These days, telling a coworker or friend that you're off to your acupuncture appointment is unlikely to generate a suspicious look. In 1998, a survey published in the Journal of the American Medical Association found that 42 percent of the population was using some sort of alternative and complementary medicine, and it's probable that these therapies are even more popular today.
Despite the widespread use of non-traditional therapies such as acupuncture, herbal remedies, prayer, guided imagery and magnet therapy, few people are sharing their use of these therapies with their conventional healthcare providers. Patients tend not to volunteer the information, and doctors don't ask. This lapse in communication may not only prevent patients from getting the best care possible though the integration of different approaches, it can sometimes threaten a patient's health.
Adam Perlman, MD, MPH, is the medical director for the Siegler Center for Integrative Medicine at the St. Barnabas Ambulatory Care Center in Livingston, New Jersey and executive director for the Institute for Complementary and Alternative Medicine at the University of Medicine and Dentistry of New Jersey. Below, Dr. Perlman discusses why doctors and patients need to have an open dialogue about complementary medicinešand offers ways to bridge the communication gap.
How would you define the terms "alternative medicine," "complementary medicine" and "integrative medicine"?
Different people define these words somewhat differently, but the way that I think about it is that "alternative medicine" implies you're either going to use conventional medicine or you're going to abandon conventional medicine and use some sort of alternative. That's not what I, nor what most of us involved in this field would advocate.
"Complementary medicine" gets a little closer to describing the way that the sorts of modalities are used most commonly in this country. For example, if you happen to have cancer and you had nausea from the chemotherapy, you would hopefully get medication for the nausea, but it often doesn't work 100 percent, or you might not want to take another medication. So you might use acupuncture to complement the conventional care you're receiving because acupuncture is supported by the National Institutes of Health (NIH) as being indicated for chemotherapy-induced nausea. So really the non-conventional, if you will, is complementing the conventional.
"Integrative" describes an approach to the care of the patient. It's trying to care for a patient by combining the best of conventional and select non-conventional modalities. It's looking beyond just the particular symptom or complaint or even disease process that someone may have and trying to look at the whole person. It's certainly a lot more than trying to replace Prozac with St. John's wort.
Are there particular diagnoses that tend to lead people to try complementary medicine?
In general, you see a higher utilization in people who have chronic diseases such as cancer and chronic pain-related conditions. The use among people with rheumatologic conditions is also quite high.
Why do you think people gravitate toward alternative therapies?
What I think is driving this whole interest in complementary medicine is actually quality of life. Most people who have cancer or rheumatoid arthritis are not coming into my office saying, "Can you tell me what herbs are going to cure me?" But they are coming in saying, "Look, I'm going to take these medications, but how can I maintain or improve my quality of life and how can I have more control?"
I also see a fair amount of use for general wellness among people without chronic conditions. I think that that's people who realize that, in order to have true wellness and true quality of life, you need to do more than take your medications if you have high blood pressure. You need to be exercising, eating right, managing stress, all these things that a more integrative approach can address.
What are some of the more popular types of complementary medicine?
It depends what you mean. There are things that get defined as complementary medicine like prayer for which rates may be high, but you're not seeing that discussed, obviously, within a doctor's office or a complementary medicine center. Specific medical conditions therapies that tend to be popular at this point are chiropractic care, acupuncture, herbs and massage therapy.
Do most patients discuss their use of complementary medicine with their doctors?
At least from what we know from the literature, the majority of patients don't talk to their physicians or healthcare providers about complementary medicine. Many times people don't view the complementary medicine that they're doing as medicine. And it's probably also a reflection of the breakdown of the doctor-patient relationship, unfortunately. Patients don't have the same relationships with their doctors, and there's a perception that doctors really won't be able to provide any meaningful feedback or advice.
A few years back, there was data that suggested that people didn't talk to their doctors because they were concerned about doctors looking down on them or not accepting what they are taking. More recent work has suggested that patients don't tell their physician about their use of complementary therapies because they don't think it's important for their physician to know about it.
But that may be changing. My sense is that patients are beginning to be more comfortable discussing the subject matter and physicians are more receptive to it.
Why aren't doctors raising the issue?
Many physicians have talked to me about time issues. I've had cardiologists say to me, "Look, I know how important nutrition and exercise are, but if I bring up nutrition and exercise, that's another 20-minute conversation, and I just don't have the time."
Another factor is that there is so much new research coming out that it's very challenging just to keep up with all that's happening within conventional medicine.
Why is it important for patients and doctors to have these conversations?
I would think you would want everyone involved in your care to be, if not literally, at least figuratively, sitting at the same table, with you at the head, discussing the most appropriate plan of care.
Also, oftentimes patients don't necessarily recognize that there is a potential downside to the herb that they're taking. But if patients aren't talking about components of what they're doing, there's a risk that what the physician recommends could conflict or interact with their complementary therapy.
There's something like 250,000 estimated potential drug-herb interactions per year. For example, ginkgo, often taken to improve memory, can thin the blood, and if you're on Coumadin to prevent blood clots, you need to be concerned. If you have a pacemaker, it's recommended you avoid electro-acupuncture. Certainly you need to be aware and not use magnets if you have any implantable device like a pacemaker.
How can doctor/patient communication be improved?
One of the best ways to remedy this is, first of all, to incorporate education about complementary medicine into medical education. And that would hopefully lead to continuing education for physicians who have already graduated.
That, in turn, would hopefully lead to a greater level of comfort on the part of healthcare providers in bringing up the subject matter. What I suggest is that when a physician is taking a medication history, for example, they need to always ask, "What else are you on?" Not only should they ask about over-the-counter medications in addition to prescribed medications, but they should say, "What about herbs, vitamins or homeopathic remedies?"
What happens when patients and their doctors disagree about the use of therapy?
Basically patients have a right to decide what they feel is best for them in terms of their healthcare. That's an accepted ethical principle of medicine. I see my role as facilitating their freedom of choice.
But if people are acting with incomplete information or misinformation, that isn't truly freedom of choice. I try to educate my patients as best I can about what I know about the efficacy of what they want to do, what literature is out there, if there's a lack of literature, the safety of what they want to pursue.
Patients' interest in complementary medicine certainly sparked the interest of medical institutions, individual practitioners and insurance companies. But it also got the interest of entrepreneurs and one of the things that you've seen, particularly with the explosion of the Internet, is a flood onto the market of products to treat all kinds of ailments. Often, these products or services are marketed to a very vulnerable population: people with chronic diseases, heart disease, cancer or chronic pain. And many of these products have not been tested: some may be very effective, some are clearly ineffective, some are clearly fraudulent and some are also probably unsafe. So that's where I get concerned.
My response to that is that the conventional healthcare providers need to develop a level of understanding of what works and what doesn't work. They also need to begin to have a conversation with their patients to help steer them away from things that may be harmful or fraudulent and help to steer them towards the things that may be beneficial.
Complementary medicine, in fact, offers doctors an opportunity to build a real bridge with their patients.
What advice would you give to someone who's looking to incorporate complementary medicine into their treatment?
If you have access to a credible place that offers complementary medicine, such as a hospital-based center or a provider who you feel very comfortable with, I think it's advisable to go there for information.
I would also try to cross-reference things. How does what you read in a book compare to what you're seeing on the Internet, compare to what your healthcare provider may be saying to you? And where there's discrepancies or potential issues, you need to explore that more.
There are a number of reliable resources out there such as the NIH, the Office of Dietary Supplements and the National Center for Complementary and Alternative Medicine. You just have to look at everything very carefully and be sure that the source you're getting the information from is a reliable one.