You may be surprised by the number of your patients using CAM therapy. This primer provides the background and tips you’ll need to have a productive conversation about it.
Fam Pract Manag. 2001 Mar;8(3):37-42.
Like it or not, our patients are using complementary and alternative medicine (CAM). Studies show that CAM is the fastest growing area in health care today. In 1997, an estimated 42 percent of the U.S. population used some form of alternative therapy.1 The numbers are even higher in family practice settings: One study found that 50 percent of patients were using at least one alternative therapy – and only half of them had told their family physician.2
To continue to provide quality care, we need a basic knowledge of CAM therapies and communication skills that will encourage patients to talk with us about the alternative therapies they’re using so that we can offer appropriate guidance and advice. This article is meant to provide those two things. It is not meant to encourage you to use CAM therapies in your practice.
Fifty percent of patients seeing family physicians are using some form of complementary and alternative medicine (CAM), according to a 1997 study.
Most patients are hesitant to share information about the CAM therapies they’re using with their physicians.
To encourage patients to talk about CAM, physicians should ask open-ended questions and avoid using terms that patients may perceive as biased.
CAM therapies your patients might ask you about
I commonly see patients using the CAM therapies described in this article. I find that having the following background information facilitates our communication about CAM therapies and the role they might play in patients’ health care.
Acupuncture. Acupuncture is the ancient practice of inserting fine needles into carefully selected points located along meridians, or energy pathways, in the body. It is thought that by adjusting the body’s life (or “chi”), healing will occur. The meridians have been documented electronically to exist, yet how the disruption of these pathways allows healing to occur remains unknown. In 1997, a National Institutes of Health (NIH) panel of experts issued a consensus statement for the use of acupuncture. According to this statement, clear evidence supports the effectiveness of acupuncture for the treatment of postoperative and chemotherapy-induced nausea and vomiting, nausea associated with pregnancy, and postoperative dental pain.3
Typically, acupuncturists receive training at schools of traditional oriental medicine. Many of these schools are now accredited by the Accreditation Commission for Acupuncture and Oriental Medicine. Currently, at least 34 states license acupuncturists; the majority require that licensees pass a national certification examination.
Chiropractic. The word chiropractic is derived from two Greek words meaning “done by hand” and is defined as “the diagnosis, treatment and rehabilitation of conditions that affect the neuromuscular system.”4 Chiropractic was practiced as long ago as 2700 B.C. It became an organized discipline approximately 100 years ago when Canadian Daniel David Palmer introduced it in the United States. Palmer believed that damage, disease and structural changes to the spine could affect other parts of the body and that manipulation of soft tissue could improve a patient’s health.
The majority of visits to chiropractors in the United States are for back pain. There is strong evidence that chiropractic treatment is as beneficial for low back pain as treatment given by primary care providers, orthopedists and physical therapists.5,6 The evidence for the use of chiropractic for other conditions is less compelling. While it has been proposed for the treatment of otitis media and asthma, there is not yet enough evidence to support or disclaim its use.
The Council on Chiropractic Education (www.cce-usa.org) has accredited 17 colleges of chiropractic medicine in the United States. Chiropractors are licensed in all 50 states and must pass either a state licensing examination or an examination given by the National Board of Chiropractic Examiners.
Herbal medicine. Ancient Egyptians used herbs for the treatment of disease as early as 3000 B.C. The Ancient Greeks also used herbal remedies, but it was the Romans who brought herbal medicine to Northern Europe. Herbs were also commonly used to treat disease in colonial America. However, as science became more established, people came to believe that synthetic ingredients were more effective than those found in nature and the use of herbal remedies quickly diminished, especially in the United States. Today, herbs are widely used in Europe and are again gaining popularity in the United States.1,7 Some of the most popular herbal remedies include St. John’s Wort for depression, Kava-Kava for anxiety, Saw Palmetto for benign prostate disease, Ginkgo biloba for memory and Echinacea for viral illnesses.
Herbal remedies are not covered by prescription drug laws and therefore are not subject to the rigorous standards and testing of the U.S. Food and Drug Administration. Manufacturers of herbal products cannot promote them as “cures” or “treatments.” They can only state that they “may promote …” a particular outcome, and they must include an FDA disclaimer on the label or advertisement. There is also no guarantee that a herbal product is formulated to ensure that the same amount of active ingredient is present in each tablet. When using herbal therapies, finding a reputable manufacturer is essential to help ensure safety, appropriate use and response.
