Incorporating Traditional AI/AN Medicine Into I/T/U Clinical Practice\
\
Moderator: Theresa Maresca, M.D., University of Washington School of
Medicine\
\
-What are the pros and cons of asking my patients about their
traditional medicine use?\
-How do I learn more about what traditional practices are common in my
area?\
-What specific strategies can be used to ask my patients diplomatically
about their traditional medicine views?\
-Where can I find resources about plant medicine?\
-Is there a \"right way\" to work collaboratively with a traditional
healer?\
-What if I do not agree with my patient\'s views of traditional
medicine?\
\
Case Study\
You are covering the ER and urgent care. A young man in his 20\'s
presents with a migraine headache. He\'s enrolled in a tribe from an
adjoining state, and is en route to a ceremony nearby. He shares with
you his belief that he should take no medicines prior to the ceremony.
His PMH reveals he is diabetic, on insulin BID.\
\
\
\* How do you handle this?\
\* What do you prescribe?\
\* Should you ask him what the ceremony involves? What if he does not
answer?\
\
\
\
Dr. Maresca is a family physician currently teaching with the Seattle
Indian Health Board family medicine residency program. She is a clinical
associate professor in the Department of Family Medicine at University
of Washington in Seattle, where she is the director of their Native
American Center of Excellence. She maintains her practice with the
Snoqualmie Tribe of western Washington, and was the former clinical
director at Rosebud, SD. She has worked for IHS and urban clinics in
both Arizona and Washington. Terry currently teaches electives in
traditional plant medicine at the medical school, and is a frequent
national lecturer on the subject of integrating western and traditional
medicine.

Se:kon to all on the listserv, and welcome.\
\
The history of traditional Indian medicine (TIM) use is as long and
complex as that of the evolution of Western medicine- and has been in
use much longer. What we know today from a variety of small published
studies since the 1970\'s is that natives in both urban and reservation
communities continue to use traditional medicines, and that how this is
defined varies between communities. Rates of use in urban settings have
been documented between 30-50%, and in rural settings, 50-70% of the
population has used TIM.\
\
There do seem to be a few \"epidemiology\" correlates to TIM use. These
include: speaking one\'s own Native language, advancing age, presence of
chronic disease, presence of a painful health condition, and connection
to one\'s own tribal culture. Despite this, national studies of American
Indian adolescents have also documented TIM use by this age group.\
\
Traditional medicine practices may include, but are not limited, to the
following:\
Prayer\
Use of herbal preparations\
Counseling with a Native elder\
Seeing an Indian doctor/medicine person for diagnosis, or treatment, or
both\
Spiritual cleansing and blessings\
Fasting\
Use of smudge or adopting other protection strategies\
Hands-on healing methods\
Participating in ceremonies, including sweat lodge, pipe ceremonies,
talking circles, Native American Church, Shaker tent ceremonies,
longhouse\
Use of song and dance\
\
[What are some of the pros and cons of asking patients about their use
of TIM?]{.underline}\
PROS\
\*A better understanding of your patients\' holistic world view and its
power\
\*A better view of your patients\"treatment adherence\" challenges
(\"Why did you sign out AMA from the hospital?\" \"Why didn\'t you take
those pills I gave you?\")\
\*Encourages a trusting bond between patient and provider to share this
information\
\*Your future treament plans may be more comprehensive\
\*May help to identify potential positive or risky interactions of herbs
with pharmaceuticals, and to allow advance treatment planning for
stressful physical events that your patient may experience\
\*Your patient may want you to participate in their TIM treatment, to
help both you and them\
\*You may learn something about plant medicine or the community you work
in that could help other people\
\*It shows respect for other healing methods available to your patients,
and those who practice these ways\
\
[Possible down sides to asking about TIM]{.underline}\
\
\*Your patient considers this too private or sacred, and may not
respond, or view you with suspicion on future interactions\
\*Your patient might consider you disrespectful and change doctors\
\*Your patient may say no initially, but actually be using TIM, and you
forget to followup about this as your relationship deepens in trust,
leading you to miss important information\
\*Information may be shared with you that you are not sure what to do
with\
\
More later this week-\
Oknise!\
Terry Maresca (Mohawk)

