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Chapter 1: An Introduction to Complementary and Alternative Medicine
The goal of this program is to introduce nurses to the concept of complementary and alternative medicine (CAM). After studying the information presented here, you will be able to -
Three-year-old Matthew Smith has a history of recurrent otitis media. Since his first ear infection at 11 months of age, he has been on eight rounds of antibiotics. Mrs. Smith, his mother, has a friend who takes her children to a pediatric practitioner group that uses, among other approaches, homeopathic and chiropractic methods for care. In view of her friend's satisfaction with this group and reports in the popular press that some ear infections may resolve without antibiotics, Mrs. Smith decides to consult with them concerning Matthew's condition. Alice Raven, MD, a homeopathic physician, shares Mrs. Smith's concern about antibiotic treatments as she feels they may help resolve the infection, but do not get at the root cause. Dr. Raven recommends that Matthew begin a course of vitamin C and zinc to boost his immune system. After doing an extensive evaluation, she also prescribes homeopathic medications derived from a variety of natural products and further suggests seeking chiropractic treatments from a colleague in her practice. After undergoing this treatment for two weeks, Matthew develops another ear infection. Mrs. Smith is concerned, but Dr. Raven assures her that the prescribed treatment may take longer to work in children who have been previously treated with antibiotics. Mrs. Smith asks for your advice.
Unless you've had the opportunity to learn about CAM or the experience of providing advice to your patients about CAM, you might be thinking, "Geez, what would I do here? Where would I even begin?" Well, take relief in knowing that this module is an excellent place to start. Studies reveal that at this time most conventional health care practitioners know very little about CAM, who uses CAM and why, where to find valid and reliable information about CAM, and the methodological issues associated with conducting and evaluating CAM research studies.1 The good news is that there are national organizations and educational programs to help us all learn more about CAM.
To help the health care community and public learn more about these and other CAM related issues, the National Institutes of Health (NIH) established the Office of Alternative Medicine (OAM) in 1996. That same year, the OAM and the Uniformed Services University of Health Sciences, a military-sponsored medical education and graduate nursing university, hosted a conference on medicine and nursing education and CAM. Based on the recommendations of the conferees (OAM, 1996), the National Center for Complementary and Alternative Medicine (NCCAM), established in 1998, develops programs to support the integration of CAM into health care education programs. At the initial publication of this module, the CAM educational program at the Rush University College of Nursing in Chicago is supported by an NCCAM educational grant.
Please visit the Rush CAM Education Program for Nursing for more information.
What is CAM?
The NCCAM is the lead agency of the federal government for CAM research. Its mission is to "explore complementary and alternative healing practices in the context of rigorous science, training CAM researchers, and disseminating authoritative information to the public and professional communities."2 According to the NCCAM, CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. While some scientific evidence exists regarding some CAM therapies, for the most part key questions remain to be answered through well-designed scientific studies - questions such as whether CAM therapies are safe and whether they work for the diseases or medical conditions for which they are used.3 To consumers, CAM represents choices above and beyond the options that most conventional allopathic (i.e. Western-trained) health care practitioners are able to provide.
Various sources estimate that there are over 100 different CAM therapies. According to the NCCAM, there are five major areas of CAM:3
Please visit the NCCAM website for further discussion of these practices.
At the writing of this module, published data indicate that therapies such as herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy are increasing the most rapidly.4 Although they are popular, controversy exists about the nature of these therapies and their role in modern health care. Are the therapies alternative, implying a choice of CAM in lieu of conventional allopathic care? Are they complementary, a term that suggests that while they may help the patient, they are best delivered adjunctively with conventional care? A recent concept is the notion of integrative care. This concept proposes that both conventional care and CAM therapies be delivered using a patient-centered approach that puts the patient's needs first.
CAM: Who is seeking CAM and why?
So you may ask, "Just how many people are interested in different CAM approaches?" A groundbreaking study conducted by a physician at Harvard and colleagues revealed that in 1990 over 30% of Americans sought treatment from alternative health care providers.5 A follow-up study revealed that CAM use rose to about 55% between 1990 and 1997.4 As a matter of fact, few changes have affected health care as rapidly and profoundly as CAM. The expenditures for alternative therapies in 1990 amounted to about $13.7 billion, three-quarters of which ($10.3 billion) was paid out of pocket. This figure is comparable to the $12.8 billion paid out of pocket in the United States. annually for all hospitalizations or visits to conventional practitioners.4
So what is it about CAM that draws so many people to it, and why are so many willing to pay out of pocket for therapies that are "alternative"? Take a look at these articles to see why: "More than one-third of U.S. adults use complementary and alternative medicine, according to new government survey and "Complementary and alternative medicine."
As you learned from the second link above, some patients who use CAM do so "largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life."6
Reflection point: Which of your patients are using CAM?
Take a moment and think about your own patients. How many of them might be visiting a CAM practitioner at this very moment? How many may talk to you about CAM during your next visit with them? Are any coming to mind? One study found a person's education to be the top predictor of CAM use.6 It seems that the higher the education, the more likely the use of CAM. How many of your patients have a high school education or less? According this study, 31% of them are using CAM.6 How many of your patients have graduate degrees? It's estimated that 50% of your patients in this group are CAM users. Are any of your patients in declining health? What about those who see you because they have specific health issues like back problems, suffer with chronic pain or anxiety, or have urinary tract infections? Well, more often then not, it's folks with these issues that are likely to use CAM therapies.6
Have you had any sort of experience talking to your patients about their CAM use?
If nothing comes to mind, you are not alone in your experience. Studies reveal that, in most cases, health care providers are not asking patients about CAM use, and in return, that in more than 70% of cases, patients are not disclosing their CAM use to health care providers. The reason? One study of breast cancer patients, published in the June 1999 edition of the Journal of Family Practice, revealed that women did not discuss their use of alternative therapies with physicians because the women didn't think that they were knowledgeable or interested in them and that they were biased against the therapies.7
To learn more about how health care providers can facilitate the collection of data on the use of CAM therapies, we welcome you to delve into the "Assessment of Complementary and Alternative Medical (CAM) Therapy Use" module, a second in the CAM education series we have developed at Rush University. At the conclusion of the "Assessment" module, you will better understand why patients fail to disclose use of CAM modalities to their health care providers and how patients' cultural and ethnic background influences health care choices and information disclosure. Plus, you will learn approaches to facilitate the collection of data on CAM use.
