 Now it's my pleasure to introduce our next two speakers. Katie Moriarty is on the faculty of the Frontier Nursing University here in the United States, which I believe is the largest educator of midwives in the United States. Katie originally studied nursing in Ontario, Canada. She is a certified nurse midwife here in the United States. She was the first midwife certified by Acupuncture Canada and her doctoral dissertation focused on acupressure as a pre-birth treatment. While she was at the University of Michigan, she launched an integrative healthcare and complementary therapies clinic in pregnancy and reproductive women's health within their nurse managed center. She's just re-elected to her second term on the board of directors of the American College of Nurse Midwives. Katie has years of experience with acupuncture, mindfulness and integrative healthcare. Helping Katie with this presentation is Janelle Kamarowski. Janelle is also an assistant professor at Frontier Nursing University. Janelle began her midwifery career as a direct entry midwife in California. She had a home birth practice there for a decade before returning to school to become a certified nurse midwife. She has years of experience with home birth and hospital births. She managed a free-standing birth center and is now a laborist at a community hospital. Katie and Janelle, we'd love to hear what you want to tell us. Thanks so much, Seal. We want to say hi to everybody. It's really exciting seeing all the different countries and everybody here, and it's a real honor for us to be able to participate. We're excited to be here and share and exchange some information and ideas with everybody about integrative healthcare, complementary therapies, and life. Some of the objectives that we're going to do is we just really want to go get some groundwork with some definitions, and then we're going to go over some uses and some trends, and then we're mostly going to focus on education. And then we want to talk to you about some implications for educators and researchers and clinicians. So there's a lot of definitions of health, but the World Health Organization in 1948 endorsed this definition, which was a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. And we see that that's actually 69 years ago, but there's a huge shifter from that time of thinking about health as being not just an absence of disease, but really a much broader concept of prevention and optimization of wellness. The Institute of Medicine and Summit Perspectives on Integrative Health. So the Institute of Medicine and the Summit Perspectives on Integrative Health, at that time the president of the Institute of Medicine was Harvey Weinberg, and he actually, prior to the conference, had really said that when we looked at a definition for integrative health care or medicine, that it almost felt like a Rorschach blot, and there were just so many definitions, but at the end of the conference they really felt that they saw these five commonalities, which were really that first that there's a broad definition of health, so that it really needs to include physical, mental, emotional, spiritual factors, and enable a real comprehensive of what makes a person really healthy, that there's a wide range of interventions from prevention to treatment to rehab and recovery, that we see a real coordination of care, so that care comes across from an array of practitioners and caregivers and institutions. One of the most fundamental and probably one of the most neglected aspects of really high quality care they felt was that it really needs to be patient-centered care, and that there's a variety of modalities included within an aspect of this. So in the United States we have the National Center for Complementary and Integrative Health, and that's housed in the National Institute of Health. It used to be called NCAM, the National Center for Complementary and Alternative Medicine, so they've kind of reworked the terminology as time kind of progresses, we see a progression then in terms. So for complementary, when people utilize that term, it really usually means that someone's using something that's considered maybe non-mainstream, but that they're using it in conjunction with conventional medicine versus an alternative healing or an alternative therapy is usually referring to someone who's using a non-mainstream approach, but they're using it in place of completely of a conventional kind of biomedicine or allopathic care. When we look at integrative health care, these are two definitions. One is from the University of Arizona, the Integrative Medicine Department, and then the other is from the Academic Consortium for Integrative Medicine and Health. So we usually see integrative health care really kind of reaffirms the importance of the relationship between that practitioner and the patient. It focuses on the whole person, it's informed by evidence, it makes use of appropriate therapeutic approaches. The healthcare professionals and disciplines help to achieve kind of optimal health and healing. So by definition, we see integrative health really addresses that biomedical, but as well it addresses sociocultural determinants of health, and it takes a real broad view of health creation and disease prevention. So we're really then focusing on prevention, patient empowerment and activation, and not treating just a patient but looking