FROM: Annals of Internal Medicine 1997 (Jul 1); 127: 61-69
David M. Eisenberg, MD
Alternative medical therapies, such as chiropractic,
acupuncture, homeopathy, and herbal remedies, are in great
public demand. Some managed care organizations now offer
these therapies as an "expanded benefit." Because the safety
and efficacy of these practices remain largely unknown,
advising patients who use or seek alternative treatments
presents a professional challenge. A step-by-step strategy
is proposed whereby conventionally trained medical providers
and their patients can proactively discuss the use or
avoidance of alternative therapies. This strategy involves a
formal discussion of patients' preferences and expectations,
the maintenance of symptom diaries, and follow-up visits to
monitor for potentially harmful situations. In the absence
of professional medical and legal guidelines, the proposed
management plan emphasizes patient safety, the need for
documentation in the patient record, and the importance of
shared decision making.
Ann Intern Med. 1997;127:61-69. Annals of
Internal Medicine is published twice monthly and
copyrighted © 1997 by the American College of
From Beth Israel Deaconess Medical Center,
Boston, Massachusetts. For the current author
address, see end of text.
Alternative therapies can be defined as medical
interventions that are neither taught widely in U.S. medical
schools nor generally available in U.S. hospitals (1).
Examples include chiropractic, acupuncture, massage, and
homeopathy. In 1993, my colleagues and I reported that an
estimated 60 million Americans used alternative medical
therapies in 1990 at an estimated cost of $13.7 billion,
that the estimated number of annual visits to providers of
alternative medicine (425 million) exceeded the number of
visits to all U.S. primary care physicians (388 million),
and that more than 70% of patients who acknowledged using
alternative therapy never mention edit to their physicians
(1). These data generated considerable
attention and debate and suggest that an "invisible
mainstream" exists within the U.S. health care system
(2). Little is known, however, about
the safety, efficacy, mechanism of action, and
cost-effectiveness of individual alternative treatments.
In the past 3 years, the lay press has reported a
national trend: third-party payers who provide alternative
therapies in the form of "expanded benefits" (3-11).
Most recently, the Oxford Health Plan began a program
whereby chiropractic, acupuncture, and naturopathy became
available to the Plan's 1.5 million subscribers as paid
benefits (12, 13). This trend poses a
predicament for physicians: how to responsibly advise
patients who use or seek alternative therapies in the face
of inconclusive evidence about the safety and effectiveness
of these therapies.
This unavoidable challenge is not without risk. Questions
of professional liability are valid. The reality is that no
case law directly answers the question, "Will I be sued if I
knowingly comanage a patient who sees an alternative therapy
practitioner and experiences a bad outcome from that
therapy?" Although physicians have been prosecuted for
malpractice when they have personally delivered alternative
treatments, no cases have involved conventionally trained
physicians who have advised patients about alternative
The other extreme involves the risk of not asking about
alternative therapies known to be dangerous. In 1996, the
media reported deaths from overdoses of Herba ephedra
(herbal ephedrine), known in Chinese herbal medicine as ma
huang (14, 15). A death attributed to
pennyroyal, an herb commonly available in health food
stores, was recently reported in the medical literature
(16). As more patients use
over-the-counter herbs, botanicals, and supplements,
physicians should discuss such practices with their
patients, if only to safeguard their health.
Undoubtedly, talking with patients about alternative
therapies requires additional skills and time. Yet, is this
responsibility significantly different from exploring
patients' use of alcohol or drugs, exposure to abuse, or
preferences for cardiopulmonary resuscitation? Each is
critically important to maintaining health and respecting
patient values, and each takes time.
I propose a step-by-step approach whereby medical
providers and patients can proactively discuss alternative
medical treatments. These suggestions emphasize patient
safety, the need for documentation in the patient record,
and the importance of shared decision making.
Asking the Unasked Question
I suggest that after completing routine questioning to
identify patients' chief symptoms, medical providers begin a
conversation about alternative therapies with some version
of the following question: "Patients with (chief symptom)
frequently use other kinds of therapy to find relief. For
example, some patients use chiropractic, massage, herbs,
vitamins, etc. Have you used or thought about using any of
these or other therapies for your chief symptom, or for
Because one third of all alternative therapy use seems to
be associated with health promotion and disease prevention
(1), providers should also ask about a
patient's use of alternative therapy in this context. This
inquiry can be assimilated into questions about lifestyle
and health risks.
