Surprisingly, dissatisfaction with conventional medicine was not predictive of use of CAM. Patients turn to CAM because they are seeking greater congruency of values regarding life, health, and wellness (8). The message is, that people are happy to use conventional medicine when they have a diseased or injured body part, but when their goal is to improve their health or manage a chronic condition or lifestyle issue, they turn to alternative care providers. Establishing a partnership with patients can help them explore all of the options for maximizing their health. The Centers for Disease Control and Prevention (CDC) reported that the majority (55%) of people stated that their reason for using CAM therapies was that they thought combining these approaches with conventional ones would help them. It is interesting to note that 26% reported they tried these approaches because medical professionals had recommended them (3).
The reluctance of patients to inform their physicians of their use of CAM creates barriers to the best practice of medicine. Included in the realm of CAM are potentially harmful practices and products and potential interactions between effective CAM and conventional approaches. In a 5-year prospective cohort study following women in San Francisco with newly diagnosed breast cancer, 72% were using at least one form of CAM in the management or treatment of their breast cancer. Of these women, 54% disclosed their use to their physician (much higher than the national average), whereas 94% discussed their conventional treatment with their CAM provider (9). Three reasons were given for the patients’ lack of disclosure: 1.
Women anticipated physician disinterest, negative response, or unwillingness or inability to contribute useful information 2.
Women believed their use of CAM to be irrelevant to their biomedical treatment 3.
Women did not view disclosure as appropriate coordination of disparate healing strategies
This study highlighted the fact that the use of conventional approaches is well integrated into CAM patient visits, whereas the history of use of CAM is poorly integrated into the conventional medical encounter. Overall, patients’ disclosure to their physicians is very cautious, even when the physicians involved would welcome the discussion.
The Challenge The demographics and trends associated with CAM use create challenges for physicians and dangers for patients. A huge market demand exists, and with it comes an opportunity for products and therapies that may be ineffective, dangerous, or fraudulently marketed. The development of the patient demand preceded the incorporation of education regarding CAM for medical students, residents, and practicing physicians. As a result, patients make decisions regarding their care without the benefit of medical advice or the coordination of their care by one provider. The best practice of medicine necessitates the integration of all therapies that can benefit the patient and the exclusion of those that can cause harm. Integration of these techniques will require the collaborative, concerted effort of physicians, CAM providers, and patients.
Biologically Based Therapies: Botanical Medicine
The many types of CAM techniques can be organized by categories as outlined by the National Institutes of Health (NIH). Each type is associated with some risk or complication. Licensing and certification requirements vary widely from state to state, but most techniques have a formal structure for training and accreditation (Table 13.2).
Botanical or herbal therapies use botanicals singly or in combination for therapeutic value. A botanical is a plant or plant part that contains chemical substances that act on the body. Botanical or herbal medicines were studied extensively in Europe, and large multicenter trials are beginning to provide more robust evidence in this country.
Botanical medicine is the area of CAM most conceptually accessible to patients. Botanicals are the source of the active agents in approximately 25% of prescription drugs and 60% of overthe-counter drugs. In the United States these products are often not perceived as active and are regulated as “dietary supplements,” that are not under the direction of the U.S. Food and Drug Administration (FDA). The most popular botanicals used in the United States are listed in Table 13.3.