CAM practices and philosophies
In the article on the "onconurse.com" site above, you learned that patients are more likely to use alternative therapies because they find such alternatives more congruent with their own values, beliefs, and philosophical orientations toward health and life. What do you know about philosophic approaches to health and illness? Click on the links below with the goal of answering the following questions:
Note: Some of the websites provide extensive information. You will need to focus only on the first few pages or sections of each site to answer the questions posed.
As you may have gathered from the above articles, there are a number of well-developed systems of medicine that have been practiced for centuries.
While many people raised in Western cultures believe that there is only one approach to medical practice, that being the allopathic ("conventional") model, you have just learned that this isn't the case. So what's the difference? In allopathy, health is defined as the absence of disease. Until recently, the emphasis of allopathic medicine had been largely on disease and its treatment, with little attention given to preventive care. The main causes of illness are considered to be pathogens, such as bacteria or viruses, or biochemical imbalances. Scientific tests are often used in diagnosis. Allopathy relies on treatments to produce an effect different from symptoms. While drugs, surgery, and radiation are among the key tools for dealing with problems, more recently, allopathic practitioners have incorporated additional approaches, such as lifestyle changes and behavior modification, into plans for care. While conventional models most often focus on disease and its treatment, the traditional models, such as those highlighted above, focus on the whole person. In treating the whole person, a holistic practitioner may typically want to know about a person's lifestyle, stressors, spiritual practices, diet, or other factors that will help get to the root of the physical complaint. These traditional approaches have been practiced for centuries and focus on natural ways of restoring balance to the body and promoting health.
Evaluating CAM-related resources
Earlier, we introduced you a variety of CAM-related practices and a few websites to learn more about each topic. With the growth of health-related information on these topics and others on the web, it's imperative that you are referring to valid and reliable sources for additional information. If you do not have access to current research or evidence-based books on CAM, it's essential to know which websites provide valid and reliable information about health care in this growing field.
There are a variety of resources to use to evaluate the safety and efficacy of CAM therapies. These include books, journals, and websites. In reviewing these materials, keep in mind that the strength of the evidence provided to support the use of an intervention may be highly variable, depending on the therapy in question, as well as the condition or symptom targeted for treatment. Very few CAM therapies have been studied extensively. Other practices, although not tested by conventional research approaches, have stood the test of time by repeated observations of their outcomes (e.g., treatments within culturally based traditional medical systems). In evaluating CAM-related resources, you need to consider the:
Reflection point: Take a moment and review the pediatric case study on page one.
Let's say for a moment that you're the healthcare practitioner who saw Mrs. Smith and her son, Matthew, earlier today. You've finished seeing patients, and you're in your office figuring out what advice to give Mrs. Smith about homeopathic or other alternative therapies for her son's recurrent otitis media. You conduct a search, and the first couple of websites that pop up are provided below. Keeping the above criteria in mind, which of the two would you find to be a more credible source of CAM information to support clinical recommendations? Why?
Reliable CAM resources
As you continue to learn about CAM therapies, there are a number of resources you may find useful. These include literature, Internet, and media sources of CAM information and professional organization sites identified on the Rush College of Nursing CAM (look under "resources") website. Other recommended information resources include:
We invite you to learn more about identifying valuable CAM-related resources on the Internet and in professional journals via the "Licensing, Education, and Training of CAM Practitioners" and "Evidence-Based Medicine and Clinical Decision Making Related to Complementary and Alternative Therapies" modules that were developed as part of this CAM education series at Rush University. Read more about these at the conclusion of this module.
Methodological issues in CAM research
As you visit reliable websites and read other evidence-based CAM resources, you will learn that, for a variety of reasons, many CAM therapies have not been adequately evaluated. According to the NCCAM website, reasons include skepticism, lack of interest, lack of funding, CAM practitioners' inexperience in conducting research studies, and methodological issues. The randomized controlled trial (RCT) method of research is considered the "gold standard" for establishing the efficacy and safety of conventional treatments. This creates a problem for some CAM therapies as it may be difficult or impossible to measure their effects in a standardized way. According to a recent JAMA article, "Some commentators have argued that the placebo-controlled trial is not a valid or fair method for evaluating CAM treatments. Specifically, it is claimed that the scientific techniques of treatment protocols, randomization, double-blind conditions, and use of placebo controls distort the 'holistic' therapeutic milieu of CAM, which values extensive personal attention, individualized treatment selection, and the use of healing rituals. Accordingly, some CAM advocates have declared that placebo-controlled trials bias the evaluation of CAM, leading to the conclusion that CAM treatments are worthless because they have not been demonstrated to be superior to placebo in rigorous RCT's.8 For example, herbal products may lack the uniformity found in conventional pharmacological agents, thus making testing more complicated. Or it may be difficult to identify appropriate placebo controls for therapies such as acupuncture or massage. Further, RCTs are not designed to evaluate individualized therapies often interwoven with culture, lifestyle, and practitioner effects.
To further explore some of the methodological issues involved in studying CAM therapies, visit recent reports by Ai L, et al (2001): and Yamey G. (2000): (scroll to pps 351-352).
Congratulations on completing the Rush University College of Nursing "An Introduction to Complementary and Alternative Medicine module." It's our hope that this module helped you gain an understanding of the most widely used CAM modalities; what types of patients are likely to be exploring CAM; and how to find reliable and valid resources about CAM for you and your patients. Clearly, this is just the tip of the "CAM information iceberg," but nevertheless an important place to begin familiarizing yourself as this field continues to grow and more research is conducted.
With the increasing use and interest in CAM, we as nurses are in a unique position to help patients, like Mrs. Smith in the "pediatric case" above, decide what types of CAM therapies are worth exploring. Did you ever consider what you would do if Mrs. Smith asked for your help in determining whether the CAM practitioners from the pediatric group were "properly" trained and licensed CAM practitioners? Or let's say Mrs. Smith challenged you to provide recommendations about the safety and efficacy of CAM therapies for her son Matthew. Would you know how to weigh the evidence and provide such advice?
If you've encountered any of these scenarios and have not known what to do -- or want more information to prepare yourself for such situations -- we welcome you to explore two modules developed exclusively by our CAM faculty and staff, "Education, Training, and Licensing of CAM Practitioners" and " Evidence-Based Practice and Clinical Decision Making Related to Complementary and Alternative Therapies." The education module provides learners with detailed information about indications for patient consultation with various CAM practitioners. In addition, it helps the learner explore and understand the training, licensing, and credentialing of frequently used CAM providers. The evidence-based practice module is unique as it helps learners use evidence-based approaches to evaluate the safety and efficacy of CAM therapies and assists learners in creating effective clinical decision-making skills regarding the use of CAM therapies as part of an overall plan of care. These, together with the "Assessment of CAM Use," will provide you with a good foundation when caring for people who are actively using or considering CAM practices.
