Complementary and alternative medicines (CAM) are popular treatment options for many Americans.1 Unfortunately, many people who use CAM therapies are not comfortable discussing them with their doctors, and many physicians are uncomfortable with the topic as well. This communication gap between patients and their doctors represents an important opportunity for family physicians. It has been my experience that discussing CAM can lead not only to new insights into illness and health, but also to enhanced patient communication, satisfaction and quality of care. Even for those doctors who don't prescribe CAM therapies or endorse their use, a basic understanding of the subject can be valuable when speaking with patients.
For experienced family physicians who are not able to commit the time to an academic program, learning about CAM can be challenging. The field is very broad and still largely uncharted. However, as the pioneer of a clinical fellowship program in integrative medicine, former medical director of the University of Maryland School of Medicine's Center for Integrative Medicine, and co-founder of a thriving private integrative medical practice, I can suggest several effective approaches to help you become more comfortable talking to your patients about CAM.
What is CAM?
The National Center for Complementary and Alternative Medicine (NCCAM) is a branch of the National Institutes of Health that specializes in CAM therapies. According to NCCAM's Web site, http://nccam.nih.gov, CAM is defined as “a group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine.” Therapies within CAM are categorized as complementary if they are combined with conventional medicine, such as using guided meditations to lessen a patient's discomfort and enhance healing following surgery. Alternative therapies are defined as those that replace conventional medicine, such as treating cancer with a special diet rather than chemotherapy. These definitions are often blurred, and the list of what is considered to be CAM changes as therapies that are proven to be safe and effective are adopted into conventional medicine.
Today many CAM therapies are practiced in the context of integrative medicine, which is the combination of mainstream medical therapies with CAM therapies that have “high-quality scientific evidence of safety and effectiveness.”2 At its core, the field of integrative medicine seeks to incorporate a broader understanding of the nature of illness, healing and wellness. This understanding is gleaned from a wide range of disciplines, such as patient-centered medicine, psychology and alternative medical traditions, including ancient Chinese medicine, Ayurveda and homeopathy. The vision of integrative medicine is not to replace pharmaceutical treatments but rather to examine other paradigms of illness and health, understand their value, and advance the science and practice of modern Western medicine in the 21st century (see “How my practice works”).
To familiarize yourself with CAM, start by picking a topic of particular interest to you. A topic that both meets your practice's needs and sparks your passion for learning will be the most enjoyable and fruitful place to begin. For example, perhaps you have several patients who have asked if you know of any “natural” alternatives to prescription medications for lowering cholesterol or for reversing insulin resistance. Or, if you treat many patients approaching menopause, you may be interested in CAM treatments for alleviating the related symptoms. Nutrition, including both food and dietary supplements, is another popular topic because of the impact it has on patients' health.
Once you have chosen a topic of special interest, these approaches will help you find answers to your questions and increase your knowledge about CAM:
Speak with your patients about their personal experiences using CAM therapies.
Speak with local CAM practitioners, nutritionists or a fellow of integrative medicine.
Read CAM-related journals and attend CAM-oriented conferences.
Each approach will offer a unique view on CAM and its benefits.
HOW MY PRACTICE WORKS
In 2005, I co-founded The Gilbert Clinic, an integrative medical clinic located in the greater Washington, D.C., area, with Jonathan Gilbert, NCCAOM, a practitioner of Chinese herbal medicine. Our vision was to create an innovative practice where patients with chronic illnesses could receive excellent Western and Eastern medical approaches to their health problems.
This model thoughtfully integrates the allopathic paradigm with other health care systems to create a unique practice environment. Our practitioners and physicians stay within their area of expertise while communicating clinical findings with practitioners of other modalities. This creates a roadmap for the optimal treatment of our patients. The clinic also offers a 12-month program for treating fibromyalgia and chronic fatigue syndrome.
The Gilbert Clinic also includes psychotherapist Anita Bains, APRN, and psychiatrist Stephen Saunders, MD. We have spent many years in collaboration to be able to effectively offer this approach to patients. More information about our clinic is available at http://www.thegilbertclinic.com.
Learning from your patients
Speaking with your patients about CAM can be constructive, but your attitude will determine how effective the conversation will be. It is important to stay positive, listen carefully and ask questions. For example, start by asking your patients whether they are taking any “natural” supplements or alternative therapies, and what symptoms or conditions they are treating. Refrain from offering direct criticism unless you are knowledgeable about the therapy in question, and always provide a thorough explanation if you feel the patient should discontinue a treatment.
If patients ask for your opinion on a supplement or therapy that you are unfamiliar with, be honest without being dismissive. You can offer to look up the information later and get back to them, refer them to the NCCAM Web site or refer them to a pharmacist who is familiar with dietary supplements. This way you have validated their question without taking any additional time during the office visit.
When patients tell you about their experiences with a CAM practitioner, ask what they liked or disliked. You can even keep a list of local CAM practitioners your patients would recommend and a list of those they would not. Typically, patients like going to CAM practitioners because they enjoy how the practitioner listens to them and how their ideas about their health are respected and validated. Just as traditional medicine values the doctor-patient relationship, most CAM paradigms emphasize the healing effects of the practitioner-patient relationship.
