Friday, November 22, 2019

Paths to Practice Interview: Dr. Annie Budhathoki, DAOM, LAc of Huntsman Cancer Institute

keywords: interview series, paths to practice, integrative oncology, research, metrics, wellness center, Huntsman Cancer Institute integrative oncology, hospital practice acupuncturist

The Hospital Practice Handbook Project Interview Series: Paths to Practice
Focus on Dr. Annie Budhathoki

www.thehospitalhandbook.com

Interview recorded on March 1st, 2019
Go to our YouTube Channel to watch the video.

This Paths to Practice interview is with Dr. Annie Budhathoki, DAOM, LAc, doctor of acupuncture and Oriental medicine, and licensed acupuncturist at the Linda B. and Robert B. Wiggins Wellness and Integrative Health Center, Huntsman Cancer Hospital and Clinics, the University of Utah, Salt Lake City, Utah.

Background 
video interview minute 0 - 5  
Annie Budhathoki, DAOM, L. Ac. is the wellness education and training coordinator at Huntsman Cancer Institute’s Linda B. and Robert B. Wiggins Wellness and Integrative Health Center.
Her clinical specialty is treating cancer-related side effects. She helps patients maintain wellness and longevity after a cancer diagnosis. Dr. Budhathoki is a research investigator on the use of acupuncture in the oncology setting. Her areas of interest include oncology, integrative medicine, pain management, geriatrics, and neurological disorders. 

Since 2012, she has worked full time as an integrative oncology clinician at Huntsman Cancer Institute in Salt Lake City, Utah. Dr. Budhathoki spends about 10% of her time in teaching and outreach. She is adjunct faculty for the University of Utah where she teaches in the medical school’s integrative medicine program.

Dr. Annie Budhathoki

Dr. Annie Budhathoki’s Path to Hospital-Based Practice
See minutes 07:55—14:00 for the related section of the video interview
Dr. Budhathoki attended Pacific College of Oriental Medicine (PCOM) San Diego where she obtained her master’s degree in acupuncture and oriental medicine. Then, she studied healthy aging and longevity at Yo San University in Los Angeles, CA, where she received her doctorate degree in the field.

In November 2009 she opened a private practice in Salt Lake City, Utah, where she enjoyed working as part of a patient’s healthcare team. She started work at Huntsman Cancer Institute pro re nata (PRN), in the summer of 2012 and by October 2012 she was a full-time employee there.

A Doctoral Degree in Healthy Aging & Longevity: Everything at Huntsman is a Longevity Prescription
minute 16:00
Megan:  So, you said your doctorate was in healthy aging and longevity.  What are some things you love about your work at Huntsman?

Annie: So, getting that doctoral degree in healthy aging and longevity my goal was to marry the ancient concepts of longevity with life after cancer and with cancer.  So that our patients can get the very best results they have possible. I see everything in our hospital as a longevity prescription.  So, our entire goal as a hospital is about patient care and about allowing a patient to get those best days as long as possible to be increasing their quality of life...to be with family, to be doing what they want to do, to be enjoying their days.

And that’s really empowering to me to be able to take these ancient pieces…, integrate [them] into what Huntsman is doing at large with treating cancer and giving patients these really amazing and sustainable results.

And that gives me goosebumps because I think patients feel that when they come to Huntsman, we are focused on them and their priorities of quality of life and improving their life for as long as possible. At Huntsman, we treat patients and caregivers. 

What is your favorite thing to do in hospital practice?
Annie: Working with patients at the wellness center. The Wellness Center helps patients regain their own power. The patients can work on themselves while the oncology teams work on their cancer.
Acupuncture helps these patients with their stress and improves their sleep. Acupuncture is empowering for them during a difficult time. We reach the patients where they are. Often offering them hope in a unique way.


The Linda B. & Robert B. Wiggins Wellness and Integrative Health Center at Huntsman Cancer Institute
Dr. Pamela Hansen began the Wellness Center in 2005 with the “power exercise” program. This grassroots program out of an auxiliary bathroom helped patients with exercise and movement while they were undergoing cancer treatment. This wellness center is one of the few wellness centers inside an academic cancer hospital. It has grown to include over 36-39 programs depending upon the season. And, the Wellness Center publishes a quarterly catalog for patients, caregivers, and staff.
In 2005-2007 the wellness center program was very small. Just an afternoon session, once a week.  And it had a big waiting list.  So, in 2012, they decided to bring acupuncture on full time.