at that woman, that family, and then the impact that that has on the community. So it has kind of the potential for really significant contributions and specific to decreasing morbidity and mortality in our society, and we really see currently that it has the potential to really help with many things that are considered to then go on to have chronic health problems such as obesity, cancer, cardiovascular disease, diabetes, and depression. For functional medicine, it's kind of a relatively new approach to care, but it assigns kind of a central role to the interactions between a patient and their environment from their GI system, their endocrine, and their immune system, and that the practitioners of functional medicine usually focus in on those interactions and then have a really individualized treatment plan. When we look at the National Center for Complementary and Integrative Health, they usually kind of categorize things, kind of into two big subgroups. One would be natural products, and the other which is, I'm sorry, there's all of a sudden something coming across my screen here. Sorry. Most complementary therapies, so they fall into these two subgroups, one being natural products and one being mind-body practices. So when we look at natural products, this group usually includes a variety of products such as herbs which are often called botanicals. We have the vitamins and minerals and then probiotics, and they're usually widely marketed and to consumers they often consider them dietary supplements. In the latest national survey in the United States, about 17.7% had used a dietary supplement other than vitamins in the past year. And mind-body practices include a real large and diverse group of procedures or techniques, and it's administered or taught by a trained practitioner or a teacher. So we definitely see veering amounts of research on mind-body approaches where some are quite widely looked at, such as acupuncture, yoga, spinal manipulation, and meditation. And then in other practices that are listed here, sometimes we have much fewer studies on some of these practices. So some don't fit into either the natural products or the mind-body, and those usually are things that might fit into a whole medical system. So those approaches often are really built upon a real system of theory and practice other than the system of allopathic or biomedicine. So there's examples here of what we often see within the Western culture, and even though both of these originated from Europe, examples could be homeopathic medicine or naturopathic medicine. And then examples in more of a non-Western culture where we have a completely different, almost like language or thought process would be traditional Chinese medicine where we're looking at Xi and Meridian and Yin and Yang, which would be kind of different paradigm or worldview. Within the United States, we might overlap that onto kind of neuroanatomic acupuncture, but it's so much wider than that. It just doesn't fit into any other category, and then Ayurvedic medicine, which originated in India. So the National Health Interview Survey is the main source of information for Americans' health, and it's conducted by the National Center for Health Statistics, which is part of the Centers for Disease Control and Prevention. And beginning in 2002 and every five years since then, they've included a section on complementary and integrative health. Information was collected on adults in all three of those years, 2002, 2007, and 2012, and they began collecting on children in 2007, I beg your pardon. So they found that in 2012, there were 33.2% of U.S. adults that used complementary health approaches, and 11.6% of U.S. children from ages 4 to 17 used complementary health approaches. So there's a significant number of people that are using these, and the most commonly used complementary approach was natural products such as dietary supplements other than vitamins and minerals. Pain is the most common condition that people use these complementary health approaches for, and more than half of people that had used complementary products had had pain during the three months prior to the survey. In 2012, Americans spent about $14.7 billion out of pocket on visits to complementary practitioners and $12.8 billion on natural products. However, there's disparities in access to integrative health care among the populations. So you can see in 2012 that complementary and alternative products were significantly used by non-Hispanic whites in much greater percentages than blacks or Hispanics. An exemplar is yoga and national use in 2012 was 8.4% of people, but it was 6.5% of whites compared to 3.3% of blacks, and we can see down the list that college education, higher income, ethnicity all affect people's access and how well they can get access to these integrative health care modalities. And so this has implications for us, not only as educators but also as researchers and for clinicians. We need to look at the rationale for education, for understanding the trends of use, the safety issues that have to do with the products that our patients are using, how it relates to cultural competency and the increasing evidence base that we're getting out of these surveys and studies for use of these products, and faculty development of competency in these areas is also important. So implementation, like how do we go about increasing