Alternative & Complementary Medicine: What's a Doctor to Do?
B-Jc, The Hastings Center Report
Surveys indicate that forms of alternative medicine are increasingly widely used by patients; the NIH's National Center for Complementary and Alternative Medicine (along with the National Cancer Institute) is conducting research on a variety of alternative therapies; and medical schools are beginning to incorporate complementary medicine in their curricula. But how do (conventionally trained) practicing physicians respond to this growing interest? Depends on which physicians you talk to, it seems.
Some are downright hostile; some have been champions of "integrative medicine" for many years (see the debate between Arnold Relman, editor emeritus of the New England Journal of Medicine, and Andrew Weil, director of the University of Arizona's Program in Integrative Medicine, Archives of Internal Medicine, 11 October 1999, for example). Others are beginning to incorporate alternative therapies into their otherwise conventional practices--for example, New York's Memorial Sloan-Kettering Cancer Center recently opened an "Integrative Medicine Service" offering massage, acupuncture, nutritional advice, and meditation (New York Times, 23 November 1999).
Not long ago John Astin and colleagues reviewed published studies of physician referrals to complementary and alternative medicine (Archives of Internal Medicine, 23 November 1998). Although they reviewed only English language publications and methodological differences across studies pose difficulties for intrepretation, they concluded that "large numbers of physicians are either referring to or practicing some of the more prominent and well-known forms of CAM" and "many physicians believe that these therapies are useful or efficacious." Median referral rates for the therapies on which the review focused ranged from 50 percent for chiropractic and 47 percent for acupuncture, to 24 percent for massage, 10 percent for homeopathy, and 4 percent for herbal medicine. Physicians' belief in the efficacy of CAM ranged from a median of 58 percent for massage to 15 percent for herbal medicine.
Arthritis Today, in coordination with the Thurston Arthritis Research Center at the University of North Carolina at Chapel Hill, conducted its own survey of patient and physician attitudes to CAM among U.S. primary care physicians and rheumatologists who treat patients with arthritis and related conditions (Arthritis Today, November-December 1999). Of the responding physicians, 85 percent believed some alternative therapies may be effective and 84 percent felt more research should be funded, while 49 percent recommended some form of CAM to their patients. Only 10 percent reported being well educated about CAM; two-thirds (66%) said they "know 'something'," whether because they actively sought information (33%) or read information when they came across it (62%). Many (38%) felt that CAM offers patients a valuable way to be involved in their own care; but a substantial minority (20%) believed that such therapies "are a waste of time and money." They worried that patients would forgo conventional treatments (73%); experience adverse interactions with prescription medications (50%) or be harmed by the therapy itself (48%).
More than half (52%) expressed concern that their patients don't tell them about using CAM, yet only 40 percent reported initiating discussions themselves while 58 percent said they discussed alternatives if the patient brought it up. Among their primary reasons for discussing CAM with their physicians, patients for their part cited wanting the doctor to be fully informed (71%) and concern about drug-therapy interactions (60%). The reasons they gave for not telling physicians about their use of alternative therapy included believing the doctor didn't know enough to help them (23%), feeling there was no reason to tell him or her (17%), and being afraid he or she wouldn't approve (12%).
At the recent annual conference of the American Institute for Cancer Research, Bernadette Marriott, former director of the NIH Office of Dietary Supplements, urged physicians to be proactive in asking patients about their use of CAM, especially herbal medications or dietary supplements ("Always Ask about Alternative Medicine Use," Internal Medicine News, I November 1999). …