This year, the wellness program has 4 acupuncturists and 9 massage therapists. The Wellness Center’s clinical services are available from 7AM to 7PM most days Monday through Friday. In the wellness center, acupuncture and massage have a daily treatment average of 20-25 patients per day for each program.  Last year, in 2018 the whole wellness center saw over 25,000 patients in our more than three dozen programs. [minute 13 of the video interview]

The Wellness Center is an outpatient acupuncture practice inside the cancer hospital.  The acupuncturists treat the side effects and symptoms of cancer and cancer treatment [such as] neuropathy, pain, nausea, insomnia, and hot flashes. Dr. Annie Budhathoki also does inpatient acupuncture for hospitalized oncology patients.

Wellness Center Funding and Revenue Streams
Annie: The Wellness and Integrative Health Center at Huntsman Cancer Hospital is a budgeted program supported and directed by our patient-centered administration. Most of our programs are low-cost to no-cost; programs with a fee are generally reduced costs similar to a copay. Acupuncture is a fee-for-service program and the cost to the patients, caregivers, and staff is $40. Additionally, Huntsman has a financial assistance program that supports persons living on a low income and our wellness center offers a sliding scale within this program. Currently, very few of the insurance providers in the state of Utah cover acupuncture, so we don’t have insurance billing set-up for our acupuncture services.  

The Wellness Center is a Place Where Patients Regain Their Power 
minute 22
Annie: You know, the Wellness Center [is amazing; ] we have all this programming. At Huntsman, we have a supportive oncology team.  Dr. Anna Beck is the director of supportive oncology; when she came to Huntsman [she reshaped] the models for integrative medicine. 
This wellness center is a place where people are empowered to take charge of their health while going through cancer treatment and beyond into survivorship.
As providers, we have the opportunity to support people affected by cancer to overcome various health and wellness obstacles. We ensure each person feels empowered to improve and maintain their individual health despite their cancer diagnosis or former health status. When championing the best care of each specific symptom, we work together as an integrative team supporting the goals and betterment of each patient. Often this includes referring them into various programs that also support their needs, knowing that this is how they can continue to regain their power.
In the Wellness Center, we are supporting the basic health needs and daily quality of life issues which affects a person’s ability to function.  We manage symptoms like nausea, fatigue or sleep while their physicians are working on the cellular level to attack their cancer or on a surgical level to get things taken care of.

[In oncology the side effects of chemotherapy, radiation, surgery can be disempowering] for a patient because medicine takes over. And rightfully so in many cases so that those specific diseases can’t become chronic illnesses or can be cured if you will.  But in wellness and integrative health and especially acupuncture and massage, fitness, nutrition—this is where patients really get a chance to shine on their own; to regain their power. 

Dr. Annie Budhathoki

Advice for those of you working in integrative oncology 
Annie: As you practice in a hospital setting, keep that in mind: how do the patients remain empowered with their own health care as they go through that? 

The Inpatient Acupuncture Program at Huntsman Cancer Institute
Annie:  We started the inpatient acupuncture program with an Imagine Perfect Care grant from the University of Utah.  The inpatient acupuncture program began in September 2018.
We started that program on the oncology floor, working with symptoms like nausea or constipation or ir-retractable vomiting.  [Any] symptoms that would keep a patient in the hospital and extend their stays and prevent them from going home. [Eventually the program] moved into the surgical ward and into other parts of the hospital.  But the initial work was symptom-based, treating any issues that would keep a patient in the hospital too long.

What is the goal of integrating acupuncturists at Huntsman?
Megan:  So, you’re using acupuncture as a complement to ongoing care to help people have shorter inpatient stays?

Annie:  Our goal, long-term is to show the efficacy of acupuncture in an inpatient oncology clinic in a hospital and to show feasibility as far as reducing costs.
We believe acupuncture is a cost-saving measure for the hospital overall.  Whether that’s a reduction of opioid use, whether that’s reduced hospital stays, or reducing re-admission rates; that’s really our goal.

Integrating Clinical Outcome Measures Seamlessly in a Clinical Research Environment
Megan:  Are you doing ongoing research studies related to either of these programs? 

Annie:  So, Huntsman is a research institution.  [Research is] a foundational force of Huntsman alongside our clinical care. Research is really embedded throughout the hospital. In the wellness and integrative health center, we have a number of research projects.

[Related to] the acupuncture program we currently have a mindfulness acupuncture research study with Dr. Eric Garland who [is] a leading mindfulness researcher.

We also have a chemotherapy-induced peripheral neuropathy (CIPN) study. Which employs an fMRI to [measure] the implications of acupuncture on CIPN.  And we have an inpatient acupuncture research study in the works.

Teaching and Outreach with Medical Students at the University of Utah
minutes 6-8 and minutes 25-26 of the video interview

Annie: The University of Utah has a very strong collaborative approach to medicine.  Recently, Dr. Amy Locke created and developed an integrative medicine pathway.  Prior to that, we had an integrative medicine elective for our medical students. I teach in both [the elective and the pathway].