knowledge and education? Some can be standalone courses. So you might have a brick and mortar classroom based. You can have web based online modules within standalone courses. There's ways to weave things through. If a program just doesn't have room they feel in their curriculum, then there's ways to weave things through their curriculum. So incorporating it into existing courses. And here are some examples of ways in which you can incorporate modules. So within health care policy, health assessment, really focusing on history taking, pharmacology, making sure that we include vital information about herbs and homeopathy and essential oils, nutrition and then research classes, evidence based courses, research courses. Other ways if individuals have finished their primary education is continuing education post-graduate. A lot of people are involved in experiential learning, sometimes going back and then getting a minor or major within that field. And then we're going to finish as well and talk a little bit about a new program that's an interprofessional, integrated primary health care program that's just had a pilot and is still in the process of launching their program. So we're going to start off with a kind of an exemplar of a standalone course that I taught at the University of Michigan. So it was taught through the public health department and then it was also cross-listed within the School of Nursing. And this course really examined principles and practices, use and outcomes of complementary therapies and integrative health care. And it really provided an overview of the field, it reviewed selected areas, and it focused on specific healing modalities that are really widely used in the general population. And students learned to use evidence-based criteria to evaluate the benefits and some of the potential risks of selected complementary therapies. We had learning experiences that included lectures and seminars, assigned readings, demonstrations, videos, group work, and the production of an evidence-based poster or a patient handout on a complementary therapy of the student's own choosing. So we had a lot of emphasis placed on how you go about taking an integrative history to really facilitate shared decision-making, so really working on decision-making regarding what they were going to utilize. The communication between all providers, so really interdisciplinary communication, and then really then we also had the students go out and engage in the observed care in the office of a practitioner. Along in that course, people had the opportunity to sign up for an extra credit, one extra credit of a mind-body skills lab, and that opportunity was just for more extended practice of mind-body skills that are thought to enhance not only the student's understanding of healing modalities, but also what could be used for themselves. So not just their patients or the clients that they're working with, but themselves as well. So in this mind-body skills lab, we met eight times during the semester for two hours per session, and each session the students were introduced to a new mind-body practice and kind of the theoretical and the research base underlying them. So we had an acupuncturist come, we had an art therapist, we did yoga, we meditated, so it was a really great experience. And the sessions focused on experiential practice, kind of introspection, self-reflection, active listening, and self-disclosure. And now Janelle's going to talk a little bit about how we weaved things through at Frontier. So at Frontier Nursing University, we both teach an evidence-based practice course. And one of the beginning assignments is asking the students to post a question that they have wondered what the evidence is about. And we have found that many of the students posted questions related to integrative care, complementary, and alternative therapies. And so we have tried to weave this into this course that teaches them how to critically appraise evidence. We emphasize the evidence-based medicine triad, which includes and places equal emphasis on the patient's values and expectations as well as individual clinical expertise and best external evidence. And we emphasize to the students that your patients are using these modalities and you need to be familiar with them so that you can adequately care for them. We also introduced them to the hierarchy of evidence and how they can find evidence on specific modalities and to understand that there are many different types of evidence. And different types are more appropriate for different types of clinical questions. To date, our course includes readings, lectures, and a discussion board where we bring up topics that are related to integrating complementary and alternative modalities into healthcare. We have one lecture that's specifically on appraising the evidence of integrative healthcare. The students do a research matrix and a critical appraisal of the research and develop a poster on a topic, and many times we have included in that topic integrative modalities. We also have them watch a couple of videos on functional medicine and join a discussion board discussion on that. And we review the purpose of the NCCIH and they can go to the website and find a lot of information and then we require them to complete a CEU course which takes about one hour on neural basis of mind-body pain therapies. And it's a free course