CAM and Your Patient
“CAM for many reasons becomes the ‘easiest bottle to grab’ and is more often a sign of what the patient is attempting to achieve in their healthcare.”
“Creating openness and communication about CAM may be more important that discussing a certain treatment — it may be about restoring a sometimes fragmented conversation about what our patients are hoping for in their healthcare.”
As physicians encountering patients utilizing or asking about complementary and alternative medicine (CAM), we often feel overwhelmed and many times feel less than enthusiastic about delving into the topic. There may be many reasons for this reaction, including:
- A lack of training or sufficient knowledge base to have an adequate discussion;
- Perceived or actual pressure by the patient to endorse use;
- Concern regarding the safety or doubtregarding the efficacy of the treatment discussed;
- Worry regarding liability issues related to the discussion or recommendation of CAM.
Studies have found that these concerns are commonplace and often decrease inquiry into and discussion regarding use of CAM. A 2002 survey of 751 Denver physicians published in the Archives of Internal Medicine found that few physicians felt comfortable discussing CAM with patients. 84 percent of the physicians surveyed “thought they needed to learn more about CAM to adequately address patient concerns.” The authors concluded that “education may help alleviate the discomfort physicians have when answering patients’ questions about CAM”(1).
This article reviews the 2004 Centers for Disease Control and Prevention’s (CDC) and National Center for Complementary and Alternative Medicine’s (NCCAM) survey on complementary and alternative medicine use among adults in the United States. This survey was the largest of its kind and asked over 31,000 Americans about 27 self-administered and practitioner-based types of CAM therapies. This surveys is especially relevant in that it utilized in-depth personal interviews in comparison to previous surveys that utilized smaller populations contacted by phone or mail(2).
The survey demonstrated many important findings, some of which are well-known and others which are quite surprising and important for reflection by the clinician. A summary of the findings are listed below:
Demographics
The most common CAM utilizers are women, those with a higher education, and those with certain health conditions or risk factors, including former smokers and those recently hospitalized. Surprisingly, this survey found that when the definition of CAM includes megavitamins and prayer, African Americans are more likely utilizers than traditional CAM users, including whites and Asians.
Overall, the survey found that at least 36 percent of the population was using some type of CAM over the last year (49 percent use beyond one year). If megavitamins and prayer were included in the survey, 62 percent were using CAM over the last year (74 percent use beyond one year (Figure 1). Interestingly, only 12 percent of CAM utilizers sought care from a licensed CAM practitioner, with most finding and using therapies on their own.
Conditions Being Treated
The top conditions for which CAM was being utilized were overwhelmingly pain. Seven of the top ten conditions were pain-related, including back pain, arthritis and headache. Other areas of treatment included colds and psychological conditions, including anxiety and depression (Figure 2).
Treatments Being Utilized
The most common treatment utilized by Americans as a whole appeared to be mind-body therapies. When prayer was taken out of the survey, the most common CAM therapy was biologically based therapies, including dietary supplements. The remaining top therapies, including deep breathing, meditation, chiropractic care, yoga and massage, are listed in Figure 3.
Rationale for Utilization
The rationale for CAM use provides insight into patient’s desires and opinions about healthcare:
- 55% thought the combination of CAM and conventional medicine would be more helpful;
- 50% tried CAM simply because CAM “would be interesting to try”;
- 26% used CAM because a conventional medical professional suggested they try it;
- 13% used CAM because they believed conventional medicine to be too expensive.
Of note, 28 percent stated that they attempted CAM because they believed conventional medicine would not be helpful. This is concerning in that in some cases we will never see these patients in the office in order to provide a balanced discussion of their condition. Previous surveys have pointed out that much of the health information available or marketed to our patients, especially that obtained from the Internet, is not factual and may be deceptive (3,4).
Bottom Line of the Survey
What We Already Knew
CAM is highly prevalent and currently utilized by at least one third and more likely by more than half of the U.S. population, depending on the treatments surveyed. CAM utilizers are typically female, educated and self-motivated to obtain treatments often in combination with conventional medicine.
What’s New (and Startling)
Surprises include higher-than-previously noted CAM use in ethnically diverse groups, including African Americans. Many users appear to self-diagnose and treat, which is often based on faulty information and sources. The survey also points to a growing population that admits less confidence in and more frustration at the cost of conventional medicine.
What to Do With the Information
The typical CAM user is combining these treatments with conventional medicine and possesses what previous research has described as an “active coping behavior.” These patients are highly motivated to engage in treatments and lifestyle changes that will bring about improved health, and they often desire greater input from their physicians. CAM for many reasons becomes the “easiest bottle to grab” and is more often a sign of what the patient is attempting to achieve in their healthcare.
Physicians can have a pivotal role in helping to inform and guide these patients about the most prudent treatment options whether they be CAM or other active coping behaviors we advocate, including dietary, activity and stress management choices. Creating openness and communication about CAM may be more important that discussing a certain treatment; it may be about restoring a sometimes fragmented conversation about what our patients are hoping for in their healthcare. Future articles will provide tools for helping to guide the discussion, including physician resources and patient handouts.
References:
- Corbin W. et al. “Physicians Want Education About CAM to Enhance Communication With Their Patients.” Archives of Internal Medicine. 2002 162 (10): 1176-81.
- Barnes P., Powell-Griner E., McFann K., Nahin R. CDC Advance Data Report #343. Complementary and Alternative Medicine Use Among Adults: United States, 2002. May 27, 2004.
- Bonakdar R. A. “Herbal Cancer Cures on the Web. Non-compliance With the Dietary Supplement Health and Education Act.” Family Medicine. 2002;34:522-527.
- Morris C. A., Avorn J. “Internet Marketing of Herbal Products.” JAMA. 2003 Sep 17;290(11):1505-9.