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If physicians don't ask, patients won't tell about CAM

Reassuring patients that they won't be judged or dismissed can help open up the lines of communication

From the November/December ACP Observer, copyright 2007 by the American College of Physicians.

By Stacey Butterfield

A 2006 survey reported that 63% of Americans age 50 or older reported using one or more complementary and alternative medicine (CAM) techniques. Yet 69% of the CAM users said that they had not talked to their doctors about it. The reason cited by 42% of patients in the survey? Most doctors never asked.

Physicians may think they are asking about CAM when they ask what medications a patient is taking, but that question is often insufficient to get a full answer about CAM use, said Ellen F. Hughes, ACP Member and director of education at the Osher Center for Integrative Medicine at the University of California, San Francisco.

Even when patients clearly understand what they're being asked, they still may give less than a complete answer, said Nancy R. Jasper, MD, an ob/gyn from Columbia University Medical Center in New York who has studied how often patients withhold information from physicians.

"Patients don't want to be judged. They don't want to be lectured to," she said. In the 2006 survey, conducted by the NIH's National Center for Complementary and Alternative Medicine (NCCAM), 12% of the patients who hadn't told their doctors about their CAM use listed "the doctor would have been dismissive or told me not to do it" as the reason for their silence.

These statistics are reason for concern, especially given the popularity of herbs and supplements, said Lois Snyder, JD, director of ACP's Center for Ethics and Professionalism. Of the survey respondents, 42% used herbal products or dietary supplements.

"Because the potential for drug interactions is really high, physicians need to ask patients specifically about their CAM use and open a dialogue," said Ms. Snyder.

Ask, don't wait

Researchers have known about the gap in patient-physician communication about CAM since 1998, when a study published in the Journal of the American Medical Association by Eisenberg and colleagues found that almost 40% of adult CAM users didn't talk to their physicians about the therapies.

The latest edition of the ACP Ethics Manual, revised in 2005, advises that "Because most patients do not affirmatively disclose their use of complementary and alternative care, physicians should ask patients about their current practices."

When Dr. Hughes teaches her medical students to talk to patients about CAM, she offers some strategies for starting an open conversation. "The two things that I usually encourage my students to do are to one, normalize it and two, give a specific example," she said.

For example, said Dr. Hughes, a question along the lines of the following would cover both points: "Many patients take over-the-counter supplements or herbs. Do you take anything such as echinacea or St. John's wort?"

It is also important to discuss patients' use of complementary therapies other than medication, noted Brent A. Bauer, FACP, director of the complementary and integrative medicine program at the Mayo Clinic in Rochester, Minn. In the 2006 survey, 45% of respondents reported using some form of bodywork (chiropractic manipulation, massage) and 14% used naturopathy, acupuncture or homeopathy.

Dr. Bauer suggests using open-ended questions and examples, such as: "Is there anything you would like to tell me about your health care? There are complementary therapies such as acupuncture, tai chi, yoga."

"If you ask it and give examples like that, it demystifies it. It tells the patient that you, as their physician, know that these things are out there and some people use them," said Dr. Bauer.

Dr. Jasper offered her techniques for getting patients to be more forthright. "Physicians need to share with the patients that they are just looking to get information so that they can counsel the patient appropriately, and make sure they can give the patient the right treatment."

Maximizing the visit

Among both patients and doctors, lack of time is a frequent excuse for incomplete communication. In the AARP/NCCAM study, 19% of patients said that there wasn't time to discuss their CAM use in an office visit. Dr. Jasper believes that many physicians are missing opportunities for additional history-taking during visits.

"Especially new physicians feel that the only time they can get a lot of factual info is when they're sitting face-to-face with the patient. But many times as you're preparing to do the exam, you can ask them additional questions," she said. "If you ask them in a different way, they may say, 'I forgot to tell you, if this makes a difference, I'm on ...'"

But effective questioning is only half the work in successfully treating patients who use CAM, noted Dr. Bauer. "The challenge, of course, is if you ask about it, then what do you do with that information when they say, 'Yes, thank you for asking. I am taking 16 different herbs.'"

He and other experts advise physicians to bone up on the evidence base for CAM, through CME offerings and reputable Web sites like ACP's PIER (pier.acponline.org) and the NCCAM site (nccam.nih.gov).

"It's not going to be good enough to say, 'I really don't know anything about that.' Then the patient's not going to raise it further. They're going to use things that could potentially interact with conventional medical therapies," said Ms. Snyder.

It is normal that physicians will be skeptical of CAM therapies that they are unfamiliar with, but they should try to keep an open mind and be aware of their own prejudices, according to David P. Rakel, MD, director of the University of Wisconsin Center for Integrative Medicine in Madison, Wis.

"It's important that we understand what our biases are. Once we recognize our own biases, we can prevent those from interfering with the communication we need to have with our patients, who have their own set of biases," he said.

Later this year, NCCAM is launching an educational campaign that should help patients and physicians overcome their biases and communicate openly about CAM. The "Time to Talk" campaign will offer tips for patients on how to bring up CAM as well as a free toolkit for health care providers which will include posters, tip sheets, patient wallet cards and other resources to encourage discussion of CAM use.

"We hope that the Time to Talk campaign will provide health care providers and patients with the tools to start an open dialogue about CAM use, which is critical for ensuring safe and appropriate integrated care," said Ruth L. Kirschstein, MD, acting director of NCCAM.

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