr Leung Itrsquos almost like splitting your brain I see myselable to complete my training because itrsquos like learning anew language Terersquos a huge dropout rate or physicianswith Western training as itrsquos a completely new paradigmChinese medicine is about balance and incorporating allthe elements o the universe Itrsquos too vague or westernmedicine

QMR How do you fit both in your practice

Dr Leung Complementary and western medicine is simi-

lar as Western medicine has realized that itrsquos about systemsbiology so I look at it this way I I see a patient I assessthem rom a western medicine point o view but [i theyare] not responding to western medicine then I withdrawand look at the entire case rom the perspective o Chinesemedicine I see them as a new patient and see them rom adiagnostic theory rom a traditional medicine perspectiveItrsquos very ascinating because you look at it rom an individ-ual treatment For example some patients may not respondwell to acupuncture so I give them herbs Itrsquos individual-

ized its individual therapy

QMR How do you deal with people who tell you therersquos noevidence or Chinese medicine

Dr Leung Itrsquos like asking why apples are apples and not anoranges itrsquos comparing two different things Tey are bothruits and similarly both western and traditional medicinewant patients to do well Te only weak point o any brancho CAM is the lack o evidence But when you look at EBMitrsquos about a very strict or even inflexible route o reachingthe peak o the pyramid o evidence You compare peoplewho are very different But this is not what alternative isabout itrsquos basic itrsquos rom antiquity that you are unique andnot supposed to compare with other people So i you useEBM to look at traditional medicine they are bound to ail

QMR How do you think CAM fits in terms o medicaleducation

Dr Leung First I think ground work needs to be laidand you guys need to accept the broadness o medicine Isee medicine like any branch o biological sciences thereshouldnrsquot be one single way to reach the answer Just likemedicine i a patient is sick you should be able to enter-tain more than one way o pathology Finally one thing Ihope to see beore I retire is the importance o wellnessWhat we want to do is make the patient well itrsquos not just

the physique Health is both the mind and the body Wehave to work on the well-being o the body and mind inparallel I really want students o the next generation to in-corporate this And then acknowledge that there are someother paradigms that exist and may offer better options todeal with the wellness o the patients Only through explor-ing other avenues can we really treatment the wellness opatients

QMR How can we improve CAM in medical education

Q MR had a chance to sit down with Dr Lawrence Leung a aculty member at Queenrsquos with training in raditional Chinese Medicine Dr Leung obtained his MD at Cambridge University and subsequently trained in the UK and Hong Kong beore

practicing in Canada Hersquos also completed a specialized program or raditional Chinese Medicine in Guangzhou Join us or hisinteresting perspective on CAM in medicine and medical education



QMRINTERVIEW

Dr Leung Get more physicians trained in CAM and givethem the due respect

QMR What would you like to tell all the young medicalstudents about CAM

Dr Leung From antiquity we are taught about linear cau-sality But itrsquos isnrsquot how it is there are many actors that enterthe equation We really need to stop neglecting other as-pects o patient wellness and what they need to be well andeel well Tey need to be conversant and not completelybias about other avenues o treatment Irsquom not saying CAMis better than Western medicine no but that this aspect omedicine should be exposed to students In a survey oneo my students ound that 85 o patients would like more

communication about CAM Be conversant

QMR Do you think there is a disconnect between whatpatients want and what doctors know about CAM

Dr Leung Yes definitely there is a dichotomy Patients useCAM whether we like it or not and we need to maintainthe physician-patient relationship be being inormed aboutCAM Tere could be negative interactions and that canbe harmul to patient especially i they are scared to speakto their doctors about it We need to be conversant benon-judgemental and open to speak about it

QMR You clearly have lived in many different countriesand experienced many different cultures what are theattitudes towards alternative medicine in other countries incomparison to Canada especially in physicians and medicalstudents

Dr Leung I come rom Hong Kong so itrsquos very dominat-ed by western medicine but lately I think the tables haveturned Schools are training young traditional medicinestudents and the stats are turning around In Europe itrsquos

definitely something people respect Other countries likeJapan or Korean the government allows people to use tra-ditional medicine under medical insurance UnortunatelyCanada is one o the countries that lack behind immenselyin turns o acceptable and unding CAM