The physician and patient must feel comfortable with how
the question is asked. Two caveats are worth considering: 1)
The neutrality with which this question is asked influences
the honesty of the answer, and 2) there is no need to refer
to the "other therapies" as "alternative," "complementary,"
or "unorthodox." Such labels may be perceived as judgmental,
thereby inhibiting disclosure and discussion.
Patients who are interested in exploring alternative
therapies do so for diverse reasons: 1) They seek health
promotion and disease prevention; 2) conventional therapies
have been exhausted ; 3) conventional therapies are of
indeterminate effectiveness or are commonly associated with
side effects or significant risk; 4) no conventional therapy
is known to relieve the patient's condition; and 5) the
conventional approach is perceived to be emotionally or
spiritually without benefit. Whether or not patients use or
seek advice about an alternative therapy, they are likely to
be pleased when their physician cares enough to ask.
Detailed discussion about alternative therapy should not
occur until the patient 1) has undergone a complete
conventional medical evaluation, including diagnostic
assessment and, where indicated, referral to consultants; 2)
has been advised of conventional therapeutic options; and 3)
has tried or exhausted conventional therapeutic options or
refused these options for reasons documented in their
record. Professional advice on the adjunctive or exclusive
use of alternative therapy without a complete diagnostic
evaluation is irresponsible and does not serve the patient's
A Step-by-Step Strategy
Consider a patient with intermittent low back pain for
whom nonsteroidal anti-inflammatory medications, physical
therapy, regular exercise, and avoidance of heavy or
improper lifting have not adequately reduced chronic or
recurrent pain. The following approach (Figure
1), guided by the principle "do no harm" and its
corollary, "monitor for unintentional side effects," can be
1. Ask the patient to identify the principal
Back pain is the principal symptom.
2. Maintain a symptom diary.
Assist the patient with a daily symptom diary to be used
for baseline assessment and evaluation of subsequent
alternative (or conventional) therapeutic interventions. A
scale from 0 ("no back pain") to 10 ("the worst pain
imaginable") is recommended. Patients should be reminded
that because accurate recall of discomfort, fatigue, and
other symptoms is difficult, daily logs are essential.
3. Discuss the patient's preferences and
Many patients come prepared to discuss opinions or
powerful anecdotes from friends or family members. The
discussion often focuses on the reasons patients seek
alternative treatment or their desire to avoid conventional
therapies. Patients with low back pain, for example, may
incorrectly assume that surgery is their only conventional
If patients wish to pursue alternative therapy but lack
strong preferences for specific therapies, encourage shared
responsibility for investigating options further. Various
texts are available to both patients and conventional
medical providers. These offer information on multiple
alternative therapies (17-32) or focus
on single treatments (33-43).
Conventional practitioners might consider attending
continuing medical education courses on this topic (44-46).
In our hypothetical example, the patient opts to pursue
4. Review issues of safety and efficacy.
It is the conventional provider's professional obligation
to monitor therapies with potential or documented toxicity,
including herbal preparations (47-73),
dietary regimens (74, 75) and
supplements (76-79), medicinal agents
delivered by injection (80),
intravenous infusion (such as chelation therapy
), and certain forms of spinal manipulation
(82-89). Advise patients that the
absence of documented toxicity for herbs, supplements, or
chemical preparations does not equal safety. Notions that
"natural" substances are inherently safe are false (90).
Snake venom is "natural" but deadly (91);
poison oak and ivy contain "natural" urushiols that cause
severe contact dermatitis (92).
Examples of potentially toxic herbs include sassafras
(55), chaparral (69),
and germander (73). Reference books
(93-95) and online resources (96)
(Appendix 1) are available to investigate
the relative safety of individual herbs and supplements.
Reviewing the current medical literature fails to provide
unequivocal documentation of the safety or efficacy of the
overwhelming majority of alternative therapies (85,
87, 89, 97-102). Notable exceptions include spinal
manipulation for acute low back pain (103),
acupuncture for nausea (104), and
behavioral and relaxation techniques for chronic pain and
insomnia (105). Adverse events
attributable to acupuncture have been reported (106,
107) but are rare (108-112). The
risk for transmission of infectious organisms can be reduced
to almost zero by using disposable needles.
