Given the wide range of alternative therapies patients are using these days, it’s important not to dismiss complementary medicine or assume it’s not relevant to your care of patients, even if you don’t incorporate alternative practices.

Patients need to feel they can talk to their doctors about alternative therapies, and that means you have to be open to that information, says Greg Plotnikoff, MD, medical director for the University of Minnesota’s Center for Spirituality and Healing. There’s the obvious concern that a patient could be taking an alternative cure that would interact badly with a drug or other therapy. Furthermore, physicians could find their patient panel diminishing as people seek doctors who show sympathy for and understand their interest in complementary remedies.

It’s particularly common for patients with chronic illnesses such as arthritis to seek alternatives, and their doctors often don’t know about it, according to a study in the Annals of Internal Medicine in September 1999. Of the 232 patients surveyed in six rheumatology practices, two thirds had used complementary medicine but only half had told their doctor about it. The reason was simple: the doctors never asked.

Studies on women undergoing treatment for breast cancer have found that many use complementary and alternative medicine (CAM): Seventy-two percent of the women in a University of California San Francisco study used at least one alternative method; about half of them told their doctors about it. By contrast, 94% of those who used CAM discussed details of their mainstream treatment with their alternative providers. Study participants commented that they felt their physician was uninterested in CAM, uneducated about it, or, even worse, would have a negative reaction to it. “When I said to my oncologist, ‘I’ve used shark cartilage,’ he almost laughed me out of the office,” one patient told the UCSF researchers.

With such an attitude, a physician risks coming across as a poor source of any type of medical information, contends Jane Murray, MD, a family physician in Kansas City. “Instead, doctors should say . . . they’ll study [the topic] and discuss it again at their next visit.”

Dr. Plotnikoff suggests doctors should remain skeptical but open-minded. “Listen for understanding rather than having to agree or disagree with the patient’s actions,” he says.

That was the conclusion of a Dana-Farber Cancer Institute study of women with newly diagnosed early-stage breast cancer. The research, published in the June 3, 1999 issue of the New England Journal of Medicine, found that 28% of the women began using an alternative therapy after surgery and that those women were more likely to be depressed or distressed. “The initiation of the use of alternative medicine should alert clinicians to inquire about anxiety, depression or physical symptoms,” the authors advise.

Questions about the use of alternative methods should be incorporated into the regular history taken from patients on initial and repeat visits, recommends David M. Eisenberg, MD. Dr. Eisenberg’s July 1997 article in the Annals of Internal Medicine, “Advising Patients Who Seek Alternative Medical Therapies,” marks one of the first comprehensive efforts to establish a standard for mainstream physicians to follow in the examining room. Among Dr. Eisenberg’s guidelines:

• Don’t use labels such as “alternative,” “complementary,” or “unorthodox” when asking patients about other therapies they may have used; these terms may seem judgmental and stifle discussion.
• Don’t discuss or recommend an alternative therapy until a complete conventional medical evaluation has been done and the patients have tried — or perhaps exhausted — conventional therapeutic options.
• Take it upon yourself to monitor therapies with potential or documented toxicity, including herbal preparations, dietary regimens and supplements, medicinal agents delivered by injection, intravenous infusion, and certain forms of spinal manipulation.
• Urge the patients to check out the credentials and licensing of any alternative provider. Note in the patients’ records whether this has been done.
• Suggest questions your patients should ask an alternative practitioner so they fully understand what’s being prescribed.
• Be sure to follow up with patients who are using an alternative therapy to ensure they are getting responsible care and haven’t abandoned useful biomedical treatment.
• Don’t feel obligated to give a referral to a CAM provider if the patient refuses a full medical evaluation and wants only the referral. “Physicians facing this predicament should follow accepted professional guidelines for referring patients to another physician,” Dr. Eisenberg suggests.

After it was published, Dr. Eisenberg’s advice drew heavy fire from some doctors and researchers who wondered why they should take unscientific methods seriously and open themselves to liability if they refer a patient for a potentially harmful therapy. In a letter to the Annals of Internal Medicine, Douglas Stalker, PhD, a University of Delaware researcher on CAM, even suggested that any patient considering an alternative therapy should be advised against it, to simplify the doctor’s life.

But Dr. Plotnikoff argues that physicians remaining ignorant about alternative medicine are simply ignoring the inevitable and will miss out on important advances as select complementary techniques are proved useful.

Although continuing education courses reviewing alternative care have become more available to doctors, they don’t always draw a big crowd. A March CME session sponsored by the American Academy of Family Physicians had to be canceled for lack of registrants.

Dr. Murray, who organized the session, says her colleagues around the country report the same phenomenon: Doctors say they need a grounding in areas such as acupuncture and Chinese herbs, but they don’t find it worth the time and money to travel to another city and devote three days to the topic in isolation.

“What this says is they are still interested in learning about new modalities, but they want it in the context of continuing education about other topics,” concludes Dr. Murray. “So if you’re putting on a women’s health seminar, they’ll want to hear about complementary medicine in that context.”

This leads to a piece of advice: When choosing continuing education courses, pick ones that incorporate alternative medicine.

It’s also wise to identify the good alternative practitioners in the community for referral purposes, Dr. Murray says. “You want to know who’s the good chiropractor the same way you check out who the cardiologists are,” she recommends. “The same process with massage therapists, acupuncturists, nutritionists, compounding pharmacists.”

Doctors who can offer a global understanding of both conventional and unconventional therapies will become more valuable to patients, research suggests. Focus group interviews with health-food store patrons found that many would welcome some objective advice about the risks and benefits of supplements, investigators from the University of Wisconsin and Medical College of Wisconsin wrote in the June 1999 issue of the Journal of Family Practice. “Doctors have training and can diagnose what is wrong,” one study participant said. “If that same doctor could go into alternative methods . . . that would be heaven.”