QMR Tank you or sitting down with us and sharinginsights and perspective



QMR


INTERVIEW

In late 2013 with both sides firmly claiming adherenceto the highest principles o patient centered care it took

more than a glance to distill the motives or the polarizedresponses to the revised regulations or the Naturopathy Actdrafed by the ransitional Council - College o Naturopathso Ontario (C-CONO) On one side the Ontario Associa-tion o Naturopathic Doctors1 (OAND) suggested the needor urther broadened scope o practice while on the oth-

er the Ontario Medical Association2 (OMA) and Collegeo Physicians and Surgeons o Ontario3 (CPSO) argued ormore restriction

From a historical perspective it is worth considering thatnaturopathic doctors (NDs) remain regulated under theDrugless Practitioners Act o 1925 in Ontario which pro-hibits them rom perorming surgery midwiery and pre-scribing or administering drugs or anesthetics Howeverthe proession was lef in a legal grey zone in terms o whatdefines their scope o practice despite the transition o sim-ilarly regulated physiotherapists chiropractors and massagetherapists to the Regulated Health Proessions Act (RHPA)ramework o 1991 More than a decade later in 2007 a

Health Systems Improvement Act was approved which in-cluded provision or the regulation o NDs under the RHPAand their governance by a newly created Naturopathy Act2007 ndash which remains unproclaimed to this day

Te C-CONO is a transient body that was initiated towork with the Ministry o Health and Long-erm Care(MOHLC) and external stakeholders (ie OAND OMACPSO) Te group is responsible or setting up the rame-work or the College o Naturopaths o Ontario to unction

which will include our distinct components outlining Au-

thorized Acts Regulation Proessional Misconduct andQuality Assurance

o become a ND in North America candidates must com-plete a baccalaureate degree and be selected or admissionto one o the seven accredited schools o which the Ca-nadian College o Naturopathic Medicine (CCNM) is theonly in Ontario Students receive our years o training inbasic sciences naturopathic medicine and holistic primarycare Currently there are only 5 provinces in Canada thatrecognize ND licensure ndash including Nova Scotia Manito-ba Saskatchewan Alberta and BC Many NDs believe the

regulatory transition in Ontario will leave their proessioninappropriately restricted and cite jurisdictions such as BCwhere they can perorm minor surgery and utilize ultra-soundxrays or diagnostic purposes4

In order to best evaluate this controversy rom balancedperspective I engaged Dr Christopher Knee who recentlycompleted his ND training at the CCNM and just openeda practice in Te Dempster Clinic in oronto Irsquoll first tryto briefly present some broad stroke criticisms o my ownabout the OAND perspective and then provide Dr Knee

the opportunity to reute and offer his own thoughts

I would like to premise the ollowing statements with thedisclaimer that I personally do believe that NDs contributean important dimension to preventive primary care andco-management o chronic diseases However the emergingbody o research the OAND cites ndash claiming that naturo-pathic care can improve outcomes or hypertension type 2diabetes chronic pain and anxiety ndash has important meth-odological deficiencies that limit their broader applicability

BRANDEN DESCHAMBAULT CLASS OF 2016 amp DR CHRISTOPHER KNEE ND

Whatrsquos the big deal Re-defining Naturo-pathic Doctorsrsquo Scope of Practice in Ontario

ldquoOn one side the Ontario Association of

Naturopathic Doctors 1 (OAND) suggested the

need for further broadened scope of practice

while on the other the Ontario Medical

Association 2 (OMA) and College of Physicians

and Surgeons of Ontario3 (CPSO) argued for

more restrictionrdquo

ldquoMany NDs believe the regulatory transition in

Ontario will leave their profession inappropriate-

ly restricted and cite jurisdictions such as BC

where they can perform minor surgery and utilize

ultrasoundxrays for diagnostic purposesrdquo



QMRINTERVIEW

In the context o prevention o cardiovascular diseases theOAND cites research rom Seely et al which compared en-hanced usual care by amily physician to enhanced usualcare with the addition o naturopathic care (including dietliestyle and natural health product recommendations) ina population o randomly assigned Canadian Postal Work-ers at elevated baseline risk Te primary outcomes were as-sessed using the Framingham Risk Score and prevalence o