Homeopathy. From the Greek words homios (“like”) and pathos (“suffering”), the word homeopathy simply means treating like with like. In other words, a substance that causes symptoms in well individuals can also be used to treat the same symptoms in sick individuals. While Hippocrates understood the basic concepts of homeopathy and used some homeopathic cures, Samuel Hahnemann, a German physician and chemist founded modern homeopathy. The theory of homeopathy is based on three of Hahnemann’s principles: 1. the “law of similars,” which states that a substance that can cause disease in a well person can cure similar symptoms in the diseased; 2. the “principle of the minimum dose,” which states that by diluting a substance, its curative properties are enhanced and its side effects minimized; and 3. prescribing for the individual, which advocates basing treatment not only on the medical diagnosis but also the patient’s temperament, personality and emotional and physical responses.
Two meta-analyses have been published suggesting homeopathic remedies are more effective than placebo alone. However, both studies state that the current research and literature in the field does not meet the rigorous, scientific proof needed to establish efficacy of homeopathy for specific clinical conditions.8,9 More research is needed before homeopathy can be declared clinically useful for any one condition.
There are currently 10 schools in the United States dedicated to teaching the art of classic homeopathy; however, there is no federal accreditation program for schools of homeopathy, nor is there a national licensure examination for homeopathic providers. Three states (Arizona, Connecticut and Nevada) do require a license to practice homeopathy, and two states (Delaware and New Hampshire) regulate the practice of homeopathy without licensure. Most homeopathic remedies can be purchased over the counter or on the Internet.
CAM AS DEFINED BY THE NIH
In 1992, the National Institutes of Health (NIH) convened a meeting to discuss the major areas of alternative medicine and to direct future research activities.1 As part of this meeting, the group defined the following seven fields of alternative therapy:
Alternative systems of medical practice. This field includes “folk” medicine and organized health care systems based on alternative practice. Examples include acupuncture, homeopathy and naturopathy.
Bioelectromagnetics. Researchers in this field study how living organisms interact with electromagnetic fields. Magnetic field therapy is one example of bioelectromagnetics practice. It is most often used to treat osteoarthritis and non-union bone fractures.
Diet and nutrition. This field includes the use of special diets to improve health. Examples include the macrobiotic diet and orthomolecular medicine.
Herbal remedies. This field includes the use of herbs and plants to promote and improve health. Herbal therapy is considered to be the most popular alternative therapy used in the United States. It is used for many conditions.
Manual healing methods. Practitioners use touch and manipulation to promote and improve health. Examples include chiropractic therapy, massage therapy and therapeutic touch.
Mind/body interventions. This therapy uses the interconnectedness of mind and body to improve health. Examples include psychotherapy, meditation, guided imagery, hypnosis, biofeedback and prayer. Used most commonly to treat nausea and vomiting (particularly for anesthesia or chemotherapy-induced hyperemesis gravidarum) and post-operative dental pain.
Pharmacological and biological treatments. This field includes treatment with drugs and vaccines not accepted by mainstream medicine. Examples include the use of shark cartilage, EDTA for chelation therapy (for coronary artery disease) and apiotherapy.
1National Institutes of Health. Alternative Medicine: Expanding Medical Horizons. Washington, D.C.: US Government Printing Office; 1992.
Naturopathy. Germany is considered the home of naturopathy. Literally meaning “natural treatment,” naturopathy is an umbrella term used for a wide range of natural medicines. Naturopaths are the “generalists” of the alternative therapy world. They are trained to use a wide variety of therapies, including nutrition, homeopathy, herbal remedies, hydrotherapy, massage, acupuncture, fasting and breathing.4
Naturopaths adhere to six basic philosophies:
The healing power of nature: The belief that the body has the inherit nature to heal itself;
Treat the whole person: The belief that health and disease result from the interaction of a person’s physical, mental, emotional, genetic, environmental and social components;
First, do no harm;
Identify and treat the cause: The belief that one should treat the cause of disease, not merely the symptoms;
Prevention is the best cure;
The physician is a teacher: The belief that a physician’s major role is to educate, empower and motivate patients to take responsibility for their own health.
