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Thu 17 Jan 2008 04:31 PM

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Talking to patients about complementary and alternative medicine

Being informed and comfortable discussing alternative therapies with patients is critical for their safety and health.

As complementary and alternative (CAM) therapies become widely available in the Gulf region and a growing number of patients seek alternatives to chemical drugs, it is becoming increasingly important that conventional physicians become familiar with the most commonly used forms of CAM. Many patients are turning to CAM to avoid the adverse effects of chemical drugs, or because they are dissatisfied with the current healthcare systems due to rising costs and the perceived influence of the insurance and pharmaceutical industries.

In the United Arab Emirates, CAM therapies have been available and spreading since at least the late 1980s, says Dr. Sassan Behjat, BHMS, MPH, former co-ordinator of the UAE Ministry of Health's Complementary and Alternative Medicine Department, which was established in 2000 to create regulations for licensing TM-CAM practitioners and products in the UAE (TM stands for "traditional medicine"). He adds that in Iran, Bahrain, Saudi Arabia, and Oman, CAM regulations are also beginning to be put in place.

When over 600 people were surveyed last year by Dubai Healthcare City and research firm You.gov, 17% said they visit a complementary or alternative medicine practitioner at least four times a year - almost half the number who said they visit a doctor with the same regularity, says Behjat, who presented these findings at a conference he chaired last January in Dubai, ‘Complementary Medicine: Evidence-Based Treatments.'

In light of this spread, it is important that conventional healthcare practitioners make sure they are comfortable discussing such therapies with their patients. While some scientific evidence exists regarding some CAM therapies, for others there are key questions that are yet to be answered through well-designed scientific studies. And some herbal dietary supplements are known to produce side effects, complications, and drug interactions that can be dangerous and even fatal when used incorrectly.

In order for patients to get the best, most effective care, an open dialog about CAM is essential. Doctors don't need to have all the answers to patients' questions. But it's essential to know where to look - and to encourage patients to ask.

What is CAM?

According to the National Center for Complementary and Alternative Medicine (NCCAM), a branch of the US National Institutes of Health, 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 (as practiced by MDs, DOs, and allied health professionals).

Basic philosophies of complementary and alternative medicine include the idea that prevention is the key to good health; the body has the ability to heal itself; learning and healing go hand-in-hand, and the focus should be on holistic care, or treating the patient as a whole person (including not just physical health but mental well-being, relationships and spiritual needs). CAM therapies are categorised as complementary medicine if they are used together with conventional medicine, alternative if they are used in place of conventional medicine, or integrative (or integrated) if they are combined with conventional medicine and have "high-quality evidence of safety and effectiveness," according to NCCAM.

Within these categories are medical systems, such as homeopathic medicine (which seeks to stimulate the body's ability to heal itself by giving very small doses of highly diluted substances that in larger doses would produce illness or symptoms); naturopathic medicine (which aims to support the body's ability to heal itself through the use of dietary and lifestyle changes together with therapies such as herbs, massage, and joint manipulation); traditional Chinese medicine (based on the concept that disease results from disruption in the flow of qi and imbalance in the forces of yin and yang, which can be restored through a combination of practices such as herbs, meditation, massage, and acupuncture); and Ayurveda (an Indian system that aims to integrate the body, mind, and spirit to prevent and treat disease through therapies including herbs, massage, and yoga).

Other approaches include mind-body medicine techniques like tai chi, yoga, meditation, prayer, mental healing, and creative therapies; biologically based practices that use substances found in nature, such as herbs, foods, and vitamins; manipulative and body-based practices, like chiropractic medicine and massage; and energy medicine, such as Reiki and therapeutic touch.

Welcoming alternatives

In the UAE, licensed CAM practitioners work in medical centres with other medical specialties so that they are "integrated into the system under the care of the medical director," says Behjat. Only after the practitioners have proven themselves in such a setting can they move to an independent practice. This approach has worked well, he says, because it allows physicians to slowly come to know CAM practitioners and appreciate their work.

Of course not every allopathic physician has an opportunity to work with a CAM practitioner. And many know little about such treatments, thanks to a gap in medical education. In some situations, says Behjat, this can lead to feelings of frustration and anxiety.

