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Special Report
Millions of Americans use some form of what is known as complementary and alternative medicine (CAM). (Other terms used to describe
non-allopathic health-related techniques include "integrative medicine" and "blended medicine.") Some patients use CAM as an adjunct to traditional allopathic medicine; others use it exclusively to treat or alleviate symptoms of a variety of physical and mental conditions. |
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A 1998 JAMA study1 reported that from 1990 to 1997, 42% of American adults used some form of complementary and alternative medicine. CAM providers had 629 million patient encounters during this seven-year period, compared to only 386 million patient encounters by allopathic physicians. Of the $21 billion paid to CAM providers, patients paid more than half themselves. In addition, patients spent nearly $15 billion for vitamins, herbs, books and classes related to CAM. Although 15% of adults interviewed for this study reported taking prescription drugs concurrent with herbal remedies and vitamins, fewer than 40% disclosed their CAM therapies to their physician. A survey of emergency department patients in the Annals of Emergency Medicine2, found that 56% had tried alternative therapies, such as massage therapy, chiropractic, herbs, meditation and acupuncture. Only 30% of these patients informed their physician. Another researcher3 reported that the conditions for which patients most commonly use CAM therapies are: chronic pain; anxiety; sprains, arthritis; rheumatism; severe headaches; depression; digestive disorders; diabetes and chronic fatigue syndrome. Today, CAM is gaining popularity and has become big business, particularly for over-the-counter dietary supplements, which are not controlled by the Food and Drug Administration or any other state or federal agency. By avoiding claims that their products cure disease, dietary supplement manufacturers avoid FDA regulation. Nevertheless, users of these supplements and herbs do claim the products are successful in the treatment and “cure” of a broad range of maladies. Ginko biloba, for example, is said to improve cognitive function, especially for Alzheimer patients; kava kava is used to combat insomnia, anxiety and muscle tension; saw palmetto is widely touted for treatment of benign prostatic hyperplasia; echinacea is said to help prevent or alleviate the symptoms of respiratory infections; garlic lovers claim this herb lowers cholesterol levels; feverfew is believed to control pain of migraine and cluster headaches; and so on. Scientific proof lacking
Marcia Angell, MD, editor- in-chief of the New England Journal of
Medicine, expresses concern about the reliance on testimonials, rather than on scientific evidence: “The power of the testimonial is very great. One of the advances in modern science has been to say, ‘Hey, just because you know somebody that got better after taking some medicine doesn’t prove that medicine worked. It could be just a coincidence. We have to look at all the people who tried it and didn’t get better and those who didn’t take it and got better anyway.’ What we’ve learned, painfully and slowly over the last century, has been the necessity to test. We’ve learned that the testimonial, the anecdote, even though very powerful, is not enough to say a particular medicine works. So what we’re seeing now is a regression to an old way of doing things in which word-of-mouth is taken as scientific evidence.”4 Managed care also is being credited, or blamed, for the increase in CAM’s popularity. The reduced availability of physicians, limitations on coverage for medical services and access restrictions imposed by third party payers may be factors. Because there have been so few controlled studies of CAM, the kinds of reports of problems, complications or morbidity that would deter patients are rare. By contrast, anecdotal reports in praise of CAM proliferate. Devotees of CAM and product manufacturers seize on the absence of adverse outcome reports to imply that herbs, supplements and non-traditional treatment modalities, some of which have been in use for thousands of years, must be safe. But in fact, there is insufficient evidence about the safety and efficacy of many forms of alternative medicine. “If you don’t test something for safety and efficacy,” Dr. Angell argues, “there’s no way to know whether it’s safe or efficacious. And that’s why we have to test all treatments for which claims are made, to see whether those claims can be supported.” A concern of critics of the trend to favorably compare alternative medicine or equate its success with traditional allopathic medicine is the inconsistency in standards for testing, assuring product purity or for packaging and labeling of CAM products. There is evidence that various brands of the same herb or dietary supplements are not accurately labeled, and that concentrations varied by as much as ten-fold. The American Society of Anesthesiologists (ASA), which “takes no position on the therapeutic properties of herbal medications and has no formal statement of policy or standard of care that is specific to phytopharmaceuticals,” nevertheless recommends that the public be aware of potential health risks of some products if they are taken before surgery. The ASA says that many people believe that if a product is labeled “all natural” it must therefore be safe. “This is an inaccurate and dangerous assumption that can put patients at unnecessary risk.”6 The ASA’s Internet website7 lists over a dozen commonly-used herbs which pose the risk of potentially-serious side effects or adverse interaction with medications and anesthetics. In March 2000, President Clinton created the Commission on Complementary and Alternative Medicine, which will make recommendations about: (a) education and training of health care practitioners in complementary and alternative medicine; (b) coordinated research to increase knowledge about CAM practices and services; (c) the provision to health care professionals of reliable and useful information about complementary and alternative medicine that [can be made] readily available and understandable to the general public, and; (d) guidelines for the appropriate access to and delivery of complementary and alternative medicine. In an editorial, The New York Times joined physicians and others who are calling for tighter regulation of the dietary supplement
industry.9 Dr. Charles Davant recommends that doctors help patients investigate CAM on their own by asking CAM providers these questions: What are your credentials and who certifies you? What treatment will I receive? What are the risks? What side effects might I experience? How much will the treatment cost? When can I expect improvement? How long will the treatment last? How will I know if it’s not
working?10
Notes
Resources from MIEC’s Loss Prevention Department Answers to professional liability questions. We can respond to a wide range of general questions about malpractice liability, and obtain legal advice for policyholders when indicated. Sample questions: How long must we keep medical records? How does a doctor properly withdraw from a patient’s care? What is the best method to obtain informed consent and how should consent be documented? (Please direct questions about specific patients to an MIEC claims representative.) Medical Records text. MIEC’s booklet, Medical Record Documentation for Patient Safety and Physician Defensibility, offers practical advice for maintaining defensible medical records and avoiding documentation deficiencies that can compromise a medical defense. The book includes useful chart forms, answers to questions about medical records, and a self- assessment form to review documentation quality. The book is free to MIEC policyholders and offers Category I continuing medical education credits. Chart forms and templates. MIEC’s Chart Forms and Templates for a Medical Practice, offered free to MIEC policyholders, is a packet that includes ready-to-use forms and templates that help physicians and staff organize medical charts, find data easily, and document important information that protects patients and physicians. Camera-ready forms can be reproduced for office use. The entire library of forms is contained on an included PC computer disk. Extensive resource library. Policyholders can request sample medical record chart and consent forms; patient education materials; articles on medical-legal topics; lists of resources for practice guidelines; vendors of electronic and voice recognition medical records systems; and more. On-site loss prevention survey. MIEC’s loss prevention specialists conduct complimentary individual or group practice surveys in which record-keeping, office procedures and practice policies are analyzed. Surveyors meet separately with physicians and their office staff to discuss liability issues relevant to the practice and specialty, and offer practical advice for reducing liability exposure. A written report summarizes the survey findings and provides constructive suggestions for improvements. Newsletters and alerts. MIEC publishes the Claims Alert; Special Report; We Get Letters...; New Law Alert; and Managing Your Practice newsletter series, and other publications that offer helpful and timely solutions to practice problems and answers to policyholders’ questions. Contact the Loss Prevention Department or view many of them on this site. |
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