Metabolic Syndrome over one year At 52 weeks the naturo-pathic group (n=124) had significantly better FraminghamRisk Scores and a lower adjusted requency o MetabolicSyndrome than the control group (n=122)5 However theauthors did not report on the relative proportions o eachgroup that were receiving medication or hypertension hy-perlipidemia or diabetes at baseline Conveniently the samegroup went on to publish a cost-effectiveness analysis usinga subset o the same population which revealed that the na-turopathic group had a significantly greater number o in-dividuals on anti-hypertensives as well as medications ordiabetes and hyperlipidemia6 In the later paper the authors

rationalized this difference as a product o multiple compari-sons and ailed to consider it as a conounder Flawed studiessuch as this do little to urther the case or co-managementbetween MDs and NDs

Dr Knee -ldquoTe study you mentioned was pragmatic in nature and de-signed as such Demonstrated benefit o naturopathic carewas modest yet significant Tis is what I would consid-er a lsquobreakthroughrsquo study that will hopeully lead to largercontrolled trials with specific endpoints While not all spe-

cific aspects o the ND scope o practice can be supportedby modern clinical trials there is a demand by the proes-sion to allocate adequate resources towards building the ev-idence base or the proession through increased researchefforts and community partnerships Additionally there is astrong lsquohistorical usersquo component o the proession which issupported by Health Canada and the MOHLC and I amunder the impression that much o the supportive evidenceprovided relates to the proven track record o saety in areas

where this expanded scope o practice has already been inplace (such as in BC or select US states) and through de-cades o empirical use Further it is my belie that there isproven demand or additional care in a wide variety o con-

ditions where relevant aspects o dietary and liestyle coun-seling and many other naturopathic services are currentlynot being provided Certainly it would be ideal i there isopportunity or co-management with an MD as this allowsor co-education surrounding treatment approach and caseunderstanding improved patient saety and care and pro-motes efficient use o health care resources A perect exam-ple o this collaboration is evidenced by the recent successo the Brampton Hospital Naturopathic eaching Clinic thefirst Canadian outpatient naturopathic clinic to exist withina hospital settingrdquo

Furthermore ollowing the applauded launch o ChoosingWisely Canada7 and the heightened scrutiny surroundingphysicians ordering diagnostic testing there are well inten-

tioned concerns about ND access to these publically undedservices For instance even amongst primary care physiciansthere is considerable uncertainty surrounding use o ProstateSpecific Antigen (PSA) testing or prostate cancer screeningdue to the inherent issues with sensitivity and specificity andspecifically whom to screen and when reerral to a urologistis appropriate8 Tus i NDs were permitted to order PSAtesting without experience in identiying high risk patientsdiscussing relative merits and uncertainties associated withscreening or the reerral and treatment process this canpose as a recipe or inappropriate or redundant testing withthe potential to cause considerable unnecessary distress or

patients

ldquothe emerging body of research the OAND cites

ndash claiming that naturopathic care can

improve outcomes for hypertension type 2

diabetes chronic pain and anxiety ndash hasimportant methodological deficiencies that

limit their broader applicabilityrdquo

ldquoit would be ideal if there is opportunity for co-management with an MD as this

allows for co-education surrounding treatment

approach and case understanding improved

patient safety and care and promotes efficient

use of health care resourcesrdquo

ldquofollowing the applauded launch of Choosing

Wisely Canada7 and the heightened scrutiny

surrounding physicians ordering diagnostic test-

ing there are well intentioned concerns about ND

access to these publically funded servicesrdquo



QMR


INTERVIEW

Dr Knee -ldquoIn my opinion NDs would and should be responsible ormaking evidence-based clinical decisions surrounding all as-pects o care including history and intake physical examina-tions ordering o diagnostic tests and in developing appro-priate treatment plans Understanding the evidence or andagainst any diagnostic test including sensitivity and speci-

