Advising Patients Who Seek
Alternative Medicine (Related Letters)

FROM: Ann Int Med 1998 (Feb 15);   128:

Annals of Internal Medicine

LETTERS

Related Article

Advising Patients Who Seek Alternative Medicine

Annals of Internal Medicine, 15 February 1998.

To the Editor: As a medical oncologist with more than 20 years in private practice, I find myself disagreeing with most aspects of the recent article by Dr. Eisenberg (1). Perhaps owing to two generations of deteriorating attention to the teaching of science and mathematics in public schools in the United States, "alternative medicine" is making a steady incursion into the health and the pocketbooks of the American people. Dr. Eisenberg regards this as a relatively benign intrusion that scientifically trained physicians should accommodate, work with, and monitor. I think that is wrong.

As expressed in the article, Dr. Eisenberg's suggestions create a new responsibility and even a legal liability for physicians that has hitherto not existed. For example, he states, "It is the conventional provider's professional obligation to monitor therapies with potential or documented toxicity, including herbal preparations." However, he gives no citation to any legal or ethical text to document this broad "obligation." Although every physician is responsible for monitoring the effects of treatment that he himself orders, including attention to the interactions of his treatments with those that other physicians have previously ordered, I have not elsewhere heard the assertion that the physician should also be responsible for monitoring the treatments ordered by other independent health care providers. Rather, it is up to the health care provider who actually orders a treatment to monitor it and ensure that it does not have an adverse effect on the patient.

I feel that a different approach to alternative health care is needed. With the patient, the physician should merely politely inquire about what other medications or treatments might be under way and make note of them. If a patient is receiving an "alternative" nonscientific treatment that is known or suspected to have dangerous or adverse effects, as shown by the scientific medical literature, the physician should make the patient aware of this. The physician should not feel any obligation to research the nonscientific treatments nor to refer to any of the references or resources provided by Dr. Eisenberg at the end of his article. The distinction between conventional medicine as scientifically based and alternative medicine as "nonscientific" medicine has been helpful in clarifying the issues in my experience. This is perhaps a change in terminology that all scientific physicians should begin to employ.

Finally, physicians should not confine their efforts to promote science over nonscientific biology in clinical situations but should participate in political and educational areas as well. In school classrooms, the teaching of nonscientific biology should be exposed and challenged whenever it is discovered. In their own children's schools and throughout public and private school systems, physicians should encourage increased emphasis on the teaching of science and mathematics from the grade school level onward to enable future generations of Americans to identify "nonscience" for what it is&emdash;mere nonsense!

Charles M. Bagley Jr., MD
Northwest Cancer Center
Seattle, WA 98133

Reference

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

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To the Editor: I read Dr. Eisenberg's article (1) with interest because I am one of those alternative providers whose "safety and efficacy remains largely unknown." I am a chiropractor. The article is a very good example of what I have to do on a regular basis because we do know the morbidity and mortality rates of conventional medicine's safest treatments. I am as apprehensive when going to my family physician as most patients should be when going to theirs.

Traditional medicine has lost sight of one of the most basic tenets of medicine, "first do no harm." This has been replaced by "the death ratio is acceptable for this procedure." You could combine every alternative provider's adverse outcomes over the past 100 years and not even come close to the morbidity and mortality caused by one simple drug (for example, aspirin) in 1 year.

I don't expect Dr. Eisenberg or traditional medicine to "get it" for another 50 years or so. People are seeking alternative providers because we will either help them or not harm them. They do not have this confidence about traditional medicine. After seeking care from alternative providers and not finding help, they will still be around to continue their search.

Dr. Eisenberg seems to be a bit uninformed about referrals to alternative providers, such as chiropractors. The referral back and forth between physicians and chiropractors has been going on for decades, and the practice is growing. If Dr. Eisenberg is worried about adverse outcomes, he should look at our malpractice rates: They are very low compared to those of traditional medicine. Either the public loves us so much that they won't sue us, or our adverse outcomes are minimal. Either option, I'm sure, is difficult to swallow.

Finally, in this day of managed care, Dr. Eisenberg's article is functionally useless. How often are you going to find a physician taking the time to talk to their patients at length about anything? I agree that the physician should be doing most of the things that the article talks about, but this discussion should take place when the physician decides to provide care or refer to one of his or her colleagues.