Because naturopathy uses healing modalities from a wide variety of areas, few studies have been published that evaluate the use of naturopathy for any specific disease. Evidence for the use of naturopathic techniques often comes from the study of more specific complementary therapies.
There are currently four schools of naturopathy in the United States. Individuals study many of the same topics taught in allopathic or osteopathic medical schools. However, instead of pharmacology, students take courses in natural therapies. Currently, naturopaths are licensed or regulated in 14 states. Although there is a movement to credential naturopaths on a national level, each state currently has its own licensing examination or other process for regulating the practice of naturopathy.
WHEN PATIENTS USE CAM
Here’s how the author would respond in three situations that involve discussing CAM therapies with patients:
What would you say to a patient who visits your office to tell you he has opted for a homeopathic treatment for cancer?
The diagnosis of cancer is a devastating one, and patients will reach out for any hope they can find. I would emphasize to the patient the benefits of conventional chemotherapy, radiation therapy and other treatments offered by physicians who specialize in oncology. I would encourage the patient to discuss his proposed homeopathic treatment with his oncologists. If no hope is available from conventional medicine, I would try to encourage him to live one day at a time. If he has faith that homeopathic remedies may help, I would acknowledge it and care for him as I would any other patient.
What would you say to a patient who tells you she’s taking medicines suggested by her herbalist in addition to the medicines you’ve prescribed to treat her diabetes, hypertension, osteoporosis and congestive heart failure?
I would emphasize to her that all herbs have pharmacologic properties just as do conventional pharmaceuticals and would explain that there is the possibility of adverse interaction between herbs and any pharmaceutical, over-the-counter preparations or other type of prescribed product. I would review each herb with the patient in detail and would ask her not to take any herb that I needed more time to review. Once I had reviewed the herbal therapy, I would try to reach a joint decision with the patient regarding what would be safe for her to take. Most patients appreciate my willingness to carefully review their herbal therapy.
What would you say to a patient who’s taking Coumadin for atrial fibrillation when he tells you he wants to start taking Gingko biloba to improve his memory?
This combination of herbs and prescription drugs definitely falls into the unsafe category. Ginkgo biloba is thought to stimulate functioning nerve cells and protect nerve cells from pathologic influences. It also increases cerebral blood flow by inhibiting platelet-activating factor. Thus, it will potentiate the effect of Coumadin and can lead to an increased risk of bleeding. I would let the patient know of the possible devastating outcome that may occur if he combines these drugs. If he chooses to use Ginkgo biloba, I would stop Coumadin therapy immediately and document the reason for it in the patient’s record. However, I’ve found that most patients willingly follow their physicians’ advice if they appear to be well-educated regarding CAM therapies.
Talking with your patients about CAM
Most patients are reluctant to share information about their use of CAM therapies because they are concerned their physicians will disapprove. By remaining open-minded, you can learn a lot about your patients’ use of unconventional therapies. These strategies will help foster open communication:
Ask the question. I recommend asking every patient about his or her use of alternative therapies during routine history taking. One approach is simply to inquire, “Are you doing anything else for this condition?” It’s an open-ended question that gives the patient the opportunity to tell you about his or her use of other health care providers or therapies. Another approach is to ask, “Are you taking any over-the-counter remedies such as vitamins or herbs?”
Avoid using the words “alternative therapy,” at least initially. This will help you to avoid appearing judgmental or biased.
Don’t dismiss any therapy as a placebo. If a patient tells you about a therapy that you are unaware of, make a note of it in the patient’s record and schedule a follow-up visit after you have learned more – when you’ll be in a better position to negotiate the patient’s care. If you determine the therapy might be harmful, you’ll have to ask the patient to stop using it. (See the vignettes for examples.) If it isn’t harmful and the patient feels better using it, you may want to consider incorporating the therapy into your care plan.
General reference – books
Clinician’s Complete Reference to Complementary and Alternative Medicine. Novey DW. St. Louis: Mosby; 2000.
Professional’s Handbook of Complementary and Alternative Medicines. Fetrow CW, Avila JR. Springhouse, Penn.: Springhouse Corp; 2000.
Complementary/Alternative Medicine: An Evidence-Based Approach. Spencer JW, Jacobs JJ. St. Louis: Mosby; 1999.
Essentials of Complementary and Alternative Medicine. Jonas WB, Levin JS. Philadelphia: Williams and Wilkins; 1999.
