August 2000 • Volume 6 • Number 8
Complementary and alternative medicine
Do you know what your patients are up to?
BY CINDY McCANSE
Pop quiz
Name the primary indication associated with each of the following:
- St. John's wort (Hypericum perforatum)
- Echinacea (Echinacea purpurea)
- Ginkgo (Ginkgo biloba)
- Saw palmetto (Serenoa repens) (answers at story's end)
These days, if you're not fluent in "herbalese," you may be shortchanging your patients.
Echinacea purpurea: Help during cold and flu season?
Patient self-medication with herbal medicines and botanicals may be one of the fastest-growing trends in health care today. In fact, more and more patients are turning to alternative medicine providers of all stripes.
One widely known and well-regarded study published in the Journal of the American Medical Association puts the number of patients using complementary/alternative therapies at slightly more than 40 percent; other studies, at closer to 60 percent. What's perhaps even more surprising is the growing body of clinical evidence for the efficacy of many of these types of therapies.
Examples of Evidence
Take ginkgo extract in the management of cerebral insufficiency, for example. Bandolier, one of the premier sources of systematic reviews of clinical trial evidence, upholds the effectiveness of ginkgo for this indication.
Now contrast those results with findings published in the Cochrane Reviews comparing the benefits of routine continuous electronic fetal heart rate monitoring during labor -- a widespread and conventionally accepted practice -- with intermittent auscultation. The evidence shows that although the number of neonatal seizures drops slightly with use of electronic fetal monitoring, the rates of Caesarean section and operative vaginal delivery increase markedly.
Not a stellar performance, by any means. Yet fetal monitoring's the norm among Western practitioners.
Herbal and botanical products line the shelves of many retail pharmacies these days.
Why You Need to Know
These and related issues were addressed at several sessions during the May 3-7 Society of Teachers of Family Medicine annual spring conference in Lake Buena Vista, Fla. Andrea Gordon, M.D., of Puyallup, Wash., discussed her experiences at the University of Washington, Tacoma, teaching about herbs using a case-oriented, evidence-based approach.
"Some of them are useful tools," Gordon said. "Some of them are better tools than what we currently have. But some of them are potentially harmful." St. John's wort, for example, when used in conjunction with the protease inhibitor indinavir, has been shown to significantly decrease the effectiveness of the HIV-1 drug.
Because so many patients are availing themselves of herbal products, Gordon added, it's important for physicians to ask patients about them -- and ask about them in the proper way.
"It's not useful to say, 'You're not using any of that herbal crap, are you?'" she said. "You have to ask in a way that shows patients you care. And it's not just patients with cancer; it's older women coming in for their yearly exam."
Learning the Ropes
How'd you do?
- St. John's wort is used to treat mild depression.
- Echinacea is thought to stimulate the immune system.
- Ginkgo extract is used in the management of cerebral insufficiency.
- Saw palmetto is used in the treatment of urinary problems stemming from benign prostatic hypertrophy.
But there's far more to complementary and alternative medicine than just herbal and botanical products, and physicians need to keep pace with their patients, said Gordon's co-facilitator, Benjamin Kligler, M.D., M.P.H., of the Beth Israel Residency Program in Urban Health in Brooklyn, N.Y. Kligler cited a 1998 survey showing that 31 percent of U.S. medical schools required coursework about various CAM topics. The percentage that offered elective CAM courses was more than double that.
According to the survey, Kligler said, when CAM was taught in medical schools, it was more likely to be offered by departments of family medicine than any other specialty department. Not surprisingly, this appears to affect how family physicians perceive and react to CAM.
In another session at the STFM meeting, presenters Janice Probst, Ph.D., and Bruce Schell, Ph.D., discussed the results of a survey about CAM mailed to primary care physicians in South Carolina. Overall, family physicians were more likely than other primary care providers to ask patients about CAM and encourage them to use certain alternative therapies. They were also more likely to use particular CAM practices themselves and more eager to learn about unfamiliar CAM modalities.
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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