1. Assess potential harm 2. Assess potential benefit What is the potential for direct harm? (from the treatment itself; e.g., toxicity, injury) High What is the potention for indirect harm? (e.g., postponing other treatments, financial exploitation) DO NOT RECOMMEND DO NOT RECOMMEND DO NOT RECOMMEND Are there data on efficacy? Low High Low Yes No Yes No DO NOT RECOMMEND Is there cultural evidence? Is there strong patient belief? 3. Assess the quality of product or provider (e.g., independent product assessment, licensing body, patient experience) 4. Assess the integration with the conventional treatment plan Acceptable Unacceptable Evidence shows no efficacy Evidence shows efficacy Indeterminant DO NOT RECOMMEND No Yes Can the provider be integrated? (e.g., desires collaboration, supports integration of conventional and CAM approaches) No Yes RECOMMEND (informing patient of rationale for recommendation and level of evidence for the approach) Can the approach be integrated? (e.g., no significant interactions or contraindications with conventional treatments)
Figure 13.1 Decision Tree for Integrating Complementary and Alternative Medicine Approaches.
Scientific Evidence A review of the peer-reviewed literature should certainly be conducted for evidence of the effectiveness of the approach under consideration.
Cultural Evidence Another form of useful information is the historic or cultural use of the approach. For example, it is valuable to consider whether a therapy has a long history of use within a given culture. If, on the other hand, the approach has no historic use, this is important to recognize. Examples include the use of black cohosh for menopausal symptoms, which was used for centuries with reported safety and effectiveness, compared with red clover, which has no historic use or track record. Another example would be acupuncture, with thousands of years of use, compared with chelation, which was in use for a relatively short time and is associated with considerable debate regarding its benefit.
Personal Belief Another part of the assessment of benefit is to recognize the patient’s belief system as it pertains to the approach. If the patient has a strong belief in the approach, and there is no evidence of potential harm, it is often reasonable to support its use. Activating a healing response or a placebo effect can often be very therapeutic.
Step Three: Assess the “Delivery System”
When assessing the delivery system, both products and providers must be considered.
Product Assessing the history of the manufacturing company and understanding its process of quality assurance can be useful. Referral to independent sources for determining the quality of product and accuracy of labeling may be useful.
Provider It can be difficult to assess the skill level of CAM providers. Inquiring about the education of a given provider and his or her licensing status (if there is a licensing body for the field) is an important place to start. It is useful to talk to other patients who used these services. Finally, one’s own sense of a provider is extremely important.
Step Four: Assess the Integration
Although the individual CAM therapy may have no evidence of harm and can be of potential benefit, the way in which it is integrated into the patient’s overall treatment plan is important. The same is true for CAM providers.
Approaches The therapy or approach should be integrated into the overall treatment plan. For example, large doses of antioxidant vitamins should not be used in patients undergoing radiation therapy, as they may counteract the action of the radiation. Likewise, patients with Down syndrome should not undergo chiropractic manipulation.
Providers Perhaps most importantly, the potential for integration of the providers is essential to assess. If the intention is to offer the patient the best possible care, all providers, conventional and CAM alike, should be assessed for their willingness to integrate their care for the benefit of their patients. If any providers are unsupportive of conventional medicine, it is critical to recognize this and look for a provider who supports integration of care.
It is useful for each physician to recognize his or her own biases about CAM and willingness to learn about the techniques. At a minimum, physicians should know the basics about which CAM approaches may be of benefit to patients and which may be of harm. Familiarity with resources in the community that are more focused on these areas can serve physician and patient alike.