that they can get on that website. I highly recommend it. It's excellent. In October of 2014, the National Center for Integrative Primary Healthcare was launched as a collaboration between the University of Arizona Center for Integrative Medicine and then the Academic Consortium for Integrative Health and Medicine. And it was supported by a HRSA grant, Health Resources and Services Administration grant. And the primary goal of the National Center for Integrative Primary Healthcare was really to develop a core set of integrative healthcare competencies and educational programs that will span the interprofessional primary care training and kind of the practice spectrum. And ultimately, it's hoped to become a required part of anyone who's going to be a primary care educator in primary care. Team members that were within developing the competencies represented nursing, physicians, pharmacy, public health, acupuncture, naturopathy, chiropractic, nutrition and behavioral medicine. So the next couple of slides go over the competencies that were presented and were kind of the basis of a 45-hour online curriculum that was produced for the use of anyone who's going to be a primary care practitioner. And it was really piloted to a wide range of programs in early 2016. I was really lucky to be part of that pilot program and then really got feedback from individuals that were in the program and then they've gone on to revise it and they're getting it ready for kind of wider use now. So the pilot was 13 weeks and it really focused on 17 units, kind of the integration or the intro to integrative healthcare. Really focused a lot on learning motivational interviewing and lifestyle behavior change. It focused on the healthcare of the professional themselves and their well-being. It looked at primary healthcare professionals and a wide spectrum of backgrounds, how to take an integrative health assessment, a variety of modalities were covered. It looked at the community and the systems at large and then there was a final reflection and post assessment. So the competencies are really meant to really focus on patient-centered and relationship-based care, really focusing on how we go about doing a health history, collaborating with individual families to have really individualized and personalized care. And really focusing on kind of lifestyle counseling. Demonstrating skills and utilizing the evidence as it pertains to integrative healthcare and really being able to critically appraise. Demonstrating knowledge about major conventional complementary and integrative health professionals and health professions, facilitating behavior change in individual families and communities and how to work effectively as an interprofessional team. We were expected as well to really engage in behavior, our own personal behaviors and self-care practices to optimize our own health and well-being, kind of walking the walk and talking the talk. How to incorporate integrative healthcare into community settings and healthcare systems and then really looking at ethical standards of practice into all interactions with individuals and organizations and community. So we really do need to expand the evidence base and really encourage individuals who are currently incorporating or practicing and integrative or complementary therapies are certified. We really do need to all kind of make it a personal goal and a professional goal to really write more and disseminate more information and get out information. We really talk a lot in our course as well that how do we critically appraise because there's a lot of critique sometimes that RCTs per se, but a lot of people don't want to be randomized into a certain arm. So why don't we expand what we're doing and have preference RCTs so that trials can include randomized and non-randomized arms and kind of look at the comparison between both of them. That studies of instead to have bundles of therapies together rather than kind of altering how individuals actually really incorporate a complementary therapy into their own treatment plan. Really focusing on interdisciplinary and mixed methods. So Janelle, so clinicians about hello, Janelle are you there? So clinicians, what can you do for your patients? You can take an integrative healthcare history, ask people about their over the counter meds and herbs and supplements, ask about what modalities people are using, ask about what support systems and stressors they have and emotional and spiritual health and know where to get information and think about what you can offer from the community to support the whole person. Janelle, there's integrative techniques that can complement conventional methods by understanding what patients are using. You can provide better care and really assist with shared decision making. I'm not sure why this is forwarding, sorry. I'm not sure who's messing with these slides. And by understanding how to use some techniques, you can also refer others. So you can give some information but also refer to others. We just kind of wanted to finish with, this is actually a project I did with some of my students as an independent study. It was called Feng Shui Project but really anyone can take a look at their environment and how can we impact what we're doing with our clients, looking at all of our senses. What do people see when they come into a clinic or what do we see when we're