Try alternatives for safety.

Gordon D. Heinrichs, DC
Fresno, CA 93726

Reference

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

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To the Editor: Eisenberg (1) wants physicians to learn more about alternative therapies and alternative practitioners, to spend more time discussing specific alternative therapies with patients, to advise patients on how they should deal with alternative practitioners, and to monitor and review any alternative treatment plans that patients follow.

Why does Eisenberg want physicians to do all of this? He is worried about patient safety because, as he notes, "the safety and efficacy of these practices remain largely unknown." As anyone who looks into this area will find, there simply isn't much real, clinical evidence behind most alternative therapies. Eisenberg knows this and says as much repeatedly-indeed, four times. However, he does not appreciate that this point supports a different and perhaps better view on how physicians should deal with patients who want to consider alternative therapies.

Physicians should handle the situation with a practice policy (2). Given the questions and problems about the safety and efficacy of alternative therapies, it is reasonable to adopt the following practice policy: If a patient is thinking about using an alternative therapy, advise the patient not to use it. This policy obviously emphasizes patient safety because it is a general warning about alternative therapies. It is also efficient because it allows physicians to deal with these situations by using a simple rule, which saves physician energy. Physicians would not have to add alternative medicine to their home study program, perhaps at the cost of decreasing the time available for keeping up to date in the standard areas of conventional internal medicine.

Eisenberg deplores the "don't ask, don't tell" approach that some physicians and their patients take with regard to the topic of alternative therapies. This practice policy puts an end to this approach by facing up to a simple fact: There isn't all that much to tell. Alternative medicine has always had evidence problems (3), and these problems aren't going away anytime soon (4).

Douglas F. Stalker, PhD
University of Delaware
Newark, DE 19716

References

1. Eisenberg DM. Advising patients who seek alternative medical therapies. Ann Intern Med. 1997;127:61-9.
2. Eddy DM. Clinical Decision Making. Sudbury, MA: Jones and Bartlett; 1996.
3. Stalker D, Glymour C, eds. Examining Holistic Medicine. Buffalo, NY: Prometheus Books; 1989.
4. Stalker DF. Evidence and alternative medicine. Mt Sinai J Med. 1995;62:132-43.

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To the Editor: Dr. Eisenberg should be congratulated, not only for previously uncovering the great underground of alternative medicine use among our patients but also for now calling upon us in conventional medicine to take some responsibility in filling the communication gap that exists between patients and physicians in these areas (1).

Although his suggestions on how to address alternative therapies with patients provide a reasonable strategy for opening dialogue about these practices, his approach lacks one key element that is needed before physicians can fulfill these responsibilities. Judgments about alternative medicine, like those in all areas of medicine, should be evidence-based. As information on the diversity, quantity, and quality of alternative practices multiplies, skills in evidence-based medicine will become necessary (2).

Rarely is unequivocal evidence available in any type of medicine, alternative or conventional, and the physician cannot always wait for or rely on consensus statements or meta-analyses. Similarly, a few anecdotal or case series reports on adverse effects from alternative practices will hardly provide definitive information on whether and when those practices should be excluded as a possible option (3).

Scientific information is available on alternative medical practices, and Dr. Eisenberg has provided several sources. The Office of Alternative Medicine is currently working to make available hundreds of thousands of research articles from the worldwide alternative medicine literature. Much good research is currently available through conventional biomedical and other on-line databases. This information is in the form of randomized, controlled trials; outcome studies; epidemiologic research; and basic science research, each of which contributes to medical decision making.

The ultimate decision in medical care must rest with the patient and the caregiver, but it is the role and obligation of the physician to provide information on the existing scientific evidence as well as expert opinion to assist patients in making informed decisions. It is no longer sufficient for physicians to make recommendations based solely on familiarity with the therapeutic option or to await a biological explanation or consensus panel opinion. Evidence-based choices and the skills necessary to make them should become a routine part of all medical practices. The critical evaluation of alternative medicine literature presents a great opportunity for physicians to learn such skills, which can be extended to other areas of medicine (4).