Terry,

I'm Coordinator of Office of Native Medicine at Chinle Hospital. These
are the notes we have as we tried to answer the question. These come
from Native Healers:

> ***Notes from Chinle IHS Native Medicine Staff***
>
> **-What are the pros and cons of asking my patients about their
> traditional medicine use?**

+-----------------------------------+-----------------------------------+
| **Pros**                          | **Cons**                          |
+-----------------------------------+-----------------------------------+
| 1.  **Acknowledges patient's      | 1.  **Not all native patients use |
|     cultural beliefs**            |     native medicine**             |
+-----------------------------------+-----------------------------------+
| 2.  **Acknowledges patient's use  | 2.  **Patient may not agree with  |
|     of Herbal medicine**          |     NTM**                         |
+-----------------------------------+-----------------------------------+
| 3.  **Shows respect for native    | 3.  **Patient may have different  |
|     culture and the use of native |     belief other than NTM**       |
|     medicine**                    |                                   |
+-----------------------------------+-----------------------------------+
| 4.  **Provides holistic health    | 4.  **Small risk to upsetting a   |
|     care.**                       |     non- traditional patient**    |
+-----------------------------------+-----------------------------------+
| 5.  **Meets cultural assessment   | 5.  **Patient may wonder why      |
|     component of patient care to  |     you're asking about NTM**     |
|     meet accreditation            |                                   |
|     standards.**                  |                                   |
+-----------------------------------+-----------------------------------+
| 6.  **Shows patients providers'   | 6.  **Patient might think you're  |
|     familiarity of native         |     nosey.**                      |
|     medicine.**                   |                                   |
+-----------------------------------+-----------------------------------+
| 7.  **Shows patients you honor    | 7.  **NTM may be considered       |
|     NTM by being willing to talk  |     private information by the    |
|     about it.**                   |     patient.**                    |
+-----------------------------------+-----------------------------------+
| 8.  **Shows patients NTM is part  | 8.  **Patient may be fearful how  |
|     of their health.**            |     you will use the              |
|                                   |     information.**                |
+-----------------------------------+-----------------------------------+

> **\
> -How do I learn more about what traditional practices are common in my
> area?**

1.  **Ask the patients. Present yourself as a student of Native
    culture.**

2.  **Use of survey questionnaire could be used.**

3.  **Ask employees who are knowledgeable in native traditional
    medicine**

4.  **Ask native practitioners in the communities.**

5.  **Research native traditional medicine.**

6.  **Attend traditional gatherings.**

7.  **Attend native cultural in-service trainings.**

8.  **Establish a dialogue forum with native practitioners.**

9.  **Attend ceremonies by invitation.**

> **-What specific strategies can be used to ask my patients
> diplomatically about their traditional medicine views?**

1.  **First, establish a trust and rapport.**

2.  **Integrate your questions with your assessment.**

3.  **Don't appear like you're interrogating patients.**

> **-Where can I find resources about plant medicine?**

1.  **Ask local herbalist.**

2.  **There are books and other publications about native herbal
    medicine.**

3.  **Check with local Native Colleges.**

4.  **Talk with local elders.**

> **\
> -Is there a \"right way\" to work collaboratively with a traditional
> healer?**

1.  **Yes**

2.  **Establish a network of practitioners and a forum for dialogue.**

3.  **Ask them how you can work together with them.**

4.  **The providers and native practitioner could come together during
    Native American Heritage Month(day).**

5.  **When communicating with a traditional practitioner, listen and let
    them tell you their story.**

6.  **Give traditional practitioners the same respect you give to other
    western medicine providers.**

> **\
> -What if I do not agree with my patient\'s views of traditional
> medicine?**

1.  **Keep your opinion to yourself. It's the patients' belief, not
    yours.**

2.  **Do not ridicule NTM even if the you believe there is no scientific
    evidence for NTM practices.**

3.  **Encourage patients to use western medicine in addition to NTM.**

4.  **Do not discourage Native Traditional Medicine.**

Response to Case Study:  

                Since the young man presented himself to ER/urgent care,
 he probably is expecting some relief for his migraine headache with
medication (or he may have received it already for acute pain).   Was
the sharing of h is belief spontaneous or was it solicited by the
provider?  If it was spontaneous, the patient may be feeling guilty for
having broken a taboo (taking medicine before a ceremony) in which case
the provider might have a discussion about patient's feelings and what
would help.  For example, would he ask for a special blessing as part of
the ceremony.

