How to talk to your doctor about complementary and alternative medicine

by Richard Glickman-Simon, MD

Dr. Jacki Hart launched this column by calling for an integration of conventional and alternative systems of healing. But since these two approaches are very different, and often seem at odds, such a process must be based on open communication between allopathic physicians (practitioners trained in the conventional model of care) and their patients, a significant number of whom already use alternative medicine. For my first contribution to this column, I will build on Dr. Harts comments regarding the patient-physician relationship as it pertains to complementary and alternative medicine.

In some respects the gap between complementary and alternative medicine (CAM) and allopathic medicine is narrowing. Nevertheless, significant differences remain, and they surely always will. On one hand, this tension is not a bad thing, since it often creates opportunities for medical innovation. In the clinical setting, however, the division can be destructive, particularly if it leads to a breakdown of communication between patients and their physicians.

Americans continue to be attracted to CAM in considerable numbers over 40% report regularly using CAM products and services, up from about a third over the past decade. The vast majority of these CAM users also see their allopathic physicians for the same medical condition. Contrary to popular opinion, most people who pursue an interest in CAM do not fundamentally reject biomedicine or the conventional physician. Rather, many patients are attracted to CAM because they find it to be consistent with their lifestyle, beliefs, and values.

Patients are far more likely to discuss both their allopathic and CAM treatments with their CAM practitioners than with their physicians. In a recent survey of 86 breast cancer patients, women cited the following reasons for not discussing their CAM interests and practices with their doctors:

• The impression of physician disinterest
• The anticipation of a negative response
• The belief that the physician is unwilling or unable to contribute useful information
• The perception that the CAM therapies they are using are irrelevant to the biomedical treatment
• Their views regarding the appropriate coordination of different healing strategies

Women in this study also said they were not looking for physicians to endorse particular CAM therapies. Rather, they appreciated those who were respectful, open-minded, willing to listen, and honest about their limited knowledge of CAM.

Physicians show considerable variation in their enthusiasm for CAM. A recent analysis of several international surveys found that a significant number of physicians selectively practice CAM, refer their patients to its practitioners, and/or believe in its effectiveness 19% of physicians practiced massage or chiropractic, about 17% practiced acupuncture or herbal medicine, and 9% practiced homeopathy.

The researchers also found that physicians commonly referred their patients to acupuncturists and chiropractors (43% and 40%, respectively) but rarely to herbalists (4%). Finally, roughly 50% believed in the effectiveness of acupuncture, chiropractic, and massage but only 13% had faith in herbal medicine. Physicians cited four main reasons for their acceptance of CAM:

• Patients lack of response to conventional treatment
• Patients request or preference
• Belief in the effectiveness of CAM therapy
• Fewer adverse effects

Many of the surveys were conducted in countries more accommodating towards CAM than the United States. A recent survey of US primary care physicians (family practitioners, pediatricians, and internists), however, reaffirms the same findings: a sizable but widely variable percentage of physicians use or accept the legitimacy of selected CAM interventions, and their opinions vary according to the nature of the intervention. American physicians, for example, tended to be more enthusiastic about mind-body interventions (meditation and biofeedback) and less keen on those therapies that require the administration of medicinal substances, such as megavitamins or homeopathic remedies.

While it appears that roughly half of physicians take at least some CAM modalities seriously, a considerable number remain skeptical. When asked why they oppose the use of CAM by their patients, physicians most often site one or more of the following:

* Alternative practitioners do not possess sufficient knowledge to properly diagnosis an illness
* There is insufficient scientific evidence of effectiveness for CAM
* CAM is potentially harmful either directly through its adverse effects or indirectly by delaying appropriate medical care

One major reason for this skepticism is a lack of training and experience in CAM. Approximately two-thirds of the 125 American medical schools offer some instruction in alternative medicine, but all of it is elective to date, no school requires courses in CAM. This means that the vast majority of practicing physicians, particularly those with long established practices, have had little if any formal exposure to CAM. Any significant education with CAM, therefore, must be obtained independently, which helps to explain the tremendous variability of CAM in physicians practices.

Moreover, since the biomedical model of disease dominates medical education in this country, most American physicians graduate with an attitude towards health and healing inconsistent with many CAM philosophies.

The perceived lack of scientific evidence to support CAM is a source of controversy. While it is true that there is limited evidence for the efficacy of most CAM therapies, it is also true that the majority of biomedical interventions also lack scientific evidence supporting their efficacy. It is interesting to note that, despite their concern for scientific proof, physicians acceptance of any medical intervention allopathic or alternative often has more to do with such factors as patient beliefs, the availability of referrals in the community, and cultural norms.

There is also the "plausibility factor" many physicians will not accept the legitimacy of a therapy without a plausible scientific explanation for its effects. Interestingly, the plausibility factor often determines the constantly shifting boundary between CAM and conventional medicine. As scientific theories are developed to explain their effects, CAM interventions tend to cross over into the mainstream of acceptability.

Even if a physician knows very little about CAM in general, he or she is often more comfortable advising patients on therapies that conform to familiar biomedical principles. For example, the growing body of research that helps to explain the clinical effects of mind-body techniques, such as meditation and biofeedback, makes physicians more likely to engage their patients in these specific interventions. Physicians are far more reluctant to discuss interventions for which a scientific explanation is less plausible, such as homeopathy or energy healing.

Based on this understanding of how patients and physicians perceive CAM, in the next article of this two-part series, I will consider how patients and physicians can effectively communicate about complementary and alternative medicine.