What to do if my patient wants alternative medicine?

Dr SF sent in this question. What to do if my patient wants to pursue alternative medicine?

Allopathy is no longer the ONLY succor of the masses. In 2008, approximately 38 percent of adults in the United States aged 18 years and over and nearly 12 percent of U.S. children aged 17 years and under use some form of complementary and alternative medicine (CAM), according to a new nationwide government survey. [1]

This number is much higher now and more in the developing world where Homeopathy, Chinese medicine, Unani and all sorts of alternatives have gained traction.

The first thing you’ve got to understand is that you can’t force anyone to stick with allopathic medicine. Those days are gone. Today the patient makes the decisions for better or worse. Your job is to inform them about treatment options, pros and cons. The majority will let you decide because you know best and most of the time you do. A small minority have read something off the net to treat HIV or watched a late night infomercial to treat cancer and want that.

The second thing is what is this alternative therapy. Supplements, diet based, massage, chemicals, exercise, what is this stuff? I personally do not trust something that comes out of a bottle with no label and that has no research on it. If something goes wrong you need the antidote and if there’s no antidote I’m not recommending it. So, you have to know what exactly this therapy is. Can it be done simultaneously while allopathy is pursued. If its a diet, can a patient still continue anti-hypertensive medications. Is it tai chi or exercise? You need to know, not just the type of therapy but also if this is going to be an ‘either or situation’ or ‘together can’ situation.

The third thing is the primary illness. Is this a serious illness where the patients is going to get considerably worse without medication? For a view of the disastrous consequences of complementary medicine in terminal illnesses read this paper. If it is then there’s no argument here, you can’t recommend something that has not been studied, recommended and scientifically proven over what you know is clinically sound. Especially if this is a life threatening condition with an expiry date looming close.

My take on this:

Listen to the patient: Address his concerns, why is he choosing this over my recommendation of x or y? Is it cost? Is it a lack of trust? I also think that if he’s lost faith in my medicine then he’s lost faith in me as physician. I can say “I’m not familiar with these other types of products,” and leave it at that, but then the patient feels the doctor is not listening or uninterested in what they have to say.

Recommend a second opinion: Sometimes I recommend the patient visit another doctor. Maybe someone else might be able to help him see that pancreatic cancer will not improve with fruit juice. A second opinion can reinforce or steer the patient better as the patient realizes that two people recommending the same thing must be for a good reason.

Read the research: Instead of saying no outright, read about the “new therapy.” That usually arms me with the ammunition to say no. When you say no right off the bat, patients get combative and feel the urge to resist you. Often I get people who want to take a cocktail of something. I write down the name of their wonder drug, and add that to my clinical reading at the end of the day. Then I find out out the dirt. Happily print it and during the next meeting hand it over to the patient, gladly informing him why said drug will not work. If the patient still doesn’t agree, reach for the paper.

Document the decisions:  You’ve tried everything, the patient still believes that cupping will heal his ulcer. Write it down. Have the patient sign a letter that he’s doing so against medical advice. Its fine if you just document this in an E.M.R, but for really controversial treatments, you need to cover yourself. Any prosecutor or judge is going to ask you, “But you with all your clinical training, how could you allow this to happen?” Don’t be an idiot. Document it, ad verbatim is even better.

Set a deadline: Keeping in mind the placebo effect, I usually set a deadline. If you’re blood pressure doesn’t come down with fenugreek water in three weeks, its back to the pills for you, sir. Its better than the patient spending endless months on a failed treatment. It also prevents him from going too far off the beaten path. The last thing you want is side effects or multi-organ complications that you have no clue how to treat, because the bottle without a label doesn’t say what’s inside.

Build rapport: Call patients for repeated followups. You don’t want them to slip through the cracks. Sometimes they may be embarrassed they’re new wonder drug, garlic oil is not working, but hey, by showing them you’re there without any judgment takes away the pain of admitting failure. You’re doing your job to make sure the patient is okay.

Reinforce the message: Repeatedly inform your patient at every follow up, the pros and cons, risks and benefits of the medication they’re taking and the allopathic options available to them. It doesn’t hurt to show them what’s still out there.

What do you do? Do you advocate CAM (Complementary and alternative medicine)?

References:

1.Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 10, 2008.