                If the sharing was provider solicited, then its
important to let the patient know what you're asking and for what
reason.  For example, "I'm learning about ceremonies......and that's why
I'm asking....so I can provide health care in a meaningful way".

                Most medicine people, given an explanation of diabetes
and how insulin helps the body, are agreeable to making an exception to
proscriptions for ceremonies.  In this case, the information needs to be
given to patient so he can communicate the doctor's recommendation to
the ceremonial practitioner.  You can ask, "Are you comfortable about
sharing with me what the ceremony involves?"  If the patient doesn't
answer after waiting for a response for longer than 1 minute; the
patient is probably not comfortable sharing or needs longer time to
think about.  Since the patient accessed health care, the person expects
medical care  so the provider can diplomatically give strong
recommendations.  Ultimately, it's the patient's choice to accept or
reject medical care recommendations.

 

Ursula Knoki-Wilson, CNM, Supervisor,

Member, Traditional Navajo Medicine Committee, CSU

And

Johnson Dennison, Office of Native Medicine, CSU

Navajo Windway Chanter

My thanks again to Ursula Knoki-Wilson and Johnson Dennison for their
thoughtful response to this case, which clearly shows experience in
handling such situations.\
\
This was an actual patient encounter in the Aberdeen Area. The patient
did spontaneously mention that he was headed to ceremony (with no detail
as to what this was), and that he was instructed to use no medicines
immediately before or at the ceremonial grounds. This led the clinician
to ask what the patient thought could be done for him in the ED, given
these restrictions, that would be appropriate and not automatically
exclude him from the gathering. He appeared appreciative of the fact
that the clinician knew he was trying not to break a taboo. Most
patients would have the expectation of a Western approach to the issue
in this situation, as was already pointed out. This young man was in a
dilemma- his symptoms precluded driving the remaining 3 hours he had
left to get to his destination on time, and he was clearly anxious about
this. He expressed to his doctor his conflicted feelings about needing
pain relief and not wanting to bring any bad actions toward himself for
possibly breaking this restriction.\
\
Options that were given to him included: check his blood sugar, use of
IV fluids, given nausea associated with the headache and the heat of the
day that the patient drove through in a non-air conditioned truck,
oxygen, caffeine, rest in a darkened room. Pain and migraine specific
abortive medicines were also offered to him, either oral or IM/IV form.
This could be a \"last resort\", he was told.\
\
He was asked if it would be helpful or even possible to contact the
leader of the ceremony or a helper and ask for advice. (Note that this
was in the days before cell phones or pagers were common, and reception
by land line phone was spotty in this remote area.) The latter was not
possible, and the patient seemed clear on the restrictions already given
to him. He accepted all therapies except pain or headache-specific
remedies. His symptoms did improve.\
\
Follow-up questions focused on whether the ceremonial leader knew of his
diabetes and insulin needs. This was the case. However, the patient also
stated that the leader was quite strict about medicine restrictions,
including insulin. The clinician did ask permission to ask about the
physical demands of the ceremony, and the response was brief- prolonged
fasting would be involved. No more details were given when asked. The
patient was told in advance that he might be able to be given more
fluids than usual in this ceremony, but by choosing to participate, he
had to place his faith in Creator to protect him and accept whatever
consequences came.\
\
The clinician was uncomfortable with the faith-based approach and what
appeared to be disregard for the man\'s medical needs. This was not
expressed to the young man. Instead, the conversation focused on patient
education of the symptoms of dehydration, heat exhaustion, and low blood
sugar, and how he could identify his need for fluids or medical
assistance, should he choose this.\
\
In situations where the patient chooses not to reveal details of the
healing ceremony, it may be best to move on and refocus your
questioning. Request that the patient to help you, the clinician, figure
out what seems \"right\" to them as a treatment by giving them a menu of
options, as the clinician in this case chose to do. Offer to write them
a brief note to accompany them that will inform the native healer what
you did for the patient, and what steps might be taken to ensure
improvement and safety while in ceremony- collaborate and share
information. The healer may or may not choose to abide by your
recommendations, but they may take them into account. Ultimately, the
patient will decide what course of action is right for them.\
\
Would you have handled this situation differently?