"Traditional medicine is based on the practitioner/healer relationship," he explains, adding that sometimes allopathic health practitioners can feel threatened by this, which is understandable given the pressure from the current medical system to evaluate and treat patients quickly. In addition, conventional medical doctors may feel that they are losing authority to practices they do not know because they are not taught about them in medical school.

Another reason physicians are justifiably sceptical is that CAM doesn't have the same evidence base to support its effectiveness as biomedicine does. But it's important to be aware that this lack of data does not necessarily reflect a lack of value, says Behjat.

There are many reasons for the lack of evidence. Among them is a lack of funding from the pharmaceutical industry.

Other research challenges include the individual tailoring, lack of standardisation, and the myriad different diagnostic considerations used in certain CAM practices. But this doesn't mean CAM therapies don't work.

In fact, there is growing evidence that CAM does work, and for all sorts of conditions ranging from anxiety and depression to back pain to menopause. The NIH's NCCAM offers a wealth of information about this evidence base at its website: http://nccam.nih.gov.

It makes sense to familiarise yourself with CAM by starting with a topic that interests you or the majority of your patients. Other sources of information include CAM practitioners themselves (they can recommend books and journals) and the National Institutes of Medicine's Medline page on CAM: http://www.nlm.nih.gov/medlineplus/complementaryandalternativemedicine.html.
It also pays to talk to your patients. If you stay open to the subject of CAM and ask questions, patients are more likely to tell you which practices most interest them - and which they are using already. Then, by researching further, you can help them differentiate between the reality of CAM and the hype - and prevent any unwanted interactions.

For example, research from NIH has shown that St. Johns wort affects how the body processes medications used to control HIV infection, anti-cancer drugs, and drugs that help prevent the body from rejecting transplanted organs.

It is also important to remember that there are unscrupulous CAM practitioners, says Behjat. Often these practitioners are unlicensed. If you work in the UAE, he recommends getting a list of practitioners that have been licensed by the Ministry of Health and the Dubai Department of Health & Medical Services.

The practitioners on that list have passed a stringent two-part exam and two-part interview that include questions about clinical medicine as well as their CAM specialty. In addition, they are licensed to work within a framework set for them by the MOH and other local health authorities in the region.

Such guidelines restrict the practice of CAM to self-limiting and non-life-threatening conditions, unless the patient is referred by a physician. In addition, CAM practitioners cannot make any claim for curing diseases, change the prescription of a medical doctor, or dispense medicines. And all of their remedies and products are to be registered by the MOH.

Another good source is the Zayed Complex for Herbal Research and Treatments, which has been in operation since 1996.

In other countries, you might ask for recommendations from people you believe to be knowledgeable regarding CAM, or contact a professional organisation for information about the type of practitioner you are seeking.

You might also consider putting pressure on your government to institute a licensing program if one does not exist already, suggests Behjat. "We have a model that has been in practice nationally in the UAE for seven years," he says. "So far, there has been no malpractice and no reported cases of complaint about registered practitioners. I invite others to try this model."

Sassan is currently consulting Dubai Healthcare City and other health regulatory organisations in the region on setting standards for licensing of CAM practices and products.

Making CPAP use easierMost commonly used CAM therapies:

Massage (62%)
Herbal medicine (45%)
Homeopathy (35%)
Nutrition (34%)
Acupuncture (14%)
Reflexology (13%)
Chiropractic (10%)
Energy healing (7%)
Hypnotherapy (5%)

CAMtherapies perceived to be most effective:

Massage (83%)
Herbal medicine (71%)
Mind-body techniques (70%)

Treatment people would use in the future if needed:

Massage (40%)
Homeopathy (24%)
Herbal medicine (22%)
Nutrition (21%)
Mind-body techniques (20%)

Most commonly identified benefits of CAM (according to medical doctors):

Pain management
Relaxation

Most common drawback of CAM (according to medical doctors):

Possible delay in seeking conventional medical treatment.

Source: Survey of 604 people by Dubai Healthcare City and Yougov.com

This article is provided courtesy of Harvard Medical International. © 2007 President and Fellows of Harvard College.

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