ficity and patient education regarding the choice to undergodiagnostic testing is an inherent responsibility o NDs I donot solely rely on a PSA reading as a means or screeningprostate cancer instead I combine this inormation with rel-evant clinical findings such as the patients personal healthhistory amily risk actors dietary and liestyle actors re-lated to cancer risk and physical examination findings suchas the digital rectal exam Having access to a relatively inex-pensive test such as the PSA could allow me to continue toprovide care while promoting chronic disease prevention ndashcertainly i in my clinical findings and judgment the patientbegan to elicit signs o prostate cancer I could reer them

or RUS or to an MD or oncologist or assessment Tispromotes efficient use o health care resources (financiallyand in MD accessibility) while allowing or additional andrequent patient ollow-up and monitoring It should also benoted that the financial cost associated with these tests wouldnot be relevant as it is expected patients will continue to payout-o-pocket under the new regulationsrdquo

I eel honored and proud to be able to engage my riend andproessional colleague in this productive discussion Medi-cal students should recognize the value o naturopaths in a

mixed care model and the rapidly growing demand or theirservices Ultimately we should be united in our call or con-tinuing cooperation between our respective governing col-leges and representative associations in defining our over-lapping yet distinctly different models or preventing andtreating chronic disease As Osler said ldquoTe good physiciantreats the disease the great physician treats the patient whohas the diseaserdquo Our ND colleagues undoubtedly have muchto teach us in the latter regard

References

1 Ontario Association o Naturopathic Doctors (2013)Submission to ransitional Council o the College o Na-turopaths o Ontario (tC-CONO) [ONLINE] Available

at httpwwwcollegeonaturopathsoncaimagesstoriesCONOControlled_Acts_Consultationoandpd [Accessed17 April 2014]2 Ontario Medical Association (2013) Submission to theransitional Council o the College o Naturopaths o On-tario Draf Regulation to the Naturopathy Act [ONLINE]Available at httpwwwcollegeonaturopathsoncaimag-esstoriesCONOControlled_Acts_Consultationomapd[Accessed 17 April 2014]3 Te College o Physicians and Surgeons o Ontario (2014)Submission to the ransitional Council o the College o Na-turopaths o Ontario Draf Regulation to the NaturopathyAct [ONLINE] Available at httpwwwcollegeonaturo-pathsoncaimagesstoriesCONOControlled_Acts_Consultationcpsopd [Accessed 17 April 2014]4 Naturopathic Physicians Regulation (2014) Naturopathic Physicians Regulation [ONLINE] Available at httpwwwbclawscaEPLibrariesbclaws_newdocumentIDreeside282_2008section4 [Accessed 17 April 2014]5 Seely D Szczurko O Cooley K Fritz H Aberdour S et al(2013) Naturopathic medicine or theprevention o cardiovascular disease a randomized clinicatrial CMAJ Jun 11185(9)E409-16

6 Herman PM Szczurko O Cooley K Seely D (2014) Anaturopathic approach to the prevention o cardiovasculardisease cost-effectiveness analysis o a pragmatic multi-worksite randomized clinical trial J Occup Environ Med2014 Feb56(2)171-67 Choosing Wisely Canada 2014 Choosing Wisely Cana-da [ONLINE] Available at httpwwwchoosingwiselycana-daorgrecommendations [Accessed 24 April 2014]8 Kell JS (2010) Prostate-specific antigen tests and prostatecancer screening an update or primary care physicians CanJ Urol 2010 Feb17 Suppl 118-25

ldquoNDs would and should be responsible for

making evidence-based clinical decisions

surrounding all aspects of care including

history and intake physical examinationsordering of diagnostic tests and in developing

appropriate treatment plansrdquo



QMROPINION

CAMIGQuick Facts


O ver 70 o Canadians regularly use Complementaryand Alternative Medicine (CAM) therapies Hal o