working with people from seeing, smelling, tasting, what people are hearing. So really kind of looking at your environment and what is the kind of message that we're sending to people. Does it resonate with that person? Is that environment uplifting? Does it feel good? What is the lighting? How do we put our exam tables? Do people feel safe? Having clean air, moving fans around, sometimes we utilize aromatherapy. What we hear is really important. Both from our words are powerful but also kind of the science of even positivity, different music that you can utilize. And then taking a look at yourself as a caregiver. What kind of compassion do you bring to the table? Making sure that we're non-judgmental, that we come into our interactions with a positive demeanor. Kind of having peace within yourself, making sure that we are of service. So taking a deep breath, per se, and really being with women. And this last slide, we're just some pictures of some artwork that we utilize just to kind of hold that image for our clients. Any questions that people have? Comments. Here's our, if anyone wants more information about anything, we'd love for people to email us. And we also have some great resources at the end here from the National Center of Complementary and Integrative Health Care, to the Benson Henry Mind Body Institute, the Cochrane Database. Love the University of Wisconsin. They have fabulous resources and modules available. And then Janelle had introduced me to two fantastic personal history and self-reflection inventories. The Duke Integrative Medicine and the Functional Medicine Inventory of Idaho. I'll put back our contact information. Katie, can you hear me? This is you. We don't know if anyone... Yes, I can. Good. I was having some microphone trouble there. I had a question. I can't hear Janelle. Janelle, are you there? We may have lost Janelle for a minute. Janelle says she can hear, but she just can't speak. I was having some issues too, and I had to log out and log back. Okay. Katie, I wanted to ask, so many of us are in busy practices. When you think that a particular woman might benefit from a complementary therapy or some sort of integrative health technique that it doesn't sound like she knows, how do you work that into a visit? You know, a lot of us have multiple rooms that we're utilizing. So, first off, I would say some of the integrative history forms are things that people can even complete even prior to coming into their care. And it really then gets at the root of what they are using, what they are open to, what they're doing for their mind, their body, their spirit. Often people don't even think of certain things that they're using, possibly herbs or dietary supplements, and they often don't share that because it's just something to them that they think, oh, this is natural, this is normal, and they might not even consider that. So really getting at a base of what people are currently doing, and then I think being open and talking to people about ways to optimize their health. The biggest thing at least in Detroit where I work, you know, we have the worst infant mortality in the United States, and we just see people with chronic and toxic stress. So we really have to introduce, even weave things through, ways to, you can't always change the level of stress, but you can assist people in how they might perceive or handle that stress. So we actually used a centering model with our clients, and within that we often weaved mindfulness through that and talked to individuals. We often would have people download apps onto their phones and help to utilize ways like that. What I often used to do too is because I'd have several rooms that I could use at the same time. So if I had someone who said, oh, I have, you know, horrible nausea, then you might want to have like acubans right in there. I would actually give them an acupuncture treatment and maybe, you know, turn on a kettle and make them a small cup of ginger tea. So doing things like that might seem like, gosh, that would just take too long, but it actually really doesn't. So if you have a person who says, oh, just have horrible back pain, and then just to say, well, why don't you, you know, come on up here, why don't I give you a massage while we're doing your appointment? Why can't you just give someone a massage while you're talking to them and doing your education and getting information? Often you would have people that just left so happy. They felt taken care of, they had felt heard. So small things like that, sometimes I would have a meditation tape. I'd ask them if they're open to that. And so after their appointment I'd say, do you want to just stay in here and I'll turn the lights down and you can just do this meditation and I'll come back and check on you. So then go on and see another client and then come on back and come back to that room. So there's ways that we can weave things in and also knowing who in your community are really good practitioners that you can refer to. You really have to have, people are using things. We know that and we want to encourage that and we want to be able to know who to refer to and then also what can we incorporate. I mean we're using guided imagery when we are in labor with people. We are using breathing techniques. We are using acupressure a lot of times when people are in labor. So just kind of connecting those dots. I'm going