Glossary
Allopathic
Allopathic, or conventional medicine, is Western medicine, as we commonly know it. In allopathy, health is defined as the absence of disease. Until recently, the emphasis of allopathic medicine had been placed largely on disease and its treatment, with little attention given to preventive care. The main causes of illness are considered to be pathogens, such as bacteria or viruses, or biochemical imbalances. Scientific tests are often used in diagnosis. Allopathy relies on treatments to produce an effect different from symptoms. While drugs, surgery, and radiation are among the key tools for dealing with problems, more recently, allopathic practitioners have incorporated additional approaches, such as lifestyle changes and behavior modification, into plans for care.
Alternative
Originally, the National Institutes of Health's Office of Alternative Medicine (OAM) defined alternative medicine as those approaches and therapies not taught in U.S. medical schools (considered to be "unconventional"), such as biofeedback, hypnosis, chiropractic, progressive relaxation, meditation, weight loss programs, and stress reduction programs. Conventional biomedicine practitioners typically do not provide these therapies. Alternative is also referred to in the context of using an unconventional treatment exclusively, in place of an allopathic treatment.
Complementary
Complementary medicine, a term originating from the British health care system, refers to alternative therapies that are used in combination with, but not as a replacement for, an allopathic treatment. True to its definition, complementary therapies are adjunctive and meant to enhance the outcomes of allopathic treatment plans.
Holistic
Holism, meaning "state of wholeness," is a principle that holds that all aspects of a person - mental, emotional, spiritual, physical - are interrelated. Holistic medicine focuses on preventing illness and maintaining health. In holism, health is a state of balance among all aspects of a person. Any disharmony is thought to stress the body and perhaps lead to sickness. To fight disease, holistic medicine uses a wide range of therapies (such as herbal products) to bolster the body's own defenses and restore balance. One illustration of the approach of holistic medicine is the fact that ancient Chinese doctors were paid only when their patients were healthy, not if they became ill.
Integrative
Integrative medicine, a term coined by Andrew Weil, MD, considers all viable options when planning care. While complementary is considered as adjunctive and alternative as exclusive care, an integrative approach considers alternative, complementary, and conventional options equally. The focus of an integrative approach is more holistic, addressing health and healing rather than disease and treatment.
Traditional
"Traditional" describes cultural, folk, or family-based systems of healing and caring. It is often incorrectly used to refer to allopathic medicine. Some of the approaches in the NCCAM-defined domain of "alternative medical systems" include traditional or cultural-based systems of care, such as Ayurveda or traditional Chinese medicine.
Chapter 2: Complementary and Alternative Medicine Practices and Practitioners
The goal of this program is to inform nurses about the three commonly used complementary and alternative medicine(CAM) therapies and the education and training of CAM practitioners.
After studying this information here, you will be able to -
Jack Sullivan, RN, works at a family practice clinic in Chicago. In the last two of his 10 years in practice, inquiries from patients and their family members about complementary and alternative medicine (CAM) have increased markedly. Jack realizes that he is in a unique position to bridge the gap between conventional Western care and complementary therapies and wants to make informed decisions when working in a collaborative manner with patients and CAM practitioners.
The challenge for Jack is two-fold: First and foremost, he wants to ensure that the type of CAM therapy his patients are seeking is indicated and appropriate for the symptom or condition for which it is used. Second, he wants to have the knowledge necessary in order to help his patients select appropriate CAM practitioners.
Jack is not alone in his situation. The reality is that few changes have affected health care as rapidly and profoundly as CAM. Despite slow acceptance by the Western medical community, it is estimated that 70% to 90% of people worldwide use complementary or alternative approaches as a routine part of their health care.1 For many, these approaches are not alternatives as they represent their traditional health care systems. For others, these therapies are complementary and are most often used in conjunction with, as opposed to being a replacement for, conventional health care. Although scientifically based CAM research is being supported by the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) and other organizations across the country, our understanding of the safety and efficacy of many CAM practices is in its infancy.
Health care providers working in settings where CAM therapies are numerous and CAM use is likely to be widespread must become familiar with CAM practices and the training and licensing of CAM practitioners.
This module has been developed as a learning tool and will expose you to three popular CAM therapies: acupuncture, chiropractic, and massage therapy. Our hope is that it will provide you with the basic guidelines to evaluate these and other CAM therapies and their practitioners. As you are well aware, information about all types of health care changes rapidly. As such, keep in mind that the information and links included here were current as of the launch of this module.
Indications, safety considerations, and contraindications
Case Study 1
Just recently, Jack encountered a 26-year-old woman in the first trimester of pregnancy with a chief complaint of low back pain. She has not been responding well to conventional therapies, such as physical therapy. She requests information on CAM treatment options. She recently read an article about CAM therapies for low back pain during pregnancy and asks your opinion about acupuncture, chiropractic, and massage.
Questions to ask yourself:
Finding the valid and reliable information needed
First, it's imperative to learn whether the CAM therapy she's inquiring about is indicated for her condition. If you do not have current, research/evidence-based books on CAM to help answer such questions, the Web can be a useful source of such information.
If you begin your search on the Internet and enter "acupuncture for the treatment of low-back pain during pregnancy," you'll get thousands of results. The challenge here is finding reputable sources. The problem is that the number of sites providing health information grows daily, and although many sites are valuable, some provide misleading information. In addition, compared to research available about conventional medicine and its treatments, CAM-related research is somewhat limited. As such, it is important to be able to assess the quality of information and take that into account when providing guidance to patients. To help identify valuable resources, The Guide to Complementary and Alternative Medicine on the Internet, by Lillian R. Brazin, MS, AHIP, suggests that you ask yourself the following questions:2
Note: Due to the changing nature of Web sites, the links to articles referenced in this module may change. As such, we have tried to provide you with the names of the related organizations in case you have to conduct a search yourself to find the needed information.
For more information on evaluating web pages, visit the following sites:
Acupuncture: Could it be an option for this patient? What is it?
Acupuncture is a form of traditional Chinese medicine that can be traced back 4,500 years. It is used by millions of people each year in the United States.3 A primary goal of acupuncture is to establish and maintain the balance of energy in the body to prevent illness and restore health.4
What is it used for?