Canadian patients who visit their amily physician will alsobe considering the use o alternative therapies Despite pa-tient acceptance o alternatives attitudes and knowledge oCanadian physicians lag considerably behind those o phy-sicians in the USA Australia and Europe

Tese can include- Alternative medical systems (naturopathy traditionalChinese medicine homeopathy)- Mind-body interventions (meditation relaxation prayer)- Biologically-based systems (herbs oods vitamins)- Manipulative and body-based methods (chiropractic andmassage therapy)- Energy therapy (qigong haptic therapy)

Because o the growing acceptance o CAM there is a needor awareness o these treatment modalities in uture phy-sicians As well an understanding o the evidence behind

these therapies and their potential value (ie in chronicback pain arthritis and mental health issues) will help theorward-thinking physician to be better able to advise hisor her patients

You are invited to explore the existence evidence andethics o CAM in the Complementary and AlternativeMedicine Interest Group (CAMIG) which will eaturespeakers o various backgrounds and panel discussions oncontemporary and controversial issues to complement yourmedical education

Student SurveyOpinions about CAM AERA JUNG CLASS OF 2017

Enter the herbal section o the local supermarket and youare presented with a vast array o herbal remedies that

guarantee to cure or alleviate Complementary and alter-native medicine (CAM) has entered the mainstream con-sciousness with promises o possibilities beyond the limitso conventional medicine Where do health care providersfit into this landscape We are introduced to the concept oevidence-based medicine early on in medical school it is

the paradigm that is supposed to shape and guide our utureeveryday practice as physicians Perhaps due to the large gapin evidence or many o its modalities CAM is ofen pushedto the side viewed by healthcare providers as unscientificand unreliable methods o treatment But as physicians wewill no doubt have patients who will request various CAMtherapies Whether or or against how will our own opin-ions affect patient care We wanted to know what medicastudents thought about CAM and sought to gather theiropinions by surveying the 2016 and 2017 classes here atQueenrsquos

A large majority o the class (86) said they would notgo out o their way to find a natural remedy i they had acold and 89 o students said they believed conventionalmedicine to be more sae than CAM O the CAM modal-ities listed (Homeopathy ColdFX Herbal Remedies andraditional Chinese Medicine) just over hal o the partic-ipants believed raditional Chinese Medicine to be effec-tive while nearly one-third o the participants believed thatnone o the treatments listed were effective However 72o participants also said that they would not deter theirpatients rom taking CAM It was interesting to note thatwhen participants were asked to rate their own knowledgeo CAM nearly one quarter o the class listed their ownknowledge as ldquogoodrdquo while nearly one fifh listed it as beingldquopoorrdquo Te ull results are listed below

Results httpswwwsurveymonkeycomresultsSM-MWY9VGJ



QMR


CREATIVE

ADAM MOSA CLASS OF 2018

Gross National Happiness in Bhutan

op Lef On our first day in Bhutan we passed grazing horses on a narrowroad during a morning trek in Paro Valley Te high altitude-thinnedair orced us to measure our steps and careully fill our lungs with lessthan ull breaths Ofen we stopped to witness the placid valley with thetall grass o the rice crop and the sharp peak o Mount Jomolhari in thedistance

Bottom Lef Bhutanese trek-guides Jigme and Ugyen help a bus drivernavigate a narrow pass between blasting sessions intended to widen theonly national highway Bhutan opened its borders to tourism in 1974Over the past 40 years the government has tried to careully balancepromotion and preservation o the unique culture and natural beauty oBhutan

op Right A birdseye view o the sacred igerrsquos Nest monastery Tis tple complex was constructed in 1692 and is precipitously perched abothe pine orests o the Paro valley Te Guru Rinpoche is said to have flhere rom ibet on the back o a tigress raditional pray flags crisscrothe landscape throughout this Kingdom

Bottom Right Te Punakha Dzong (or ldquoPalace o Great Happinessrdquo) obeautiul clear day Sitting at the confluence o the Pho Chu and Mo Crivers this ortress was constructed in 1637 and served as the nationrsquoscapital and seat o government until 1955 Troughout Bhutan dzongcontinue to serve religious and administrative unctions as well as hosannual estivals



