Alternative medicine

Friday Feedback: Can Physicians Be Comfortable With “Alternative Medicine”?

MedPage todayF. Perry Wilson, MD, recently sat down with Steven Novella, MD, of Yale, a well-known critic of alternative and complementary medicine. While physicians like Novella are clearly skeptical of unconventional remedies that lack strong evidence or prior plausibility, many patients continue to experiment with supplements and homeopathic remedies, while continuing to see their regular physicians.

We reached out to experts from a variety of specialties to get their thoughts on alternative medicine and whether it creates challenges in caring for patients.

Do you usually ask patients what unconventional remedies they take, and how well does it work? Are patients generally honest about what they use?

David Spiegel, MDStanford University: Yes, and it works well. Patients are generally proud of the extra efforts they make to improve their health.

Mikhail Kogan, MDGeorge Washington University School of Medicine and Health Sciences: All providers should ask all patients what remedies they are taking, whether herbal, supplemental, or homeopathic. Often, patients do not disclose this information to their doctors for fear of being judged. Expressing understanding and interest in natural products will not only help minimize the risk of interactions and side effects, but will also improve the patient-doctor alliance.

Aaron Michelfelder, MDLoyola medicine: It is essential that doctors know all the therapies that a patient is using so that we can think very holistically about the care of a patient. I regularly ask patients questions about other remedies and treatments, and phrase them in a way that lets patients know that I am open to alternatives. For example, “Sometimes people use herbal therapies to help lower their blood pressure, have you tried herbal remedies or other types of therapies for your condition?”

Richard Bedlack, MD, Ph.D.Duke ALS Clinic: I make it clear from day one that I have no way to stop or reverse ALS, and I am personally trying to find it through research. Some people cannot undertake studies and others do not want to bear the associated burdens. Thus, I mention to each new patient that I am open to discussing their self-experimentation with alternative therapies.

Joep Perk, MDUniversity of Linnaeus: I do it whenever I suspect they do. It works quite well because I tend not to accuse. Honest? I fear that many patients remain silent about this.

What do you say to patients who say they want to try alternative medicine instead of the scientific treatments you recommend?

Advantage: I try to explain what science-based treatment is, and if it’s life-saving medicine, I go to great lengths to convince and usually engage a close relative. My message is clear: I will not take any responsibility if they start an alternative treatment.

Steven E. Nissen MDCleveland Clinic Foundation: I urge patients not to take any of these products. I explain that supplements are not regulated by the FDA, may or may not contain the ingredients claimed, and may interact negatively with prescription products.

Spiegel: I advise them to think carefully about the risks and benefits, and to discuss their decisions with the doctors treating them. There are risk/benefit trade-offs in scientific medical care as well as “alternatives”. I prefer the term “integrative” medicine to “alternative” medicine to indicate that most of the time patients can do both.

Andrew T. Pavia MDUniversity of Utah: I think of non-traditional medicines in two groups. One is one that is likely to be safe, inexpensive, and used to supplement traditional medications that may be needed. They may or may not help, but are not likely to harm the patient’s body or pocket. As long as we talk about the use of these products, I am generally in favor. The other group consists of remedies whose composition and safety are unknown and which are very expensive. They make someone rich but the patient poor. These are usually sold with outlandish and unproven claims.

bed sickness: I try to ensure that my patients have as much information as possible about alternative therapy. I make suggestions about alternative therapies that have more plausible mechanisms, better preclinical data, more credible anecdotes, and better safety. I tell them what I think; it’s really the best I can do. I will always support patients and reassure them that I will continue to be their doctor even if they do things that I personally don’t agree with.

Kogan: I like to know why they want to do it. If I know that the modality they are going to try is safe, possibly helpful, and they are not wasting time not using a possibly much more effective treatment, I never limit them. It is important to be patient-centred. We view healing as a journey where a patient’s intuitive selection of modalities is often an essential part of finding the best approach.

Michelfelder: If alternative therapies are inexpensive and safe, and the condition does not need immediate action, then there is no harm in trying an alternative therapy, and I say “why not?” Many of our current medicines come from herbal therapies, and there’s a lot to learn about alternative therapies. I can help patients decide when to use alternative therapies and when conventional medical therapies are needed. We make a much better team when a doctor and a patient have open and honest conversations about all the possible therapies for a disease.

Do you support increased regulation of “natural” supplements and medicines, including their marketing as well as their production?

Michelfelder: I support greater regulation of supplements to ensure products contain advertised ingredients, are free of harmful contaminants, and contain consistent levels of advertised ingredients. I also support natural medicine testing for safety. I also believe that all people who make recommendations to others on the treatment of health problems should be trained and authorized.

bed sickness: I think it would be great to have a way to hold proponents of alternative therapies accountable for the claims they make.

Spiegel: We want to be sure that they contain what they are supposed to contain, which is not always the case, and that the claims made about them are based on fact.

Pavia: A primary problem is the lack of standards in the production, content or quality of supplements and nutritional products. Patients and their healthcare team need to know what’s actually in the bottle. In the world of HIV medicine, we always ask about supplements and non-traditional therapies. Some have strong interactions with anti-HIV drugs and there are potentially dangerous combinations.

Kogan: Absolutely. The current status quo is a wild west where any company can produce a product that may not even contain the active ingredients listed on the label. Most European countries regulate supplements very similar to drugs, and that’s what we have to do in the United States. Better regulations will ensure better quality supplements even as the cost increases. Having a market saturated with cheap, low quality retail brand supplements that have little or no therapeutic value continues to create a “bad reputation” for the industry that has very high quality brands that try to do what is necessary.

Advantage: Yes, the rules here in Sweden are quite rigid and the Swedish Medical Agency keeps a critical eye on this, but sometimes misleading marketing slips in. Our problem is that the SMA has no real authority over internet marketing from overseas, so we have a stream of potentially harmful substances being imported via postal delivery.