In 1997, the NIH Office of Alternative Medicine Consensus Panel reviewed the scientific literature and concluded that acupuncture is an effective treatment for postoperative and chemotherapy-induced nausea and vomiting and postoperative dental pain, and that acupressure is effective for reducing nausea relating to pregnancy. The panel also found that acupuncture may be useful alone or in combination with other therapies for addiction, headache, dysmenorrhea, lateral epicondylitis, stroke rehabilitation, fibromyalgia, low back pain, and asthma.3 A survey of approximately 4,000 physicians practicing Western medicine both within and outside of the United States indicated that almost 43% had referred at least one patient to an acupuncturist and more than half believed in its efficacy.3
In addition, in 1979, the World Health Organization indicated more than 40 conditions for which acupuncture may be effective. Such health conditions fall into the following categories: neurological, psychological, GI, musculoskeletal, ear/eye/nose/dental, respiratory, gynecological, and stress management.5
Safety considerations
As with many therapies, there are safety considerations related to acupuncture therapy. Fortunately, the occurrences of serious adverse effects are low. Less serious adverse effects include slight dizziness that occurs if someone receives treatment on an empty stomach and a minor hematoma that may result if the acupuncture needle pricks a small vessel under the skin. In addition, since most practitioners use a "clean needle technique," using only sterilized needles, risk of infection is minimal if any. On occasion, the original symptoms being treated may worsen for a day or two, but this should not cause concern as it is simply an indication that the acupuncture is starting to work. Other cautions include: 6
Contraindications
Acupuncture is contraindicated for the following people or situations: 7
For discussion of these contraindications, please see the Acupuncture Today article "Surveys Confirm the Safety of Acupuncture (November 2001).
Is it an option?
For help in answering the patient's question about whether acupuncture is a viable option for low back pain during pregnancy, we suggest the following sites:
Do you feel acupuncture is an option for this patient? Why or why not?
Chiropractic: could this be an option for this patient?
What is it?
What is it used for?
Indications for chiropractic manipulation are diverse. The usual presentation for a client selecting chiropractic care is chronic pain in the neck, midback, low back, or hips that has not been diagnosed as something more severe. As long as there is no contraindication to treatment, chiropractic manipulative therapy may be beneficial for: 8-11
Safety considerations
Chiropractic is not necessarily for everyone, and, in fact, there are levels of contraindication to manipulative therapy. Of major concern is the risk of stroke from cervical (neck) manipulations, calculated to be between 1 in 400,000 to 1 in 5.85 million cervical manipulations. Screening procedures should routinely be used to bar susceptible clients from having their neck manipulated. Concerns over herniated discs and other spinal injury from chiropractic manipulation remain unfounded.8-11
Contraindications
Chiropractic is contraindicated for the following people or situations:8-11
Is it an option?
To help answer the patient's question about whether chiropractic is a viable option for low back pain during pregnancy, we suggest trying the following resources:
What is it?
Massage is defined as a "systematic and scientific manipulation of the soft tissue of the body."7 It is one of the oldest forms of therapy, first described in China in the second century B.C. and soon thereafter in India and Egypt. The development of modern massage is attributed to the late Per Henrik Ling, a Swede who developed an integrative system that consisted of massage and exercise techniques, which were later called "Swedish massage." In the mid-19th century, massage was introduced to the United States and was practiced predominately by physicians until the early 20th century.
What is it used for?
Massage therapy is based upon the concept of vis medicatrix naturae, or helping the body heal itself. It is a method of manipulating the soft tissues and has beneficial effects on many systems of the body.
According to the University of Miami's School of Medicine Touch Research Institute, over 90 studies have demonstrated the positive effects of massage therapy. Significant research findings include enhanced growth (e.g., in preterm infants), diminished pain (e.g., in fibromyalgia), decreased autoimmune problems (e.g., increased pulmonary function in asthma and decreased glucose levels in diabetes), enhanced immune function (e.g., increased natural killer cells in HIV and cancer), and enhanced alertness and performance (e.g., EEG pattern of alertness and better performance on math computations). Many of these effects appear to be mediated by decreased stress hormones.12
Additional positive outcomes of massage therapy are reported to include:13
Safety considerations
Caution should be used in people with the following conditions:13
Contraindications
Massage is contraindicated in people with the following conditions:13
Is it an option?
As previously mentioned, CAM-related research is sometimes limited, and such seems to be the case for massage. However, even though the research is somewhat limited, use the following articles to decide whether massage is a viable option for the chief complaint of low back pain during pregnancy.
After reviewing these articles, would you recommend massage for low-back pain during pregnancy? Why or why not?
Questions to consider:
1. Now that you have had a chance to review acupuncture, chiropractic, and massage, which ones could be used to treat the patient's chief complaint (low back pain during pregnancy)? Why?
2. Are there any safety issues to consider? If yes, what and how would that change your recommendation for the therapy?
To help stay abreast of recent research, health care practitioners can visit NCCAM for "alerts and advisories" . In addition, for links to other CAM-related resources, see the "resources" page at the end of this module.
Education and licensing of CAM practitioners
Case Study 2
Recently, a long-time patient of yours returns to the clinic for her annual check-up. Dr. Geneva, a 64-year-old woman, is a retired professor of nursing from a local university. Over the past five years, she has been receiving bimonthly acupuncture, chiropractic, or massage treatments from local providers "to maintain health." She is leaving for the summer to visit extended family in a rural town in Georgia and wants to continue her "health maintenance" regimen. Dr. Geneva asks for your advice about locating practitioners with appropriate training and whether licensing is important.
Questions to consider:
What do you know about the education and training of various CAM practitioners? What does it mean to be licensed as a CAM practitioner? What advice would you give Dr. Geneva? We've provided the following information to help you answer these questions.
Education of CAM practitioners
Acupuncture
The program of study for an acupuncturist to obtain a professional master's degree is a minimum of three years (minimum 2,000 hours). This includes 705 hours of acupuncture-oriental theory, diagnosis, and treatment; 360 hours of biomedical clinical sciences; 660 hours of clinical training; and 450 hours of oriental herbology for students who incorporate herbology into their practice. Basic training for students who study herbology takes four years.14,15 Currently, 70 schools offer traditional training in traditional Chinese medicine (TCM) in the United States. However, at this time, only 47 schools are accredited by the Accreditation Commission of Acupuncture and Oriental Medicine (ACAOM). About 30% of the states that license acupuncturists require graduation from an ACAOM school.14-15 It is imperative to realize that there are Western physicians and dentists who are allowed to incorporate acupuncture into their practices with minimal or no training.14-15 In other cases, a "certification" in acupuncture is issued by various colleges after students read a 300-page manual, pass a written examination, and perform a therapy recommended for an imaginary patient with a variety of complaints. To find traditionally trained practitioners, go to the home page of the National Certification Commission for Acupuncture and Oriental Medicine at www.nccaom.org.
