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Things Do Not Get Better by Being Left Alone. The Physician and Complementary Medicine

At a recent Grand Rounds I stated that physicians should now routinely ask their patients about the use of complementary and alternative medicine (CAM) whenever they take a comprehensive history. I suggested that, as has been done for drug and alcohol use and domestic violence, physicians should be more aware of the importance of asking patients about CAM. After that presentation, a colleague challenged that I had been overzealous in my assertions. He questioned whether the data were strong enough to advocate that physicians add yet another area of inquiry to the history and physical. He was wrong. Let me explain.

I am not alone when I advocate that physicians need to enter a dialogue with their patients on the subject of CAM^1-3. The use of CAM therapies is clearly increasing in the USA, although the actual proportion of Americans using these therapies varies greatly, depending on the study and how CAM is defined^4,5. Utilization of CAM therapies is particularly prevalent among patients with rheumatic disease⁶. Glucosamine, chondroitin, sam-e, boswellia, bee venom injections — the list keeps growing. A recent edition of the Rheumatic Disease Clinics of North America was dedicated to complementary and alternative therapies, and as guest editor, my colleague and friend Dr. Richard Panush wrote in the preface: “we may not like it, we may not approve of it, but we cannot ignore it”⁷.

It has been argued that physicians have an ethical obligation to advise patients on CAM therapies. The principle of beneficence implies a responsibility for physicians to encourage potentially beneficial interventions while the principle of non-maleficence obligates physicians to protect patients from clearly harmful treatments and modalities⁸. There may be great potential financial incentives to some who espouse these treatments. The herbal market, for example, has become a multibillion dollar industry. As the potential for profitability increases, so will the list of available products. A large proportion of the population seeking CAM therapies suffer from life-threatening or chronic disease. These individuals are often willing to pay large amounts of money to find relief. This renders them vulnerable to those who might seek to take advantage of their quest for hope. If patients cannot turn to their physicians for help and guidance, then to whom?

Entering a dialogue with our patients about their use of CAM is only a first step. Clearly, more quality research needs to be undertaken to validate or invalidate potential therapies and thereby enable us to responsibly counsel our patients. Carrying out this type of research is fraught with problems. As pointed out in the study by Chopra and colleagues, Ayurvedic medicine is in fact a system of medicine⁹. Therapies often must be individualized and include not only herbal treatments, but also lifestyle modifications, in order to realize their putative full potential. The methodologic challenges inherent in attempting to evaluate many therapies from other cultures and healing systems has meant that studies are often not undertaken, and when they are, they are often of inadequate methodologic quality.

The real value of the Chopra study is not in how it will influence the treatment of rheumatoid arthritis. The Ayurvedic formulation RA1 may be an interesting potential treatment for RA, and warrants further study to more adequately assess its efficacy. However, this effort has shown that herbal treatments from other systems of healing, and from other cultures, can be studied with adherence to validated scientific methodology. This research can be done collaboratively, across borders and on indigenous populations. For this, Chopra and colleagues are to be commended.

It has been argued that there cannot be two kinds of medicine. There is only medicine that works and medicine that does not; medicine that has been studied and tested and medicine that has not¹⁰. However, there are approaches and treatments for disease that we never anticipated in medical school. Some treatments currently categorized as CAM, when studied, will probably prove to be efficacious, and many will not. It is only through rigorous, science based research that we will be able to appropriately counsel our patients and be assured that we are practicing “best medicine.”

At the Saint Barnabas Medical Center and Health Care System, we have developed a center for integrative medicine. For us, integrative medicine means using an evidence based approach to integrate certain validated CAM therapies with the high quality Western medicine already provided at our institutions. This approach means that we provide care using the best evidence available, together with our experience. Our center emphasizes education and research in conjunction with evidence based clinical services. Our health care system committed to this undertaking in response to perceived community needs. Our vision was to do this credibly, responsibly, and scientifically. This is more of a commitment than many individuals and/or institutions are now willing to undertake. Nevertheless, as I concluded in my Grand Rounds, one need not advocate the use of CAM therapies, and one need not be pleased with their increasing utilization. But as Winston Churchill said, “Things do not get better by being left alone.”

ADAM I. PERLMAN, MD, MPH,
Director, Integrative Medicine,
Saint Barnabas Health Care System,
Director, Carol and Morton Siegler Center for Integrative Medicine,
Saint Barnabas Ambulatory Care Center,
Department of Medicine, Saint Barnabas Medical Center,
Livingston, New Jersey 07039, USA.
E-mail: Aperlman@sbhcs.com

ACKNOWLEDGMENT

I thank Dr. Richard S. Panush for his thoughtful guidance in preparation of this editorial.

REFERENCES

1.Perlman AP, Eisenberg DM, Panush RS. Talking with patients about alternative and complementary medicine. Rheum Dis Clin North Am 1999;25:815-22.

2.Borkan J, Neher JO, Anson O, et al. Referrals for alternative therapies. J Fam Pract 1994;39:545-50.

3. Eisenberg DM. Advising patients who seek alternative medical therapies. Ann Intern Med 1997;127:61-9.

4.Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA 280:1569-75.

5.Druss BG, Rosencheck RA. Association between use of unconventional therapies and conventional medical services. JAMA 1999;282:651-6.

6.Visser GJ, Peters L, Rasker JJ. Rheumatologists and their patients who seek alternative care. Br J Rheumatol 1992;31:485-90.

7.Panush RS. Complementary and alternative therapies for rheumatic diseases I [preface]. Rheum Dis Clin North Am 1999;25:xiii-xviii.

8.Sugarman J, Burk L. Physicians’ ethical obligations regarding alternative medicine. JAMA 1998;280:1623-5.

9.Chopra A, Lavin P, Patwardhan B, Chitre D. Randomized double blind trial of an Ayurvedic plant derived formulation for treatment of rheumatoid arthritis. J Rheumatol 2000;27:1365-72.

10.Angell M, Kassirer JP. Alternative medicine — the risks of untested and unregulated remedies [editorial]. N Engl J Med 1998:
339:839-41.