Risk is also associated with manipulation of the cervical
spine (82, 83, 87-89). Other
treatments with potential significant risks include some
single herbs; some Chinese "patent" remedies manufactured
overseas that routinely include various herbs and are
occasionally adulterated with steroids or lead (68);
high-dose vitamins and minerals, radical diets, certain
deep-tissue massage; and any substance administered
Relatively low-risk therapies include homeopathy, most
forms of massage, prayer, guided imagery, spiritual healing,
hypnosis, and relaxation techniques. Two caveats are worth
noting: 1) Any therapy can cause "indirect toxicity" if it
results in a delay of a proven treatment, and 2) there is a
risk for perceived blame and failure among patients who,
expecting a "cure" as a result of mental or spiritual
exercises, do not experience the desired result (113).
Thus, thinking of alternative therapies in terms of relative
risk or benefit is reasonable.
Indirect toxicity is exemplified by documented drug-drug
interactions. Examples include the potentiation of calcium
channel blockers by grapefruit juice (63)
and decrease in the bioavailability of digoxin in the
presence of guar gum consumption (48).
Given the potential for unintended drug-drug interactions,
patients who take prescription medications, especially drugs
with known toxicity to the liver or kidneys (such as
chemotherapeutic agents), should be cautioned about, if not
dissuaded from, simultaneously using herbs, supplements, and
other substances with poorly studied pharmacologic
activities. Perhaps the most common, vexing example involves
the patient who is receiving chemotherapy or radiation
therapy and considers the consumption of herbs, high-dose
vitamins, or supplements before or during treatment. These
substances may, hypothetically, inhibit or potentiate the
activity of conventional therapeutic agents. Physicians must
warn patients about unintended drug-drug interactions and
the prospect of not knowing which substance is responsible.
In general, a strategy that uses one therapeutic
intervention at a time, at least until a therapeutic plateau
is reached or a reasonable period of monitoring elapses,
should be discussed and documented in the record.
5. Identify a suitable licensed provider.
Patients may have already identified a provider by word
of mouth or informal referral. Physicians should emphasize
that alternative therapy providers are licensed by state
governments and commonly maintain professional malpractice
insurance. Licensure laws and the scope of practice
guidelines regulating individual practices vary by state
2) and are subject to frequent change. Patients should
review the professional credentials of any prospective
alternative provider. Ideally, this information should be
documented in the patient's record.
6. Provide key questions for the alternative therapy
provider during initial consultation.
When patients are being counseled about use of
alternative therapy, providing the following questions to
ask the alternative medical provider is helpful: 1) Is the
provider's belief in the effectiveness of the therapy (for
example, acupuncture) based on clinical experience with
similar patients? If so, is it possible to speak to such a
patient? 2) Of what will the therapy consist? What is the
recommended frequency of therapy? 3) How many weeks will
pass before the patient and provider can decide that the
therapy is or is not beneficial? 4) What is the cost per
session, with or without medication, and the anticipated
total cost for the specified time period? Is third-party
reimbursement available? 5) Are there potential side
effects? 6) Is the provider willing to communicate
diagnostic findings, therapeutic plans, and follow-up with
the patient's primary care provider or subspecialist? Are
there any limitations to this communication?
Ideally, the physician should obtain patients' permission
to release relevant information (including information on
the use of prescription medications) to the alternative
therapy provider in order to offer accurate historical
information and avoid conflicting recommendations.
7. Schedule a follow-up visit (or telephone call) to
review treatment plan.
Topics to be addressed during this session include 1) the
alternative practitioner's responses to the questions
outlined above; 2) potential risks or toxicity, particularly
those involving therapies taken orally, intramuscularly, or
intravenously; and 3) recommendations that directly conflict
with those of the conventional provider. An extreme example
is the recommendation that a patient delay or forego
surgery, chemotherapy, or radiation therapy for a
potentially treatable malignant condition.