What is the University’s Integrative Medicine Elective?
Annie: It’s an elective for medical students to [shadow] integrative medicine practitioners and [observe] integrative medicine in action.  So, they come and spend about 1-2 weeks with us here in the wellness center [where they follow me] in the acupuncture clinic and [other] practitioners in their clinical work.

What is the Integrative Medicine Pathway?
Annie: In the integrative medicine pathway, we [have several learning structures]. We do panel discussions about integrative medicine.  We’re developing a modalities class.  There are different ways in which we work together to educate medical students. [The vision is] to develop their [knowledge base on integrative health] and [improve their ability and confidence] in referring to integrative medicine and utilizing it in their future [healthcare workplaces].

minute 25:50
Megan:  So, as an instructor in the medical school and as a clinical observation site you are shaping the future of healthcare integration and help the physicians be informed and feel comfortable referring to different integrative medicine services.

Annie: I really love that. I think, you know, spending a day with a student, a medical student is very powerful. A whole day together in an acupuncture clinic where they can ask all the questions they have in the world. And they can try the needle and they can explore the ideas on how to find an acupuncturist; “what could I use it for in my specialty?”. For me, that also gives me goosebumps for the future. Because I think that being a template or a first impression on acupuncture for their field is very rewarding.

Advice for future and current hospital acupuncturists
minute 14:10
Megan: What do you see as the biggest work-related challenge or learning experience for acupuncturists?

Biomedicine Communication, Conventional Medicine Literacy, and Practicing Research Literacy
Annie: “I think when it comes to work-related challenges, I think that our education [programs] as a whole need to do a better job at the literacy of speaking with elite oncologists, amazing world-class surgeons, nursing staff, and then, of course, patients.”

Annie recommends you learn and practice research literacy, study your hospital-based specialty whether it is oncology or OB/GYN. When you do this, you are better prepared to be “at the table [and] present our profession in the very best way possible”. The key factor in good communication with someone is language. Integrate both the practices and languages of TCM and Western medicine to “create a synthesized dialog that medical professionals can understand.” 

Annie: “Many of the ancient tools we were given are amazing. But [you need to] bring those to the table and translate [their usefulness] in a way that makes sense for the medical professions at large and ultimately [how these tools] benefit the patient [by giving] them the very best results in their care.”

minute 18:00
Dr. Annie Budhathoki’s Advice for Students and Professors of Acupuncture Education Programs
The educators at acupuncture programs could do better at informing students about research literacy and how it relates to growing the acupuncture practice field. The language of research is essential to know and hone for communication with your hospital practice team, your physician advocates/physician champions, and your hospital administrators. Dr. Budhathoki’s doctorate degree, she says, helped her build and grow research in the field.

Take time, on a regular basis, to read the research in your field and related fields and discuss it with your colleagues.
Megan: This skill, research literacy, is one of the “5 ingredients” noted as essential in the HH Project resource booklet, Getting Your Foot in the Door of Hospital-Based Practice: First Steps.

Advice for the Student: Know Your Dream; Allow Your Dream to Grow & Expand
Annie: “Allow [your] dream to be as big as possible.  Thread every piece of [new] information you have into that dream as you learn.  So, as you attain that dream and those pieces come together, your dream then expands. And then, once you get that dream job, you [then] see all the professors, all of the people… that guided you and mentored you.  And, like in my case now I am guiding and mentoring.  And so, the dream expands.”

Dr. Budhathoki’s advice for the New Hospital Practitioner
Hone your patient care skills. “Sharpen your diamond”, Dr. Budhathoki says. “Become a masterful practitioner” in your facility, for your specialty, for your patients. Ways to hone your skills may include: completing a doctoral degree, practicing your research literacy skills, and reading acupuncture books written by physicians to better understand their perspective.

Patient Care First 
minute 19:50
On Gloving During Clinical Care: “Always Wear Gloves”
Dr. Budhathoki wants all her hospital-based practice colleagues, especially those working with immune-compromised patients to think about where the microbes are. Keep infectious disease at the forefront of your mind. Hand washing is extra important with immune-compromised patients.

Annie: Keep the patient in the forefront of your mind. Think about what is best for them and the risks involved. Align the safety of the patient with meeting their needs for symptom/condition. Keep the patient is as safe as possible. Always wear gloves. Hospital gloves are very thin and there are some good tricks to getting them to fit you well. Once you get used to them, it will not interfere with your palpation skills.
I never want to bring what I have from my life into a patient’s internal environment. So, as a protection for myself and as a protection for the patient, gloving is my number one [priority in my hospital practice environment]. Get to know your infectious disease nurse.  Get to know your infectious disease team.  [Contemplate] where things live and how they live on you and others so you are not putting a patient at risk any time, ever, including yourself.