Chiropractic
Currently, there are 16 chiropractic colleges in the United States, all of which are accredited by the Council on Chiropractic Education.14-15 A chiropractic program consists of four academic years of professional education averaging 4,800 hours (four to five academic years) of course work.14-15 Several areas of study are emphasized during the course of chiropractic education: adjustment techniques/spinal analysis, principles/practices of chiropractic, physiologic therapeutics, and biomechanics. The standards for chiropractic education have been established and monitored by the Council on Chiropractic Education, which is recognized by the U.S. Department of Education as the specialized accrediting agency for chiropractic education. The CCE sets the standards for the curriculum, faculty and staff, facilities, patient care, and research. Surveys find that a small percentage of chiropractors receive certification in such subspecialties as clinical sciences, orthopedics, neurology, radiology, or sports medicine.14-15
To find a traditionally trained chiropractor, go ChiroFind.com.
Massage therapy
Recent estimates suggest there are 92,000 licensed massage therapists in the United States. The current standard of training for an entry-level massage therapist is 500 hours of in-class supervised instruction, with at least 100 hours of that devoted to anatomy, physiology, and pathology, with 200 hours devoted to instruction on technique. However, this varies from state to state. Unfortunately, some training programs do not meet the 500-hour standard set by the Commission on Massage Therapy Accreditation. For a school to receive COMTA accreditation, the most widely recognized seal of a quality school, schools must meet and maintain COMTA's rigorous standards.14 It is likely that many schools are considering or seeking accreditation as the Department of Education is providing federal benefits to schools accredited by COMTA. Go to www.comta.org for more information about massage schools accredited in the United States.
Licensing of CAM practitioners
Despite the growing popularity of CAM therapies, few consumers are well informed about the licensing, credentialing, and education of these health professionals, thus making selection of a CAM practitioner challenging.14-15 Since the late 19th century, professional medical organizations and state legislatures have licensed physicians and conventional nonphysician providers. In addition, to protect health care consumers, standardized credentials have been established as markers of competence.14 In most situations, a state license grants someone the right to practice and includes the right to offer a specialized range of clinical services. Credentialing is established by institutions that employ health care providers.
In some states, requirements for licensure include (1) graduation from an accredited school; (2) completion of a minimum number of hours of training; (3) examination and assessment of knowledge and practice technique; and (4) knowledge of both professional and ethical standards.14 The following are examples of licensing criteria for three commonly used CAM therapies:
Acupuncture
Currently, acupuncturists are regulated in 42 states, and all require passage of a national licensure examination offered by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). Additionally, 12 of the 42 states require acupuncturists to pass a practical examination.14-15 Upon passing the licensure examination(s), an acupuncturist is granted a license to practice in the state in which the exam was taken. The credential granted to the professional is LAc (licensed acupuncturist). In most situations, national reciprocity is not granted, and therefore acupuncturists must take the exam in the state in which they wish to practice. An estimated 14,000 practitioners, plus an additional 3,000 physicians, have formally studied and have incorporated acupuncture into their practices. Some states permit licensed CAM providers, such as chiropractors or holistic dentists, who have not received their master's of science degree in traditional oriental medicine or taken the licensing examination to incorporate acupuncture into their practice. Also, some physicians have incorporated acupuncture into their practice with as little as a two-weekend training program. To find a licensed acupuncturist, go to the National Certification Commission for Acupuncture and Oriental Medicine at www.nccaom.org/find.htm.
Chiropractic
Chiropractors are licensed and regulated in all 50 states, as well as in a growing number of countries around the world. In Illinois, chiropractic physicians are licensed under the state's Medical Practice Act. However, such licensure precludes the chiropractic physician from prescribing medication or performing surgery. Numerous states require chiropractors to have both a bachelor's degree and doctor of chiropractic (DC) to obtain a license.14-15 Due to varying scopes of practice, there is no national reciprocity, and chiropractors must take additional examinations to practice in other states. In addition to state licensure examination, national competency board examinations are required in basic sciences, clinical sciences, and clinical areas. To find a licensed chiropractor in your state, go to the Federation of Chiropractic Licensing Boards website. (Make sure to select the "chiropractic boards" link on the left side.)
Massage therapy
It has become more common for states that license practitioners to require (1) a minimum of 500 hours of in-class supervised training at an accredited institution; (2) passage of the National Certification Board for Therapeutic Massage and Bodywork national certification examination; (3) continuing education; and (4) malpractice insurance.14,15
According to the Illinois Department of Professional Regulation, professional licensing of CAM providers varies across the country. For example, the regulatory board in Alabama requires 1,000 hours of training from an accredited massage therapy school, 16 hours of continuing education biennially, and passage of the National Certification Board for Therapeutic Massage and Bodywork exam. In Texas, the educational requirements include 300 hours from a state-approved school, 10 hours of continuing education per year, and passage of a state exam. To see what is required of licensed massage therapists in your state, go to your official state website. To find a nationally certified massage therapist in your area, go to The National Certification Board of Therapeutic Massage and Bodywork homepage.
Credentialing
Credentialing of CAM providers differs across the country, just as licensing does. Credentialing is carried out by institutions interested in hiring a health care practitioner to validate background and assess qualifications. The credentialing process involves the objective evaluation of a professional's current licensure, professional training and experience, and ability to perform professional services.
The lack of consistency in licensing and credentialing of CAM providers makes it difficult to provide advice on selecting CAM therapies and practitioners. However, educating patients about the risks and benefits of CAM therapies and how to evaluate the training of a practitioner is of critical importance.
If, by chance, you are a resident in a city or state not requiring CAM practitioners to have a license to practice, you may want to proceed with caution when seeking their services. In this situation, it would be beneficial to inquire about their education and training, and to perhaps ask to be able to contact health care practitioners they have collaborated with.
Question to consider:
Now that you have learned about the education and licensing in relation to three popular CAM therapies, what information would you give Dr. Geneva so that she could maintain her bimonthly CAM treatments?
Conclusion
There are a number of reasons for the growing interest in and use of CAM therapies. Certain people seek CAM therapies because of the adverse effects of Western medical therapies; others because a particular CAM modality is more congruent with their own values or beliefs. In many cases, choosing a CAM modality provides patients with a sense of empowerment.
As nurses, we are in a unique position to help patients decide what types of CAM therapies and therapists are worth exploring. As such, it's important to familiarize ourselves with the basic principles of CAM therapies and to be able to differentiate those that may be beneficial from those that may be harmful.