Wayne B. Jonas, MD
Carol I. Hudgings, PhD
Office of Alternative Medicine
Bethesda, MD 20892

References

1. Eisenberg DM. Advising patients who seek alternative medical therapies. Ann Intern Med. 1997;127:61-9.
2. Dixon R, Munro J. Evidence Based Medicine: A Practical Workbook for Clinical Problem Solving. London: Butterworth-Heinemann; 1997.
3. Jonas WB. Safety in complementary medicine. In: Ernst E, ed. Complementary Medicine: An Objective Appraisal. London: Butterworth-Heinemann; 1996:126-49.
4. Vickers A, Cassileth B, Ernst E, Fisher P, Goldman P, Jonas W, et al. How should we research unconventional therapies? A panel report from the conference on complementary and alternative medicine research methodology, National Institutes of Health. Int J Technol Assess Health Care. 1997;13:111-21.

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In response: Three of the four letters received display a level of professional indignation that borders on contempt. These letters' hostile tone underscores the challenge of generating constructive professional guidelines for alternative medical therapies. The good news is that this debate has finally begun in earnest.

Dr. Bagley suggests that physicians inquire about alternative medical therapies; make note of them; and, when appropriate, advise patients about potential adverse effects. He disagrees with my suggestion that physicians consider referral to alternative practitioners or investigate alternative therapies. I accept this suggestion because it would constitute a considerable advance over the current status quo. I disagree, however, with Dr. Bagley's attempt to distinguish "scientifically based" conventional medicine from its "nonsensical" counterpart, alternative medicine. Such a distinction does not consider the numerous pharmaceutical products (and surgical procedures) that have never been subjected to randomized, controlled trials.

In response to Dr. Heinrich, claims of "safety" should be evidence based and should weigh relative risk and benefit. Aspirin can be hazardous but has proven effective for diverse conditions in randomized trials and meta-analyses. By contrast, the relative risk-benefit ratio of cervical manipulation of the spine remains controversial. Dr. Heinrich's unkind tone fuels the mistrust that obscures science and divides the conventional and alternative communities.

Dr. Stalker's comments seem equally divisive and unhelpful. He contends that the best response to patients who seek professional guidance regarding alternative therapy usage is to "just say no." This rigid, impractical posture does not engage patients in the respectful give and take of fact and opinion that characterizes shared decision making. Is it not equally arrogant to condemn or condone the universe of alternative therapies?

I thank Dr. Jonas, who has made substantial contributions as the Director of the Office of Alternative Medicine, National Institutes of Health, and should be commended for his efforts to organize research initiatives in this area. I agree with his conviction that clinical recommendations about individual therapies, regardless of their origin, must be evidence-based. To paraphrase David Sackett, MD, most clinical recommendations are based on " induction, deduction or seduction" (1). Each type of evidence has its value; however, the more controversial a therapy is, the greater the likelihood that its clinical acceptance will await overwhelming evidence in support of its use. Dr. Jonas and I disagree about the quality of existing research on alternative therapies. In my opinion, the quantity of this literature far exceeds its quality. Moreover, we lack a satisfactory assessment of the adverse effects of commonly used alternative treatments; this further limits a clinician's ability to offer sound recommendations.

The field of alternative medicine research is young. The U.S. Congress created the National Institutes of Health Office of Alternative Medicine in 1992. Eight of the 10 federally funded Centers of Alternative Medicine Research are not quite 2 years old. The ambitious distillation of the existing database alluded to by Drs. Jonas and Hudgings is ongoing and will require considerable time and effort. Prospective studies to evaluate commonly used alternative therapies are just beginning.

As I stated in my article, "as long as information on the efficacy and toxicity of alternative therapies remains inadequate, advice will remain imperfect and a matter of judgment." In time, we will possess far more convincing information on the safety and efficacy of alternative therapies. Our "evidence base" will be larger. Nevertheless, advice will remain imperfect and a matter of shared judgment. This is true for most therapies, regardless of whether they are deemed alternative or conventional.

David Eisenberg, MD
Beth Israel Deaconess Medical Center
Boston, MA 02215

Reference

1. Sackett D, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine. Boston: Little, Brown; 1991:191.

Advising Patients Who Seek Alternative Medicine