8. Follow up to review the response to
This should occur after a "reasonable" period (usually 4
to 8 weeks). By the time this follow-up session takes place,
patients usually have decided whether or not to continue the
alternative therapy. If the therapy was effective, the
patient's positive experience constitutes a beneficial
clinical outcome and provides anecdotal evidence that this
therapy (or, one might argue, the provider of this
therapy) may be helpful to others with similar problems. If
the therapy was ineffective, the patient and physician
together can review other alternative and conventional
therapeutic options. Regardless of the perceived efficacy o
r lack thereof, patients who pursue an alternative therapy
while being monitored by their physician tend to feel
"listened to" and enjoy a degree of perceived safety that
they might otherwise be denied.
9. Provide documentation.
Conventional providers are encouraged to build a record
of the clinical encounters, conversations, and advice that
lead to all treatment decisions.
Patients Who Already Use Alternative Therapies
Such patients may not wish to discuss these alternative
practices; this should be recorded in their medical records.
For patients who welcome this conversation, the physician's
challenge is to explore whether the patient and alternative
provider are willing to follow the steps discussed above.
Refusal on the part of either party should be documented in
the patient's record.
Patients Who Reject Conventional Diagnosis or
A more challenging situation involves the new patient who
currently uses an alternative therapy (or wants a referral)
but refuses conventional evaluation. Patients have the right
to forego conventional treatment, but this choice does not
constitute a right to obtain a referral or tacit medical
approval for alternative therapy in the absence of a
Physicians might convince such patients that an
"integrated" approach is in their best interest. If patients
refuse this advice, they are best served by the unequivocal
message that requests for referral to an alternative
provider are unreasonable and cannot be met. Physicians
facing this predicament should follow accepted professional
guidelines for referring patients to another physician.
Under no circumstances should a conventional medical
provider feel professionally obligated to make or support
referrals to alternative therapy providers in the absence of
a thorough medical evaluation.
Discussions about the use of alternative medicine are
primarily influenced by patient preference, perceived need
for alternative interventions, and anecdotal evidence that
the therapy may provide relief and long-term benefit
or be toxic. Together, patients and providers must
acknowledge that as long as information on the efficacy and
toxicity of alternative therapies remains inadequate, advice
will remain imperfect and a matter of judgment.
As with all good care, the patient's wishes should not
override a physician's professional judgment. If the
physician believes that an alternative therapy is unsafe or
inappropriate, patient requests for it should not be
endorsed. Perhaps the question each clinician must ask is,
"Would I let a family member follow this course of action?"
Patients, I believe, want their physician's opinion, even if
it is a blunt "I wouldn't be comfortable watching a family
member do this. " If, however, little evidence suggests that
risks outweigh potential benefits and the physician is
willing to monitor the patient, it is often appropriate to
pursue alternative treatment.
By implementing the proposed strategy, physicians and
patients may disagree about which alternative therapy is
safe and potentially effective. I believe that this kind of
disagreement is extremely valuable. Kassirer (115)
the patient should be given the benefit of the
doubt when important decisions are contemplated. The
physician initially should assume that the patient is
capable of becoming a full partner in the decision-making
process and encourage active participation. This means
the patient will have to assume more responsibility for
outcomes of medical decisions and the physician will have
to relinquish some....
Kassirer concludes that
when discussing details with the patient,
physicians should disclose whatever uncertainties exist.
Most patients are not horrified to learn that a
considerable body of medical information is fuzzy and
uncertain. Neither do they fail to comprehend that some
tests and treatments are risky, that some treatments are
not always efficacious, and that on occasion the
treatment may turn out to be worse than the disease.
Physicians and patients should dare to disagree,
especially about therapies for which scientific support is
anecdotal, equivocal, or preliminary. Often, the most
sensitive barometer of a relationship is the ability to
resolve disagreement. A rabbi commented that when providing
premarital counseling, she always asks the couple, "Tell me
how you disagree. I'm not interested in what you
disagree about, but rather how you work through your
disagreement." The manner in which the patient and physician
wrestle with disagreements about therapeutic choices helps
define their relationship and its value to each party.
We as a profession must address the challenge of
discussing alternative therapies with our patients and put
an end to the "don't ask, don't tell" approach that
characterizes communication in this area. These discussions
are opportunities for shared decision making and
"relationship-centered care" (116).