We hope that this module has helped you gain an understanding of some of the most widely used CAM modalities, including their indications and contraindications, and provided you with the appropriate resources to assist your patients in choosing professionally educated and licensed CAM professionals.
For additional information about CAM, including how to assess CAM use and the evidence-based practice and decision making in CAM, we welcome you to explore three other modules developed exclusively by our CAM faculty and staff. These include "Overview of Evidence-Based Practice and Clinical Decision Making Related to CAM Therapies." The "Overview" module provides readers with information about the five major areas of CAM; current patterns of CAM use by the American public; the underlying philosophic principles underlying both traditional and conventional medical systems; and factors to consider when evaluating CAM resources and research studies. The "Assessment" module was developed to help readers understand how a patient's cultural and ethical background may influence healthcare choices, why patients often fail to disclose CAM use to their health care providers, and what to do to elicit information on its use. The "Evidence-Based Practice" module was developed to help readers evaluate the safety and efficacy of CAM therapies and make effective clinical decisions about the use of CAM.
Resources
Acupuncture/Chinese Medicine
Acupuncture.com
Chinese Medical Journal
National Certification Commission for Acupuncture and Oriental Medicine
American Association of Oriental Medicine
Acupuncture and Oriental Medicine Alliance
Chiropractic
American Chiropractic Association
International Chiropractic Association
World Chiropractic Alliance
Council on Chiropractic Education
Federation of Chiropractic Licensing Boards
National Board of Chiropractic Examiners
Massage
Associated Bodywork and Massage Professionals
Commission on Massage Therapy Accreditation
Touch Research Institute
National Certification Board for Therapeutic Massage and Bodywork
CAM information
Alternative Medicine Foundation
American Botanical Council
The Continuum Center for Health and Healing
Memorial Sloan Kettering Cancer Center Integrative Center
The Richard and Hinda Rosenthal Center for Alternative and Complementary Medicine
University of Maryland School of Medicine Center for Integrative Medicine Program in CAM
University of Pittsburgh Alternative Medicine
Consumer Health Information Service
Chapter 3: Evidence-Based Practice and Clinical Decision Making Related to Complementary and Alternative Medical Therapies
The goal of this program is to introduce health care providers to the concept of evidence-based practice (EBP), its relationship to CAM, and a model that can be used in practice when determining whether evidence supports use of particular CAM therapies.
After completion of this session, the participant will be able to -
With the increasing use of therapies by the American public, conventional health care providers are being challenged to provide information to their patients about the safety and efficacy of CAM. Health care providers have an obligation to provide evidence-based care pertaining to CAM therapies and to assist consumers in evaluating the safety and efficacy of CAM therapies. In your practice, you may encounter a situation such as this:
Mr. Jones is a 55-year-old man, 35 pounds overweight, and a heavy smoker of two packs a day, who does not want to stop smoking or go on a diet. However, he would like to try other approaches to promote wellness. He has read that vitamin E and carotene reduce the risk of cardiovascular disease and wants to know whether these would be of benefit to him.
This patient is unwilling to use conventional approaches to health promotion but is interested in the use of supplements. Do you feel qualified to make recommendations regarding the therapy he's considering? Using evidence to make your recommendations may help.
EBP: What is it and why is it important
According to a recent article in the American Journal of Nursing, EBP is a systematic approach to problem solving for health care providers, including RNs, characterized by the use of the best evidence currently available for clinical decision making to provide the most consistent and best possible care to patients.1 The EBP movement calls on all health care practitioners to make use of the best evidence to help formulate individual treatments for their patients. Nurses often do not use evidence to guide their practice, as evidence for a particular intervention may be limited or nonexistent. Also, according to recent studies, a large majority of nurses underutilize the literature because they don't understand or value research and have received scant or no training to use tools that would help them find evidence on which to base their practice.1 Therefore, nurses are encouraged to gain proficiency in accessing reliable evidence-based resources and to judiciously use limited evidence to support clinical decision making.
So how does one access the best evidence? Are there useful websites to consider? Conventional health care dictates that treatments be safe and efficacious. EBP addresses this by emphasizing the value of reproducibility of findings from randomized control trials . RCTs represent the gold standard study design used in conventional health care for evaluating treatments.
Data from RCTs are often summarized in narrative reviews or are more systematically evaluated using approaches to minimize bias and random error. One approach to systematic evaluation - the metaanalysis -uses statistical methods to combine the results from a number of previous experiments or studies examining the same question, to try and summarize all evidence relating to a particular issue.2 This information can then be used to develop evidence-based clinical practice guidelines.
A number of agencies and centers publish data summaries and/or evidence-based clinical practice guidelines.1
1. National Guideline Clearinghouse: a program of the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, publishes a database of evidence-based clinical practice guidelines and related documents designed for nurses, physicians, and other health care providers.
2. The Agency for Healthcare Research and Quality (formerly the Agency for Healthcare Policy and Research) created a program to promote evidence-based practice in everyday healthcare via the establishment of 12 Evidence-based Practice Centers (EPCs). A goal of this program is to improve the quality, effectiveness, and appropriateness of health care by synthesizing the evidence and facilitating the translations of evidence-based research findings.3
3. The Cochrane Collaboration Centre in Oxford is an excellent source for identifying systematic reviews of health care interventions.
4. The Sarah Cole Hirsh Institute for Best Nursing Practices Based on Evidence is a repository of systematic reviews of evidence-based practices at the Frances Payne Bolton School of Nursing, Case Western University. It publishes the reviews through the Online Journal of Issues in Nursing.
5. The Centre for Clinical Effectiveness is operated through the Monash Medical Center in Australia. Its objective is to enhance clinical outcomes through application of best available evidence regarding treatments. Full evidence reports are available on a number of topics. Its site has a workbook titled Evidence-Based Answers to Clinical Questions for Busy Clinicians, available in PDF format.
6. The National Medicine Comprehensive Database , accessible through the Wake Forest University Baptist Medical Center website, provides highly objective evidence-based information for health care professionals about prescription and nonprescription drugs and natural medicines. Recognized as the gold standard, it claims to be the most complete and practical guide, offering up-to-date information about interactions and safety concerns of natural medicines as quickly as they become available.
7. An independent journal focusing on evidence-based care, Bandolier , maintains that it is the premiere source of such information for health care practitioners and the lay public.
8. Many health care providers search the literature by way of the PubMed, which is a service of the National Library of Medicine.
