Providers or products that make claims that are grandiose and dubious, for example; chiropractors who claim to cure insulin-dependent diabetes or offer alternative approaches to cure cancer.
2.
Providers or products who foster dependence, for example, therapists who recommend multiple visits per week or frequent visits for an unlimited period.
3.
Providers who recommend products that they sell and from which they profit.
4.
Providers or products that support the use of alternative approaches exclusive of conventional medicine or conventional providers.
Decreased harm of interventions: Chiropractic medicine to treat acute low-back pain and potentially avoid surgery; mind–body approaches to decrease anxiety and need for medical management
Treatment of conditions when conventional approaches fail: Treatment of nausea and vomiting of pregnancy with acupuncture, vitamin B6, and ginger
Prevention: Increased intake of isoﬂavones to potentially decrease the risk of breast cancer
Improved outcomes: Successful management of menopausal symptoms in patients at risk for breast cancer
One of the greatest barriers regarding issues of CAM is a lack of communication. As multiple studies show, most patients do not tell their physicians of their use of CAM. Often, this is the case even when the physicians are receptive to the topic. Given the prevalence of use and the potential for interactions with conventional approaches, it is imperative that questions regarding CAM be integrated into the patient history. Many patients simply do not think of sharing this information with their physicians, so direct and specific inquiry is necessary. Many practices incorporate this information in a separate sheet for patients to fill out and for physicians to review and add to the chart. It is useful to know all CAM therapies that patients used in the past or are using presently, particularly anything ingestible. If a patient is seeing a CAM practitioner, it is best to specifically ask if they recommended any supplements or botanicals. Oriental medicine practitioners or acupuncturists, for example, often treat with botanical products or herbal teas. Naturopaths and chiropractors often recommend vitamins and supplements. When patients are asked this history directly in an atmosphere of respect, they usually are very forthcoming, and the most significant barrier is broken.
Three factors contribute to an interesting dynamic that often arises when discussing issues of CAM with patients. This is an area in which (i) very few physicians received formal training, (ii) there is little (albeit increasing) research in the mainstream medical journals, and (iii) there is a tremendous amount of information, of variable quality, in the lay press. All of these factors contribute to a circumstance that often is uncomfortable for physicians. This discomfort is important to recognize because it can contribute to avoidance of the topic altogether. The development of CAM therapies and their integration into the treatment plans is a new and evolving area. It is appropriate to begin the conversation with a patient by explaining that this is new territory in conventional medicine and that you are not an expert. Most patients have assumed this to be the case, appreciate the honesty, and value the opportunity to discuss these dilemmas. This is a significant step in building a trusting and therapeutic relationship with patients interested in CAM.
It is useful to share the following decision tree with patients when making decisions regarding the use of CAM (Fig. 13.1).
Step One: Assess Potential Harm
Although research regarding CAM approaches is often less than optimal, the potential for any therapy to do harm should be thoroughly evaluated (to the best of available knowledge). It is necessary to evaluate the potential to cause both direct harm and indirect harm.
Potential for Direct Harm This should include any evidence regarding potential harm directly from the therapy or potential interactions. When lacking good evidence, assessment of the invasiveness of the therapy is a strong predictor of risk.
Potential for Indirect Harm This should include an assessment of potential harm caused by postponing effective treatments, and by financial exploitation. Many CAM approaches are costly, and the patient usually assumes all of the cost. Marketing can prey on vulnerable patients and result in significant and unnecessary expenditures.
Step Two: Assess Potential Benefits
The potential for any approach to be of benefit should be assessed on several levels.