The Permanente Journal PRSRT STD 500 NE Multnomah St, Suite 100 US POSTAGE Portland, Oregon 97232 PAID Portland OR Change Service Requested Permit No 1452 Fall 2002 Volume 6 No. 4 THE PERMANENTE JOURN THE PERMANENTE JOURN AL 6 NO. 4 — F VOLUME AL 6 NO. 4 — F VOLUME Complementary and Alternative Medicine 2 National Institutes of Health “Oregon Center for Complementary and Alternative Medicine”: Value to Permanente Medical Groups and to Kaiser Foundation Health Plan and Hospitals 22 The Herbal Medicine Pharmacy Update 28 Jimson Weed Poisoning—A Case Report 34 The Macrobiotic Diet as Treatment for Cancer: Review of the Evidence 44 Symposium on Complementary and Alternative Medicine: In the Era of Evidence-Based Medicine, What’s a Physician to Do? ALL 2002 ALL 2002 The Permanente Journal Printed on Fall 2002 recycled paper. Volume 6 No. 4 www.kp.org/permanentejournal Fall 2002/ Volume 6 No. 4 PermanenteThe Journal EDITORIAL COMMENTS 22 The Herbal Medicine 2 National Institutes of Health Pharmacy Update. “Oregon Center for Complemen- Philip J Tuso, MD, FACP tary and Alternative Medicine”: Because of continued use of Mission: The Permanente Journal is Value to Permanente Medical over-the-counter therapy and written and published by the clinicians Groups and to Kaiser Foundation the lack of routine screening of the Permanente Medical Groups and Health Plan and Hospitals. for drug interaction, it is impor- KFHP to promote the delivery of superior Tom Janisse, MD, Editor-In-Chief tant for physicians to under- health care through the principles and stand risks and benefits of benefits of Permanente Medicine. COMMENTARY herbal treatment. This article is a partial review of selected 8Views and Use of Complementary herbal medicines with potential and Alternative Medicine by to harm patients. Mid-Atlantic Permanente Medical Group Health Care Providers. 27 The 79-Year Illness. Lydia S Segal, MD, MPH David Clarke, MD ○○○○○○○○○○○○ ○○○○○○○○○○○○○○ Psychosocial stress is respon- SOUL OF THE HEALER sible for many primary care of- On the cover: fice visits. A case study is pre- “Teardrop Arch” by 6 “Glade Creek Grist Mill” sented with positive outcomes. Ahmad Abdalla, MD, Ahmad Abdalla, MD is a photograph of this 28 Jimson Weed Poisoning— beautiful arch tucked deep 38 “A Gathering of Crabs” A Case Report. Kit Chan, MD in Monument Valley, Utah, Ahmad Abdalla, MD far from the eyes of the 43 “Tools of the Trade” The hallucinogenic effects of casual passerby. It required John J Kuiper, MD, FACP this common plant have been a long desert drive and a known for many centuries, and short hike for Dr Abdalla 64 “Spider Web” it is widely used by young to arrive when the light Suzanne Ackley, MD people. The atropine, scopola- was perfect for this mid- morning shot. 69 You Can’t Go Home. mine, and hyoscyamine content Calvin Weisberger, MD can produce profound anticho- Dr Abdalla has been a Head and Neck Surgeon linergic effects; recognition and with SCPMG since 1978. He is a graduate of 72 In Memory of Carol management are discussed. the New York Institute of Photography and has Abramowski, RN, NP, MS. been designated a “Master Photographer.” Winnie Star, RNP 31 Corridor Consult: More art by Dr Abdalla can be seen on pages 77 “Portland Head Light” 6, 38, and 77. How Can We Integrate Ahmad Abdalla, MD Alternative Approaches and Mainstream Medicine to Treat CLINICAL CONTRIBUTIONS Chronic Low Back Pain? Lydia S Segal, MD, MPH 17 Immediate Hypersensitivity to Methylparaben Causing Using a case history as an ex- False-Positive Results of Local ample, this article outlines Anesthetic Skin Testing or lifestyle, biosocial, and alterna- Provocative Dose Testing. tive measures available to treat Eric Macy, MD; Michael Schatz, this common condition. Skillful MD, MS; Robert S Zeiger, MD, PhD integration of alternative mea- 7 LETTERS TO THE EDITOR sures can bring about distinct Parabens are commonly used 13 PERMANENTE ABSTRACTS benefit for these patients. preservatives in multidose vials 81 ANNOUNCEMENTS of local anesthetics but rarely 34 The Macrobiotic Diet as Treatment 81 THE LIGHTER SIDE OF MEDICINE cause immediate hypersensitiv- for Cancer: Review of the ity reactions. Data confirms Evidence. Joellyn Horowitz, MD; 82 BOOK REVIEWS the rarity of these reactions. Mitsuo Tomita, MD 87 CME EVALUATION FORM Because of the possibility of In this Independent Study false reactions, provocative Project by a medical student positive sensitivity tests should mentored by a KP physician, be repeated. potential risks and benefits of a macrobiotic diet as treat- ment are explored. The Permanente Journal 500 NE Multnomah St, Suite 100, Portland, Oregon 97232 www.kp.org/permanentejournal The Permanente Journal/ Fall 2002/ Volume 6 No. 4 HEALTH SYSTEMS 73 Physicians as Leaders: SPECIAL FEATURE 39 Successful Practices in the Roundtable Discussion — Complementary & Physician Work Environment: Human Resource Leaders from Alternative Medicine We Work Together. Karen Tallman, the Permanente Medical Groups Symposium PhD; Jill Steinbruegge, MD; Lee Jacobs, MD, Moderator Michelle Hatzis, PhD A panel of Permanente human In May 2002, The Southeast The Physician Work Environ- resource experts, called to- Permanente Medical Group’s ment Workgroup conducted gether in a roundtable discus- Spring CME Program was held in focus groups to identify suc- sion, discusses the important Georgia. A panel of speakers: Paul cessful practices in the physi- informal leadership role physi- Wallace, MD; Tieraona Low Dog, cian work environment. This cians play in the work unit. MD; Lee Ballance, MD; and Charles article explores the practices Elder, MD, joined Lee Jacobs, MD, that discriminate “highly rated” in presenting the Symposium on teams from “medium-rated” MEDICAL ETHICS Complementary and Alternative or “low-rated” teams. 