to guess that we use complementary therapies more in labor than we do in our office practices. So we have real opportunity to expand more into the offices. We definitely do. And when we look at most people's common discomforts of pregnancy, I remember Dr. Komarowski, Janelle and I were talking when we had our students share a shared decision-making tool. We were really taken back by the number of students who actually sometimes brought up midwifery students a shared decision-making tool on what antidepressants they could utilize with their clients. And we were both really taken back that that was kind of, we'd have to stimulate and think for them, okay, well within this shared decision-making tool, anything about mind-body work, about meditation, about going to the, I don't want to say lowest intervention because that is high in work sometimes. Some people might think well it's so much easier to take a pill. But it still doesn't get at the root issue or problem of what someone is confronting. So kind of working with someone. We're now seeing, I mean they told us, oh, there's no problem with antidepressants and we're seeing more research that's coming out. So almost all the common discomforts of pregnancy, you can really utilize complementary therapies. I've had patients come to me, I had a physician who came, they were a surgeon and they needed their hands and they had horrendous purple tunnel. And they would come a couple of times a week for an acupuncture treatment and I taught them acupressure points as well and they were fabulous and able to continue. And I loved because this physician was like, I have heard about this, I do not believe in any of this but I need to keep working and so I'm willing to give this a try. And I said, you're the perfect person to come. I love it when someone doesn't believe in it. So let's go ahead and let's try. And it was fabulous experience for them. But so for nausea and vomiting, sciatica, stress and anxiety, back discomfort, increasing breast milk supply. It's really the front line thing that I'm usually utilizing with my clients is mind body work, acupressure that they can incorporate, dietary changes. That's usually, that's my front line. You mentioned increasing milk supply. That's kind of interesting. Do you have a favorite technique for that? There's acupressure points. So there's a fabulous website by Deborah Betts who I absolutely love. If you Google acupressure and labor and spell it L-A-B-O-U-R and then you can put in Deborah Betts, B-E-T-T-S and she has a free downloadable booklet that people can utilize for labor and discomfort but she also, what I love about her website is she has different things for nausea and vomiting. She has it for breast milk, increasing breast milk and she'll have little vignettes that you can actually pull up a YouTube and learn the acupressure points and then she'll also kind of go into from a traditional Chinese medicine perspective different dietary things that you can include as well. So really check out that website. From all of my clients, I ask them to print that off and put it in their bag. I spend one appointment where I really go over a birth plan and what are their expectations but working as a family and their partner, whoever their partner is, and teaching them some techniques and empowering them to utilize these techniques and then when they can see, they'll just go right on the computer when we're in the clinic and I'll show them the website and I'll say, here, so you don't even need me. You've got these vignettes. Let's practice. Let's make sure you feel comfortable doing this yourself and it's very empowering for individuals. Nice. Thanks so much, Katie. We have time for one quick question. Is there anybody among the listeners who wants to type in a question or come on over the mic? While we're waiting, Janelle, is there a last comment you'd like to make for us? I think she's typing. Janelle, I don't think she can unmute herself for some reason. My microphone is acting very finicky. I'm not sure what's going on. But I really encourage people to contact us if you need any resources. I would really check out the interprofessional that 45-hour online module that primary health care practitioners can utilize. And then Janelle wrote, I encourage everyone to look at the links for the health assessments. They give great ideas of what you can incorporate into your patient intakes and lead to really great discussions. And those are right here on the last one, the Duke Integrative Medicine Personal History and Self-Reflection Inventory and then the Functional Medicine Inventory of Idaho. I really encourage people to also take a peek at the resources from the University of Wisconsin. Dr. Raeckel is there, and they've got a great integrative health program there. Great. Thanks so much. I'm going to leave that slide up for just a minute or so if people want to take another look at it. Janelle, it took a little while, but your comment has popped up encouraging everybody to look at the links for health assessments. We really appreciate the time you both have spent with us. Thank you so much. An area of midwifery practice that we can enrich and certainly needs a lot more investigation. Thank you. Thank you both. Katie, just remember now to mute your mic if you're going to stay listening. I've got a little more housework to do. I'm going to turn off the recording.