The PubMed website provides a "drop down" file so users can target their search to find evidence that falls into reviews, metaanalysis, and RCTs (all higher levels of evidence). In addition, the "limits" tab can narrow searches to the most relevant articles of a search. For more information on using PubMed, go to the PubMed tutorial located on the left sidebar (under the Help/FAQ link) of its home webpage.
These are just a few of the many EBP resources available for health care providers. Books, journals, newsletters, databases, and other websites are also available. Some may require a fee.
Despite these excellent resources, keep in mind that research findings must be integrated with clinical expertise. Clinicians need to be able to use past experience and clinical judgment to identify the patient's state of health and the risks and benefits of potential interventions. Also, values or preferences unique to each individual and clinical expectations that may differ among individuals necessitate open communication between the clinician and patient when addressing the risks and benefits of various treatment options.
Implications of EBP for CAM
Clinicians can focus on four widely used basic tenets of EBP when evaluating conventional health care practices:
Applying EBP to CAM therapies is not always easy. Although most CAM therapies have not been tested using conventional methods such as RCTs, a significant proportion of people who use them remain convinced of their effectiveness. Research of CAM therapies is limited for a variety of reasons, the most compelling of which is that conventional research methods may not be suitable for studying CAM approaches.
Developing placebo-controlled CAM interventions for study may not be possible or may prove to be extremely difficult. For example, researchers continue to struggle with the development of a sham intervention for acupuncture studies. While it has been recommended that one use control points in close proximity to standard points, these in fact, may be points used for other intentions. In addition, the use of sham acupuncture needles, specifically those not piercing the skin, has been called into question.
Additionally, some argue that because CAM approaches are more intuitive in nature than conventional therapies, RCTs are not conducive for testing CAM modalities. Many CAM approaches use individualized interventions, and often no two interventions are the same. Others propose that much of CAM's therapeutic benefits may be due to patient-practitioner interaction.
Furthermore, CAM therapies may be complex so that distilling them down to a single, pure intervention may be impossible. For example, because traditional Chinese medicine typically uses compound herbal remedies that work in a coordinated manner; testing the effectiveness of the preparation by analyzing the effects of the individual components would be without merit.
Reviewing the evidence hierarchy pyramid depicted in Figure 1, you can see that the higher one ascends the pyramid, the better the quality of evidence. While collecting evidence to evaluate a clinical practice, optimally seek out evidence from the top of the pyramid, if available. EBP is largely based on RCTs and laboratory reproducibility studies (second highest level) and analyses of multiple study results (highest level).
Collectively, most CAM studies in the literature are case reports, qualitative in nature, or are based on anecdotes or survey results. Thus, they represent the bottom level of the evidence hierarchy. As discussed, problems exist when evidence-based research methods are applied to CAM therapies, but continued and increasing research efforts are underway. Studies evaluating CAM therapies in an increasingly rigorous manner are becoming more prevalent in peer-reviewed literature. This may be in part driven by the idea that some health care plans and government agencies may require systematic reviews to support treatment coverage. Answering questions related to safety and efficacy of a practice requires that CAM modalities be evaluated at higher levels of the evidence hierarchy.
Figure 1
Used with written permission from BMJ Publishing Group
Clinical decision-making process
How does a conventional health care provider evaluate a CAM therapy that a patient is interested in pursuing? Approaches include:
After collecting information on the safety and efficacy of a particular CAM therapy, you may ask yourself, "What approach will I use when communicating this information to my patient?" Below is a method to help you provide guidance.5
Evaluating CAM treatments
Figure 2
Adapted from Cohen MH, Eisenberg DM. Potential physician malpractice liability associated with complementary and integrative medical therapies. Ann Intern Med. 2002;136:596-603.
In Panel A, evidence supports a treatment as both safe and effective. Once you have consulted such databases as those discussed earlier and are convinced that evidence supports both safety and efficacy, you can accept the CAM therapy as a treatment option that may afford benefit with little risk for patient harm. Discuss the evidence with your patient, indicate you would recommend this approach if he or she is interested in it, and monitor the treatment outcome. Clinical examples in this area are those for which the NIH has published a clinical practice guideline or a consensus or assessment statement, that is, chiropractic for acute low back pain; acupuncture for chemotherapy-induced nausea and dental pain; and mind-body techniques for chronic pain and insomnia.5
In Panel B, evidence supports safety of the therapy, but efficacy is somewhat doubtful, according to information collected from databases. You should discuss this with your patient, advising caution regarding the efficacy of the treatment. If he or she is willing to try the CAM therapy, closely monitor your patient for signs of effectiveness. Examples in this region include massage, homeopathy, mind-body techniques, dietary fat reduction, and acupuncture, which are rarely associated with clinically significant adverse events, but evidence for their efficacy generally is inconclusive.5
In Panel C, evidence supports efficacy, but safety issues are inconclusive. Given the limitations of scientific evidence related to safety of a particular CAM therapy, if your patient decides to proceed with the therapy, you should urge caution and closely monitor the safety of the treatment. For example, the use of many herbs may fall in this category, such as the use of St. John's wort for certain types of depression, saw palmetto for uncomplicated benign prostatic hyperplasia, chondroitin sulfate for osteoarthritis, and Ginkgo biloba for cognitive function in dementia.5
In Panel D, evidence does not support either the efficacy or safety of a treatment. This approach may have little or no benefit and could present a serious risk for harm to your patient. This treatment should be strongly discouraged. Clinical examples include the IV or IM injection of unapproved substances; the use of herbs known to be toxic (for example, chaparral and Aristolochia fangchi); clinical use of herbs known to be associated with clinically significant drug-herb interactions; or knowing use of a CAM therapy that delays treatment for a potentially curable condition, for example, delay of recommended lumpectomy and radiation in favor of adopting a macrobiotic diet for a patient with stage I cancer.5
All of the above scenarios require that health care providers rely on optimal documentation and communication when dealing with a patient. Also, you need to document the information on safety and efficacy that you gave the patient about the CAM therapy, the advice you gave, and the patient's choice of therapy. Treatment monitoring should be documented at timed intervals. An open line of communication with a patient is critical so he or she can provide you with needed follow-up monitoring information.
Illustrative cases
Now that we have discussed EBP and the clinical decision-making process; where to find reliable resources; and how to communicate with your patients about CAM, let's review your decision-making skills using the cases below.