78 To Be or Not to Be— Medicine. Each presenter spoke Preimplantation Genetic from their area of expertise and 65 Clinical Information System Diagnosis. Kate Scannell, MD, shared their thoughts on the inte- (CIS) Baselets Help Standardize Editor; Commentary by Jeffrey R gration of CAM into practice. The Evaluation of ADHD in the KP Botkin, MD, MPH edited transcripts of each speaker Colorado Region. along with the transcript of the Mark Groshek, MD The rapid development of panel discussion with questions One powerful tool of CIS is reproductive technologies from the audience conducted at the baselet, a module contain- has given birth to formidable the end of the symposium are ing a set of prewritten items ethical questions. A case study excerpted in this special feature. that can be inserted into a of the biologic construction clinical progress note. This of a child is presented with 44 Symposium on Complementary article discusses the successful commentary addressing the and Alternative Medicine: In the use of these baselets in the KP physician’s, the patients’, and Era of Evidence-Based Medicine, Colorado Region. the unborn’s positions as well What’s a Physician to Do? as society’s. Lee Jacobs, MD, Moderator 70 CPC Corner: 45 Using Evidence to How to Say No. Book reviews Understand New Approaches. Edward Wang, MD; Andrew page 82 Paul Wallace, MD Golden, MD; Pamela J Butterworth, MA, MHRD 49 Dietary Supplements and Botanical Medicines: A A good clinician-patient rela- Commonsense Approach. tionship is essential in deter- Tieraona Low Dog, MD mining treatment plans and Subscriptions: The Permanente Journal is available by goals. This article discusses the group or individual subscriptions. For information about 54 Integrating CAM Into a Group importance of this relationship subscriptions contact 503-813-2623 or e-mail: Practice: The Experience of The when the clinician must tell the [email protected]. Permanente Medical Group in patient “no,” and offers strate- Submitting Manuscripts: Manuscripts submitted to TPJ Northern California. gies for addressing these un- are reviewed by members of the editorial staff. For more Lee Ballance, MD comfortable situations. information regarding manuscript submissions, read “Instructions for Authors” on our Web site at www.kp.org/ 57 Integrating CAM Into Practice: permanentejournal or contact our editorial office. The KP Northwest Story. Submitting Artwork: Send our editorial office a high-quality Charles Elder, MD color photograph of your art no smaller than 4”x5” and no 60 Complementary and Alternative larger than 8”x10”. Please include a cover letter explaining Medicine: Panel Discussion. Kaiser Permanente association, art background, medium, and a brief statement about the artwork (description, Lee Jacobs, MD, Moderator inspiration, etc). Electronic and e-mail submissions are accepted; 600 dpi resolution is required. Editorial Office: The Permanente Journal 500 NE Multnomah St, Suite 100, Portland, Oregon 97232 Phone: 503-813-4387; Fax: 503-813-2348 E-mail: [email protected] www.kp.org/permanentejournal Calling all Artists Distribution: If you have any questions regarding The Permanente Journal is always interested in considering artwork by KP clinicians distribution of this journal, contact 503-813-2623 or e-mail: [email protected]. and employees. Why not submit a sample of your work today? Where to find The Permanente Journal: A full-text version Send a high-quality sample of your artwork no smaller than 4"x5" and no larger of this journal is available on our Web site: www.kp.org/ than 8"x10" to: Managing Editor, The Permanente Journal, 500 NE Multnomah St, permanentejournal. In addition, copies of The Permanente Journal are available in Kaiser Permanente libraries Suite 100, Portland, OR 97232. E-mail: [email protected]. programwide. The Permanente Journal/ Fall 2002/ Volume 6 No. 4 1 editorial comments National Institutes of Health “Oregon Center for Complementary and Alternative Medicine”: Value to Permanente Medical Groups and to Kaiser Foundation Health Plan and Hospitals n 1999, the National Center for Complementary and ties. This group’s expertise would ensure importing the IAlternative Medicine (NCCAM), one of the institutes best scientific thinking and experience in these disci- and centers that make up the National Institutes of plines.