Alternative Medicine: The Definitive Guide. The Burton Goldberg Group. Tiburon, Calif.: Future Medical Publishing; 1997.
General reference – journals
Journal of Alternative and Complementary Medicine
For more information: www.liebertpub.com/ACM/default1.asp
Alternative Therapies in Health and Medicine
For more information: www.alternative-therapies.com
General reference – Web sites
NIH Center for Complementary and Alternative Medicine www.nccam.nih.gov
NIH Office of Dietary Supplements ods.od.nih.gov/index.asp
The Richard and Hinda Rosenthal Center for Complementary and Alternative Medicine cpmcnet.columbia.edu/dept/rosenthal/
“Acupuncture.” NIH Consensus Development Panel on Acupuncture. JAMA. 1998;280(17):1518–1524.
“Acupuncture in the 1990s. A Review for the Primary Care Physician.” Peterson JR. Arch Fam Med. 1996; 5(4):237–240.
Chiropractic in the United States: Training, Practice, and Research. Springfield, Mass.: U.S. Publications Office; 1997.
“The Outcomes and Costs of Care for Acute Low Back Pain Among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons. The North Carolina Back Pain Project.” Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. N Engl J Med. 1995; 333(14):913–917.
Natural Medicines Comprehensive Database. 3d ed. Stockton, Calif.: Therapeutic Research Faculty; 2000.
PDR for Herbal Medicines. 2d ed. Montvale, N.J: Medical Economics; 2000.
The Review of Natural Products. St. Louis: Facts and Comparisons; 1999.
The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Blumenthal M, ed. Austin, Texas: American Botanical Council; 1998.
“Are the Clinical Effects of Homeopathy Placebo Effects? A Meta-Analysis of Placebo Controlled Trials.” Linde K, Clausius N, Ramirez G, et al. The Lancet. 1997;350: 834–843.
“Is Evidence for Homeopathy Reproducible?” Reilly D, Taylor M, Beattie N, et al. The Lancet. 1994;344(8937): 1601–1606.
A Textbook of Natural Medicine. Pizzorno JE, Murray MT, eds. Seattle: Bastyr College Publications; 1998.
Pocket Guide to Naturopathic Medicine. Boice J. Freedom, Calif.: The Crossing Press; 1996.
Discuss providers as well as therapies
Another way to help your patients negotiate the maze of alternative therapies is by stressing that they see appropriately trained and licensed providers and knowing whom to refer to in your area. Encourage your patients to ask alternative providers about their background and training and the treatment modalities they use. By doing so, your patients will be better equipped to make educated decisions about their health care.
Discuss CAM therapies with your patients at every visit. Charting the details of their use will remind you to raise the issue. It may also help alert you to potential complications before they occur.
TALKING ABOUT CAM
The following simple strategies will help you to get your patients to talk with you about their use of CAM therapies:
Ask the question.
Avoid using the words “alternative therapy,” at least initially.
Don’t dismiss any therapy as a placebo.
Discuss providers as well as therapies.
Discuss CAM therapies with your patients at every visit.
All things considered
By not educating ourselves about CAM therapy or avoiding the subject during patient visits, we risk poor outcomes for our patients. Instead, let me suggest that we learn more, keep the lines of communication open and become effective guides for our patients.
Dr. Steyer is an assistant professor of family medicine at the Medical University of South Carolina, Charleston, and a former Robert Wood Johnson clinical scholar at the University of Michigan, Ann Arbor.
1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997. JAMA. 1998;280(18):1569–1575.
2. Elder NC, Gillcrist A, Minz R. Use of alternative health care by family practice patients. Arch Fam Med. 1997;6(2):180–184.
3. NIH Consensus Development Panel on Acupuncture. Acupuncture. JAMA. 1998;280(17):1518–1524.
4. Shealy CN, Thomas R, eds. The Complete Family Guide to Alternative Medicine. Rockport, Mass.: Element Books; 1996.
5. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors and orthopedic surgeons: The North Carolina back pain project. N Engl J Med. 1995;333(14):913–917.
6. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998;339(15):1021–1029.
7. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med. 1993;328(4):246–252.
8. Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials. The Lancet. 1997;350(9081):834–843.
9. Linde K, Melchart D. Randomized controlled trials of individualized homeopathy: A state-of-the-art review. J Altern Complement Med. 1998;4(4):371–388.
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