QMRCREATIVE

op Right A mother macaque nurses her baby along a road leadingto the mountain pass rom Punakha to Bhumtang valley Bhutanrsquosrich biodiversity is a source o national pride In 1995 a governmental ruling on orestry and logging was introduced to help preservethe pristine natural environment Bhutan must now maintain at lea60 orest cover at all times A nearby roadside sign admonished

potential polluters with the words ldquoRemember nature is the sourceo all happinessrdquo

op Lef A young boy ran over to say hello when I was retracing the Kingrsquos historichorse riding grounds by bicycle Te clouds were descending on the predominantlyagricultural Punakha valley at dusk In 2013 the Bhutanese government announcedthat they would become to worlds first 100 organic arming nation

Bottom Lef A grandmother walks with young child through the oggy GangteyValley on our final day in Bhutan Locals told me about the importance o multigen-erational households in Bhutanese lie

Bottom Right Te evocative fleetingly anthropomorphized bonfiresets the stage or women rom Bhumtang valley to lead a ceremoniadance Preservation o Bhutanrsquos unique cultural identity is a practicaconcern o the government For example men and women arerequired to wear national dress at schools and government buildingHere the women are wearing the customary kira dress



QMR


CREATIVE

Ipaint circles on her hunched bony back her pale skinstaining pink under the gauze She whimpers when my

gloved hands press the sterile adhesive plastic sheet to herskin and I murmur something sof something I hope iscomorting to her everish nine-year-old mind

lsquoAre her vaccinations up to datersquo I had asked her mother awell-educated conservatively dressed woman who speaksin a way that makes me want to be her riend

I had looked back to her daughter supine on the emergen-cy department bed eyes squeezed shut against a blindingheadache She doesnrsquot move her head ndash her neck is stiff andsore and she has been vomiting Her mum appropriatelyconcerned tells me shersquos had a ever

Irsquove travelled west on elective to a province in the midsto a measles outbreak Here almost every child has been vaccinated whether out o ear routine or persuasivediscourse Even those I expect to be inexplicably anti-vac-cination ndash the granola-crunching wheatgrass-drinking seto which I count mysel a member ndash are vaccinating their

kids Irsquove already spent two days in this paediatric emer-gency department and almost every parent Irsquove spoken tohas affirmed their childrsquos status as ully immunised or ontheir way

Measles is the concern in this city but Irsquom not worriedabout measles in this pre-teen Irsquom hoping I donrsquot need toworry about bacterial meningitis instead

lsquoWe have chosen not to vaccinate our kidsrsquo the pale girlrsquosmother had told me and my heart had sunk When she

spoke she did so with an air o confidence a note o de-fiance a slight smile at the end o her sentence as thoughshe was daring me to question her judgement

She came in worried about meningitis but even in hereducated ear about her childrsquos illness she challenged me todebate her

I donrsquot debate her because Irsquom too worried about the dark-haired little girl on the emergency department bed who

has not received acetaminophen no ibuproen or her painShe received no medical attention beore reaching thispoint o crisis Instead she has been drinking the tradi-tional mountain tea o my European ancestors and takingEchinacea and oil o oregano to strengthen her immunesystem Vitamin C tablets B vitamins zinc

I thought o my own childhood o hot olive oil drippedinto my ear or an earache until I was finally taken to med-ical care delirious with ever and inection I thought o

flower water to treat every ailment and so many tablets ozinc that I vomited them onto the floor

I thought o the MMR jab I took to the lef arm threemonths ago the meningitis shot I took on arriving atuniversity the flu vaccine Irsquove had each year since I startedmedical school and I examined the girl who wonrsquot openher eyes canrsquot turn her head

When finally I plunge a spinal needle into a space betweenher vertebrae I say a little prayer that Echinacea oil ooregano and wheat-grass was enough

SARAH LUCKETT 983085GATOPOULOS CLASS OF 2014

Has she been Vaccinated





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Queen's Medical Review Issue 7.2- May 2014

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