Se:kon and happy impending new year to you all!

In this last installment of our month-long discussion, I would like to
focus on three questions initially posed to the group:

 

**1. What specific strategies can be used to ask my
patients diplomatically about their traditional medicine views?**

 

Some of these strategies have been mentioned: direct questioning, with
an explanation as to relevance, inquiring about herbal medicine when
asking about CAM/prescription and OTC medicine use, and adopting a
\"spiritual history\" approach when doing a more comprehensive intake as
part of the social history. Awareness of life cycle events that may
incorporate traditional healing methods (birth, major life change) can
also be productive segues into this area.

 

In practice, I often use a reference to a third party to bring up the
subject and check for applicability to my patient to avoid stereotyping.
This is particularly true for those with mental health issues, or
chronic illness. For example: \"Some of my other patients who got into
alcohol treatment have used Indian medicine to help them with their
detox- is this something you have also tried?\"

 

If the patient is a young person, I will ask them if their parents (or
other family members) have taken them for ceremony or treatment by a
native doctor, and their own views about this. Again, this is usually in
the context of a chronic illness situation, and not acute care visits.

 

**2. Where can I find resources about plant medicine?**

 

Some have already been mentioned, including locally credible texts about
the community or region, use of tribal college materials, and the
internet. Salish Kootenai College in Montana, for example, offers a
course on local plant medicine with written materials only given to
those enrolled in the course. There is currently an ongoing plant
\"seminar\" sponsored by Northweset Indian College here in Bellingham,
WA on the Lummi reservation focused on native plants to address
diabetes. Some tribes have a natural resource division that also
publishes materials on local plant uses (Colville, WA is a good example
of this). Some areas, especially those near urban sites, may have county
agricultural extensions, community colleges, or native plant societies
that can help with plant identification and local experts. Some
communities (urban and reservation) have herbalists that run a business
locally, and are knowledgable. If at all possible, it is highly
desirable  to have a reliable consultant in the area help you. As
always, Elders are a rich source of information and support in
determining reliability within a community.

The internet is full of ethnobotanical information, not all of it
reliable. For those of you who are interested in \"evidence based\"
plant information, one excellent site used often by our students and
residents here at University of Washington, is the Natural Medicines
Comprehensive Database. It does charge for subscription access (unless
you can arrange this via a local hospital or library system or
university). It is regularly updated, and lists Latin plant names,
English, and other synonyms (not usually Native names, alas). Doses and
indications are listed, and a rating system used of efficacy, in addtion
to known plant-drug interactions.

**3. Is there a \"right way\" to work collaboratively with a traditional
healer?**\
\
As our Chinle colleagues said, \"YES\". Some issues to consider include
the willingness of a local healer to work with Western clinicians in
general, for what types of conditions, and what their preferred protocol
is for such a referral.  For example- is a phone call ok? In-person or
group meeting only? Written referral within a health system? Male or
female preferences may also come into play. At Seattle Indian Health
Board, one of our healers will not see clients who are acutely using
drugs or alcohol, or an unaccompanied woman.

According to Dr. Ted Mala, Director of Traditional Healing at
Southcentral Foundation in Anchorage, Alaska, it is critical to
follow-up with the tribal doctor for their perspective on your patient.
He notes that this often does not occur among primary care providers.

 

*Thanks to all of you for participating in this discussion, and sharing
your wisdom with the 386 others on this listserv. Blessings to you all
for the work you do and continue to do to serve the people. Happy 2008!\
Oknise-*

*In friendship,\
Terry Maresca*