The following four cases are based on the model in Figure 2. After reviewing each illustrative case, determine which of the four categories each case best fits:
A. Evidence supports both safety and efficacy.
B. Evidence supports safety, but evidence regarding efficacy is inconclusive.
C. Evidence supports efficacy, but evidence regarding safety is inconclusive.
D. Evidence indicates serious risk and lack of efficacy.
First case
A 39-year-old man comes to your office for his annual visit. During your discussion about his weight gain, he tells you he has found the magic bullet to help him in his battle with weight. He states that after consulting with a manager at a nutrition supplement store, he bought Guar Gum to help him lose weight. He has been using this supplement for three months and is disappointed because he is not seeing any results. He asks if he should just wait it out and be patient. What does the evidence suggest? What category in the above model is most consistent with this case? Refer to following websites for more information:
www.nauraldatabase.com and www.findarticles.com
This case falls in Category ____ in the above model. How would you effectively communicate this information to your patient?
The correct answer: B: Evidence supports safety, but evidence regarding efficacy is inconclusive.
It is important to note that the authors at one of the above sites considered this product only "relatively" safe. Did you notice that the same authors stated that the clinical trials were small? How would you interpret this?
Second case
A 54-year-old woman with a three-month history of menopause asks your advice about using black cohosh for symptom management during menopause as it has been an herb that women in her family have been using for generations. She said that she is glad to be using a natural remedy during this time in her life, but is concerned because her energy has been extremely low and she has had fairly severe headaches for the past week. She would like to know what she should do.
You realize that you need to check the literature to determine both the safety and efficacy of black cohosh for menopause and decide to use PubMed to get some answers. What category does this case fall into? Refer to this website for more information.
This case falls in Category ____ in the above model. How would you effectively communicate this information to your patient?
The correct answer: C: Evidence supports efficacy, but evidence about safety is inconclusive. However, even though this review describes black cohosh as useful for some menopausal symptoms, it states that the methodology used to date has been poor and further clinical assessment is needed. In addition, regarding safety, it reports transient adverse events, such as vomiting, headaches, and dizziness.
Third case
Today you are seeing a 43-year-old man who is 170 pounds overweight and has a three-year history of hypertension. He is seeing you today because he has become increasingly concerned about his weight, especially since his father, who was also overweight, died six months ago from complications of a heart attack. Since his father's death, his family has asked him to make a commitment to lose weight. He is interested in losing weight, but does not have time to exercise, and instead is interested in supplements to shed the pounds. He tells you that his brother, who is also overweight, recently came back from an international business trip and brought back a bunch of weight-loss supplements. He then pulls a bottle out of his coat pocket and asks you how many milligrams you would recommend he take. You look at the ingredients and notice that the main ingredient is ephedra.
What would you tell him? What category does this case fall into? Refer to these websites for more information:
http://nccam.nih.gov/health/alerts/ephedra/consumeradvisory.htm
www.cfsan.fda.gov/~lrd/fpephed6.html
The correct answer is D: You should strongly suggest that this patient (and his brother, for that matter) not take the supplement. The supplement has been banned in the United States because it was found to be unsafe and ineffective.
Fourth case
A 19-year-old woman with a three-week history of mild depression presents to your office. She brings with her a bottle of St. John's wort that she purchased at a national vitamin and supplement chain. She indicates that based on information provided by the company's website, daily use of the supplement should help lift her spirits. She tells you that the information clearly stated that the herb was effective. When questioned, she says that her depression is most likely due to a recent break-up and says she's beginning to feel better, but doesn't want to stay on it if it's not safe. She asks you if it's OK to be using this and how long she could continue using this before it is considered unsafe. What would you say?
You go to Natural Medicine Database and review the following:
What category does this case fall into? How would you effectively communicate this information to your patient?
The correct answer is A: You can tell the patient that she could essentially continue using it for an additional five weeks. However, it would be essential to inquire about the use of other supplements or pharmaceutical drugs that she is on due to potential for drug interactions.
As you continue to review CAM evidence-based information, keep in mind that as more CAM research is conducted, a given therapy may change its position in the spectrum of clinical risk, regardless of allopathic or complementary origin.5 In addition, situation-specific variables, such as personal beliefs, cultural values and practices, and therapeutic goals may challenge your decision-making skills. The type and severity of illness may also affect decision making.6 In any situation, healthcare practitioners can choose to use the four "Ps" as a quick practical guide when advising patients about use of CAM therapies.7 These four principles are:
1. Protect. Find out if the product or procedure under consideration has any harmful aspects. Make sure the therapy is safe, low cost, and nontoxic.
2. Permit. Permit CAM therapies that are safe, inexpensive products or procedures, even if their efficacy has not been conclusively proven. Although unproven therapies of any type cannot be recommended, if they empower the patient and enhance 'nonspecific' effects (the so-called placebo effect), they can often be helpful.
3. Promote proven practices. If rigorous research shows that a CAM product or procedure is safe and effective, promote its use if it is of interest to the patient. For example, a practitioner may feel comfortable promoting the use of acupuncture for treating chemotherapy-associated nausea.
4. Partnership. Work as a team with your patient and his or her therapists who provide complementary approaches to care. While it is ultimately the patient's decision, it is the health care practitioner's responsibility to collect the evidence, evaluate it, and make professional recommendations.
When discussing CAM therapies with patients, the combination of the best available evidence with the practitioner's clinical experience should be used to guide the clinical decision-making process.
Chapter 4: Assessment of Complementary and Alternative Medical (CAM) Therapy Use
The goal of this program is to help readers identify and work with patients who are using CAM therapies. After studying the information presented here, you will be able to -
Researchers have found that patients are aware of conventional Western medicine's ambivalence and hostility toward CAM.1 In addition to the fear of being ridiculed, most patients do not raise the subject because they do not expect their health care provider to be conversant about CAM therapies and it doesn't occur to them that the topic is germane in a conventional health care setting. They speak to their acupuncturist about acupuncture, their herbalist about herbal regimens, and their physician about conventional treatments issues.1
Collecting data about CAM
Due to potential harmful interactions between CAM and conventional approaches to health care, especially those of herbal medicine and pharmaceuticals, the responsibility to discuss CAM falls in the lap of health care providers. The key, however, is doing so in a manner that is respectful and creates a nonthreatening environment in which patients feel safe and welcome to disclose CAM use. According to investigators, inquires about nonbiomedical healing modalities must be included when taking a patient history. It's recommended to do so on a routine basis because patients' interests in CAM may vary over time as their health status changes.2,3
Several strategies can help facilitate discussion of CAM use.1,4
Open-ended questions: Beginning your discussion with an open-ended question, such as "What else do you do to take care of your health?" may provide the most information. If there seems to be confusion, continue with "For example, have you tried herbs, supplements, or acupuncture for your health condition?" It is not recommended, however, to ask "Do you use any alternative therapies?" This type of question may either be construed as judgment