All Kinds of Evidence
Twenty years of complementary medicine research has yielded some information about safety—namely, what works and what doesn’t. For example, saw palmetto has not panned out as an effective treatment for benign prostatic hyperplasia; St. John’s wort, useful for mild depression, interferes with many medications, including cyclosporine and warfarin, and should be avoided at least five days prior to surgery.7,8
Since NCCAM’s inception in October 1998, its research portfolio has stirred debate in the scientific community. Part of the disagreement stems from the difficulty of fitting multidimensional interventions, some of which are provider-dependent (e.g., massage or acupuncture), into the gold standard of the randomized, double-blind, placebo-controlled trial, explains Darshan Mehta, MD, MPH, associate director of medical education at the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital in Boston. The manner in which the effectiveness of integrative techniques is assessed requires a higher sophistication of systems research, Dr. Mehta says.
“The way we construe evidence needs to change,” she adds.
Likely to Expand
Most private health plans do not cover complementary services, although Medicare and numerous insurance plans will reimburse treatment in conjunction with physical therapy (e.g., massage) in the outpatient setting. Twenty-three states cover chiropractic care under Medicaid, and Medicare has begun to assess the cost-effectiveness of including acupuncture—especially for postoperative and chemotherapy-associated nausea and vomiting—in its benefits package.9 Other modalities, ranging from aromatherapy to guided imagery training, are paid for largely out-of-pocket.10
Dr. Rakel notes that the delivery of integrative medicine services at UW entails conversations with patients about out-of-pocket payments. “It can pose a barrier to the clinician-patient relationship if you give them acupuncture to help with their chemotherapy-induced nausea and then ask for their credit card,” he says.
Most complementary therapies are currently offered on an outpatient basis. Because of this trend, and because they deal with acute conditions, hospitalists are less likely to be involved with complementary or integrative medicine services, says Beth Israel Deaconess Medical Center hospitalist Andrew C. Ahn, MD, MPH. But that’s not to say complementary medicine is something hospitalists should ignore; patients arrive at the hospital with CAM regimens in tow. It’s the No. 1 reason, Dr. Ahn says, hospitalists should be knowledgeable and exposed to CAM therapies.
Physicians must understand patient patterns and preferences regarding allopathic and complementary medicine, says Sita Ananth, MHA, director of knowledge services and optimal healing environments at the Samueli Institute in Alexandria, Va., and author of the 2007 AHA report. She points to a 2006 survey conducted by AARP and NCCAM that found almost 70% of respondents did not tell their physicians about their complementary medicine approaches. These patients are within the age range most likely to be cared for by hospitalists, and failure to communicate about complementary treatment, such as supplemental vitamin use, could lead to safety issues. Moreover, without complete disclosure, the patient-physician relationship might not be as open as possible, Dr. Ananth says.
Many acute-care hospitalists do not have formal dietary supplement policies, and less than half of U.S. children’s hospitals require documentation of a check for drug or dietary supplement interaction.11,12 As a safety issue, it is always incumbent on hospitalists, says Dr. Li, to ask about any supplements or therapies patients are trying on their own as part of the history and physical examination. The policy at Memorial Sloan-Kettering Cancer Center, Dr. Cassileth says, is that patients on chemotherapy or who are undergoing radiation or facing surgery must avoid herbal dietary supplements.
Dr. Bertisch advises hospitalists to pose questions about complementary therapies in an open manner, avoiding antagonistic discussions. “Even when I disagree, I try to guide them to issues about safety and nonsafety, and coax in my concerns,” she says. “The most challenging part about complementary medicine is that patients’ beliefs in these therapies may be so strong that even if the doctor says it won’t work, that will not necessarily change that belief.” A 2001 study in the Archives of Internal Medicine revealed that 70% of respondents would continue to take supplements even if a major study or their physician told them they didn’t work.13