PURSUING FORMAL TRAINING IN CAM
There are more than 30 academic programs in integrative medicine in the United States. These programs consist of CAM education courses in medical schools, research projects in CAM-related therapies or clinical programs offering various CAM modalities through the family medicine clinic. There are also seven integrative family medicine residency programs in the United States, some of which extend the training to a total of four years.3
For physicians who have completed a primary care residency program, there are several fellowship training programs in integrative medicine. The University of Arizona offers both a residential fellowship program and a distance-learning program designed to enable physicians to study while maintaining their practice. Philanthropic funding is available for study in the University of Arizona distance-learning program to medical school faculty who teach at schools that are members of the Bravewell Clinical Network (http://www.bravewell.org).
|University of Arizona*||http://www.integrativemedicine.arizona.edu/ifm/index.html|
|Beth Israel/Albert Einstein College of Medicine* (New York)||http://www.montefiore.org/prof/departments/family/residency|
|Maine Medical Center*||http://www.mmc.org/mmc_body.cfm?id=1551|
|Middlesex Hospital* (Connecticut)||http://www.midhosp.org/go/midHome|
|Oregon Health & Science University*||http://www.ohsu.edu/som/fammed/residency|
|University of Michigan||http://www.med.umich.edu/umim/education/fellowship.htm|
|University of Wisconsin*||http://www.fammed.wisc.edu|
|Program in Integrative Medicine, University of Arizona||http://www.integrativemedicine.arizona.edu/af|
|Duke Center for Integrative Medicine (North Carolina)||http://www.dukeintegrativemedicine.org|
|Center for Integrative Medicine, University of Maryland||http://www.compmed.umm.edu|
|Mayo Clinic Integrative Medicine (Minnesota)||http://www.mayoclinic.org/general-internal-medicine-rst/cimc.html|
|Jefferson-Myrna Brind Center for Integrative Medicine (Pennsylvania)||http://www.jeffersonhospital.org/cim|
|Osher Center for Integrative Medicine, University of California, San Francisco||http://www.osher.ucsf.edu|
|Scripps Center for Integrative Medicine (California)||http://www.scrippsintegrativemedicine.org|
Learning from CAM practitioners
CAM practitioners can share valuable information about the therapies they prescribe and the services they perform. Start with those practitioners recommended by your own patients. You can also find a directory for all types of CAM practitioners using an online search engine, such as http://www.google.com, or for a narrower search use http://www.yellowpages.com. (Try searching for “alternative medicine & health practitioners” in your city.) When you initiate contact and introduce yourself, understand that many CAM practitioners are apprehensive of medical doctors. Their natural instincts will be to assume you are calling to complain or criticize. You can put them at ease by explaining that you got their name from a patient of yours who was pleased with their care. Expressing sincere interest in learning about what they do is another good way to break the ice.
As you get to know CAM practitioners, ask about their education, licensing, scope of practice and how long they have practiced. There are different educational paths for each CAM modality, with some requiring several years of full-time study at accredited institutions and some requiring only a few weekends of study or merely correspondence courses with no actual clinical experience. Learn how their education compares with similar practitioners. For example, naturopaths may have graduated from a four-year, full-time school, or they may have only studied in a correspondence program. Well-trained CAM practitioners should be happy to tell you about their education, including where and how long they trained.
Once you have identified some credible CAM practitioners in your area, consider becoming a patient under their care. During my fellowship training in integrative medicine, I was expected to experience the various CAM modalities that I was studying. These experiences provided insight into my own health that I would not have achieved through reading or observation alone.
Tapping other resources
Information about CAM is available from a variety of other sources. Ask your local CAM practitioners to recommend books and journals. You can also find relevant articles on the NCCAM Web site, as well as a series of CAM video conferences that offer CME (http://nccam.nih.gov/videolectures).
Attending a conference is another good way to learn about CAM. CME credits are available for many of the CAM and integrative medicine conferences designed for physicians. Here is a small sample of organizations that sponsor conferences on CAM and integrative medicine:
The American Board of Holistic Medicine (http://www.holisticboard.org);
The American Holistic Medical Association (http://www.holisticmedicine.org);
The Center for Mind-Body Medicine (http://www.cmbm.org), which offers the Food as Medicine conference;
The Consortium of Academic Health Center for Integrative Medicine (http://www.imconsortium.org);
The Institute of Functional Medicine (http://www.functionalmedicine.org).
CAM and your patients' health
As you explore the world of CAM and integrative medicine, you will likely find that it opens up the communication between you and your patients and fosters discussions on healthy lifestyle choices. I have learned – and continue to teach my patients – that no amount of vitamins, minerals or other CAM modalities can undo the harm of an unhealthy lifestyle. Neither CAM nor integrative medicine is a panacea, but both can be useful. If we talk openly about these issues with our patients and really listen to them, they will be more likely to heed our advice on how to take care of themselves.