No patient should feel that their medical journey is to be
taken alone or according to some stealth trajectory,
invisible to their conventional providers. The delivery of
medical care, like the experience of illness, is best viewed
as a journey shared.
Appendix 1. Selected Information Resources on Herbs and
U.S. Department of Agriculture
Agricultural Genome Information System
Free access to 80 000 records on herb taxonomy and the
use of herbs worldwide, developed by Dr. James Duke. Other
available databases include a WAIS (wide-area information
server)-based subset of Agricola.
College of Pharmacy
The University of Illinois at Chicago
Contact: Mary Lou Quinn
Contains 124 000 scientific articles on the chemical
constituents and pharmacology of plants (75% were published
after 1975). Requires annual subscription fee for mediated
searching plus a fee for each record retrieved.
Journal of Natural Products
American Society of Pharmacognosy
555 31st Street
Downers Grove, IL 60515
Journal of Ethnopharmacy
Elsevier Science Ireland, Ltd.
Madison Square Station, Box 882
New York, NY 10159
International Journal of Pharmacognosy
Swets & Zeilinger
400 Creamery Way, Suite A
Exton, PA 19341
American Botanical Council
PO Box 201660
Austin, TX 78720
Herb Research Foundation
1007 Pearl Street, Suite 200
Boulder, CO 80302
Hand searching of private library composed of 125 000
papers that cover a full range of botanical issues. Hourly
fee for searching plus a per-page charge.
U.S. Department of Agriculture National Agricultural
Food and Nutrition Information Center
National Institutes of Health Office of Dietary
Supplements' public information service. No charge for
telephone requests. Reference service hours are Monday
through Friday, 12:30 to 4:30 p.m. Eastern Standard
917 Plum Street
Cincinnati, OH 45202
One of the largest comprehensive collections of books and
serials on natural pharmaceuticals in North America.
Searches are free, but a copy fee is charged for materials
List of Associations
Extensive annotated listing of commercial, nonprofit,
national, and regional organizations dedicated to the
support of herbal medicine. Other resources available
through Herbnet include recent news and publications.
Appendix 2. Information Resources for State
Federation of Chiropractic Licensing Boards
901 54th Avenue, Suite 101
Greeley, CO 80634
National Center for Homeopathy
801 North Fairfax Street, Suite 306
Alexandria, VA 22314
Homeopathy is licensed in three states. Contact state
licensing boards for general information.
National Certification Board for Therapeutic Massage
8201 Greensboro Drive, Suite 300
McLean, VA 22102
Provides detailed information on state licensing and
regulatory requirements and on individual certified
practitioners. Certification is not consistently required
for licensure. Not all massage therapists are nationally
No single acupuncture organization can provide
information by telephone on a state-by-state basis. State
boards of registration in medicine should be contacted for
National Certification Commission for Acupuncture and
Oriental Medicine (NCCA)
1424 16th Street NW
Washington, DC 20036
Book (cost, $7.00) available that provides each state's
licensing and regulatory requirements.
American Academy of Medical Acupuncture
5820 Wilshire Boulevard, Suite 500
Los Angeles, CA 90036
Membership limited to allopathic and osteopathic
physicians who have had 200 hours of acupuncture
American Association of Naturopathic Physicians
601 Valley Street, Suite 105
Seattle, WA 98109
Naturopathy is licensed in 12 states and the District of
Columbia (Figure 2). The AANP
provides contacts for local licensing and regulatory boards
and general information on naturopathy.
Acknowledgments: The author thanks Ellen Meisels,
JD, MPH, Janis Claflin, PhD, and Rabbi Elaine Zecher for
their contributions; Janet Walzer, MEd, Christopher Tuttle,
Thomas Delbanco, MD, Thomas Inui, MD, and Debi Arcarese for
editorial suggestions; and Debora Fischer for technical
Grant Support: In part by National Institutes of
Health grant U24 AR43441, the John E. Fetzer Institute, the
Waletzky Charitable Trust, the Friends of Beth Israel
Hospital, and the Kenneth J. Germeshausen Foundation.
Requests for Reprints: David M. Eisenberg, MD, the
Center for Alternative Medicine Research, Beth Israel
Deaconess Medical Center, 330 Brookline Avenue, Boston, MA
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