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Patient advocacy encompasses promoting patients’ well-being, protecting them from harmful practices, facilitating informed choice, honoring their values and decision making, and promoting dialogue and partnership. It also includes the purposeful identification of the physicians’ own medical experience and knowledge within the limits of their training, which results in the responsibility to seek appropriate consultation and referral. The interplay of patient advocacy, the difficulty in achieving the goals of medicine, the perceived and real limits of conventional medicine, and the reality of today’s practice environment serves as the motivation to 1) learn why patients are seeking and using complementary and alternative practices for their health needs; and 2) help define the significant role physicians play in these areas. We recommend that physicians follow the framework of “Protect, permit, promote, and partner” when approaching CAM in their clinical practices :

• Protect patients against dangerous practices.
• Permit practices that are harmless and may assist in comfort or palliation.
• Promote and use those practices that are proven safe and effective.
• Partner with patients by communicating with them about the use of specific CAM therapies and products.

Reference:

• Studdert DH, Eisenberg DH, Miller FH, et al. Medical malpractice implications of alternative medicine. JAMA 1998;280:1610–1615.

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Patients who use unconventional medicine are not necessarily unconventional patients. Many interventions used by the patients in the Eisenberg studies straddle or are part of current conventional medical practice. This can result in confusion as to the definition of CAM. For instance, the more frequently used interventions included exercise, relaxation techniques, and massage; all of these are part of treatment programs prescribed by medical doctors. Other approaches included imagery, prayer, and spiritual healing. Medical doctors usually do not interfere with the use of these modalities.
Chiropractic manipulation was also a frequently used intervention. Although there has been resistance by organized medicine to chiropractic, this modality has been demonstrated to be equally effective as other treatments that can be offered for acute lower back pain of nonorganic etiology. It has even been recommended as such by the United States Public Health Service.
The list of the more frequently used CAM modalities in the Eisenberg study also included herbal medicines and megavitamins. Herbal medicine is a difficult area for most medical doctors because most lack formal training in it, many of the medicaments are unfamiliar, and only recently has there been an authoritative source, such as the Physicians Desk Reference for prescription items. Also, there is little required Food and Drug Administration overview and labeling of herbal products sold in the United States, although other countries (such as Germany and Australia) have established guidelines and oversight procedures. These same factors apply to the difficulty that physicians find in sanctioning the use of megadose vitamins. As a result, physicians cite generalized concerns about safety and efficacy if these products are used by their patients.

Reference:

• Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States— prevalence, costs, and patterns of use. N Engl J Med 1993;328:246–252.
• Eisenberg DM, Davis RB, Ettner S, et al. Trends in alternative medicine use in the United States. JAMA 1998;280:1569–1575.
• Bigos S, Bowyer OB, Braen G. Acute low back problems in adults: clinical practice guideline No 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, 1994.
• PDR. The herbal Physicians Desk Reference. Philadelphia: PDR Press, 1999.

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The predominant conditions for which Americans use CAM are chronic and stress-related conditions such as back problems, arthritis, headaches, digestive problems, depression, cancer, hypertension, and autoimmune syndromes—in other words, conditions for which there are no cures and for which inadequate treatment regimens sometimes produce adverse side effects.
Patients use alternative practices because these modalities are part of their social network, they are not satisfied with the process or result of conventional care, or they are attracted to CAM philosophies and health beliefs. Patients who use CAM do not generally hold anti-science or anti-conventional medicine sentiment, nor do they represent a disproportionate number of the uneducated, poor, seriously ill, or neurotic. Included in these multiple motivations is the patient’s wish to obtain faster resolution of illness. Some patients are motivated by the desires to prevent illness or injuries and maintain wellness. Most of these patients function as active participants in their own health care.