Collaborate & Connect with your Champion 
minute 21:20
Dr. Budhathoki believes the collaborative connection to colleagues in the workplace are important.
Annie:  “So, who do you know who really loves acupuncture in your hospital? Who can become your physician champion?  And, as you find a champion, you know, what is their dream for your dream?”
Allow them [your physician champion] to help you grow and [expand your work/your program]. 
Find your physician champion. This is your advocate to help you grow and connect with others.
Ask your hospital champion what you can do for them. Don’t email your champion too frequently.
Be concise, courteous and respectful of their time. For example, when communicating with them, use three bullet points, no more. They are very busy and get hundreds of emails a day.

Luckily at Huntsman, we have had a number of physician champions through the years that have… really allowed acupuncture to become a very integral part of their oncology practice or surgical practice.

Megan’s note on “physician champion”:
Sometimes we talk about them as our “change agents” or our “advocates” or “hospital sponsors”. There are different terms for this. In the Project, I call them our “hospital sponsors” because sometimes they are not a physician, sometimes they are a nurse practitioner. Basically, a sponsor or champion is someone very established in the system who wants to advocate for you. This is a very important connection. More on this subject here.

Metrics and Integrative Oncology
How do you define success for an integrative health program within a mainstream oncology/cancer care clinic and/or wellness program?
Look at programs that have acupuncturists integrated as part of the treatment team. It is important to measure patient results, such as patient outcome measures and patient satisfaction. You should have research projects in place.

What are meaningful metrics for a patient-centered oncology program?
Annie: We use Facit.org questionnaires.
The website has an extensive set of oncology issue-specific questionnaires. It includes the following types of questions: pediatric oncology-specific, general adult functional assessments, metrics specific to the type of cancer, metrics specific to cancer therapy, specific to symptoms, specific to treatments, for patients receiving enteral nutrition and feeding, for non-cancer specific measures like dyspnea in chronic illness and palliative care.

Dr. Annie Budhathoki’s Recommended Reading for the Prospective or Current Hospital-Based Practitioner interested in Oncology and Wellness Center Work
minute 27:00
Annie likes reading material that helps her better understand other perspectives, such as the patient’s perspective and the oncologist’s perspective.

Annie: “I love to read books by physicians and patients about my specialty on cancer and oncology as a lay book or as an easy reading. I like to go outside of our box and get into the physicians’ minds. I really love reading books that are written by physicians about acupuncture and oriental medicine or integrative medicine.”  

Kitchen Table Wisdom: Stories that Heal

Book that Annie recommends to everyone reading this article or watching the interview is Kitchen Table Wisdom: Stories that Heal by Rachel Naomi Remen, MD. This is a gathering of short stories the author compiled as she learned to practice compassion in her oncology practice.

Annie: “These types of books inspire me every day to become a better provider. [They help me keep a patient-centered] focus. And they help me see the physician's perspective and the conventional medical perspective. [I like] reading material that helps me put [myself] in the shoes of a physician [or the] shoes of the whole team. And, [books that put me] into the shoes of [my] patients, of course.”

Megan: I love that idea… for perspective, to read what physicians write about what we (acupuncturists) do so to better understand their perspective. And so, improve our communication with them.


Closing Notes
What else do you want the hospital-based acupuncturist community to know about integrative oncology and acupuncture?
Annie: Please wear gloves and work alongside with your infectious disease nurse to develop patient safety protocols in your hospital.
I really love integrative medicine and acupuncture. I am excited to see the research move forward. We are right on the cutting edge of integrative medicine. It is a powerful place.

Want to learn more?

Video editing acknowledgments
Thank you to Albert Stern, MSAOM, for editing this video. 
You can review his Chinese Herbal Medicine formulas at his TCM Picture Book YouTube channel 

Definitions of terms used in this article
PRN = “pro re nata” or as the situation arises aka “as needed”. 
You can read more about this term here: “What Does a PRN Job Position Mean in a Hospital Setting?” and “Pro Re Nata (aka “PRN”)-Is It For You?”

Related blog posts
Other Program Interviews
Oncology and Acupuncture 
Research Literacy and Hospital-based Practice, some Resources
Recommended Reading Lists
Dr. Budhathoki recommended this book in her interview: Kitchen Table Wisdom: Stories that Heal by Rachel Naomi Remen, MD.

If you follow the Amazon links from this blog and make a purchase within a few hours, a few pennies from your purchase will go toward supporting the Hospital Handbook Project at no extra cost to you.
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More Reading & Listening Lists from the HH Project Community

  
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