Reference:

1. Furnham A, Forey J. The attitudes, behaviors and beliefs of patients of conventional vs complementary (alternative) medicine. J Clin Psychol 1994; 50:458–469.
2. Astin JA. Why patients use alternative medicine. JAMA 1998;279:1548–1553.
3. Cassileth BR, Lussk EJ, Strouss TB, Bodenheimer BJ. Contemporary unorthodox treatments in cancer medicine: a study of patients, treatments, and practitioners. Ann Intern Med 1984;101: 105–112.
4. Vincent C, Furnham A, Willsmore M. The perceived efficacy of complementary and orthodox medicine in complementary and general practice patients. Health Education: Theory and Practice 1995;10:395–405.

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The best data on rates of usage of CAM come from two identical surveys conducted by Eisenberg and colleagues in 1990 and 1996. These authors extrapolated data from a 1990 U.S. telephone survey  of approximately 1500 respondents. In 1990, they found that one-third of Americans (representative of all sociodemographic groups) used CAM that year. Almost all of these patients were also being cared for by traditional medical doctors. However, approximately 90% self-referred to alternative providers, and, importantly, three of four did not tell their physicians about use of the alternative care. A repeat of this survey in 1996 with more than 2000 respondents showed a dramatic increase in CAM use—to 42% of the population—and out-of-pocket CAM expenditures equaling the amount spent out-of-pocket for conventional medicine. The rate for women was 49%. Other surveys have shown that approximately 50% of patients who have cancer or human immunodeficiency virus will use unconventional practices at some point during their illness. The medical records of these patients were incomplete, however, because they did not reflect the use of CAM therapies. Therefore, Americans are using CAM in substantial and increasing numbers. Similar and even higher figures are found in Europe, Australia, and other countries. This fact should stimulate each practicing physician to ask why his or her patients are seeking out these therapies, pay attention to the patients’ answers, and decide how the practitioner should respond as a health care provider.

Reference:

• Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States— prevalence, costs, and patterns of use. N Engl J Med 1993;328:246–252.
• Eisenberg DM, Davis RB, Ettner S, et al. Trends in alternative medicine use in the United States. JAMA 1998;280:1569–1575.
• McGinnis LS. Alternative therapies, 1990. Cancer 1991;67:1788–1792.
• Anderson W, O’Connor BB, MacGregor RR, Schwartz JS, et al. Patient use and assessment of conventional and alternative therapies for HIV infection and AIDS. AIDS 1993;74:561–564.
• Fisher P, Ward A. Complementary medicine in Europe. BMJ 1994;309:107–111.
• MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996;347:569–573.

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The public’s use of complementary and alternative medicine (CAM) is not a peripheral practice, fad, or medical side issue. Rather, it reflects a genuine public health care need that will not disappear. What then is the conventional practitioner’s responsibility for offering meaningful counsel to a patient who is considering CAM? How does a practitioner make informed decisions about a particular CAM modality to determine whether it has a role in the patient’s care?

The chief goals of medicine have recently been summarized in a report by the Hastings Institute. Dominant emphases relate to curing disease, promoting health and preventing illness and injury, restoring functional capacity, avoiding premature death, relieving suffering, enhancing quality of life, and caring for those who cannot be cured. These goals are the same for all practitioners, regardless of their methods or beliefs.
Critics of conventional medicine argue that these goals are not being fulfilled. Instead, they are being replaced by an approach to patients that is reductionistic, cure oriented, organ specific, mechanistic, depersonalized, and subspecialized. A dogmatic attempt to address chronic disease with this approach is infringing on the aforementioned goals. Nevertheless, even severe detractors acknowledge the great value of conventional medicine regarding competent care for acute disease and trauma, the capacity to expertly apply innovations in both diagnosis and treatment, and the ability to translate basic science discoveries into clinical care.
Most physicians are aware of the finite aspects of their scope of practice. They recognize that it is impossible to be all things to all patients and keep current with every aspect of the rapid continuous advance of conventional medicine. Coupled with this knowledge is the diminishing ability of physicians to fulfill their responsibility to function as a patient advocate. Medical decision making is increasingly altered because of economic considerations in the provision of health care, which includes the actions of hospital boards and administrators, employers, third-party payers, the legal profession, and government regulations.

Reference: Hastings Center Report. The goals of medicine: setting new priorities. Briarcliff Manor, NY: The Hastings Center, 1996.

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