LA JOLLA, CALIF. — The first step in advising patients who may want to try complementary and alternative medicine therapies is to ask them a simple question: “Have you used, or considered using, any other therapy for your [chief complaint]?” David M. Eisenberg, M.D., said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.
If your patient responds, “I'm interested in therapies like [acupuncture, massage, etc.],” tell him or her, “I have the time.”
Those four words “are rarely spoken in a doctor's office,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston.
“Those are the four most powerful words you can say if you want a direct answer. I challenge you to try it.”
Some of the meeting attendees laughed out loud at the challenge.
“I'm not kidding,” he countered. “When you do it, they will talk to you. If you don't, they may or may not. It's all about your body language.”
Before you offer specific advice, consider the following questions:
▸ Has the patient's conventional diagnostic work-up been complete?
▸ If so, what is the diagnosis?
▸ What are the conventional treatment options? Have they all been tried?
▸ What are the risks of the conventional treatment options?
▸ What are the risks of the CAM options?
Once you address these questions, identify a key symptom and ask the patient to keep a symptom diary on a scale of 0-10, with 0 meaning there is no symptom. (For more details on the symptom diary, see Ann. Intern. Med. 1997;127:61-9).
“I tell patients to put up a piece of paper where they brush their teeth at night and put a number down for how bad the symptom was that day, whether it's abdominal pain, headache, anxiety, you name it,” Dr. Eisenberg said at the meeting, which was cosponsored by the University of California, San Diego.
Have the patient “keep the diary for a week or two, or a month if it's a monthly symptom. Then discuss with the patient the therapy that you're suggesting or they're asking about,” he said.
Review the safety of the CAM therapy, formulate a plan, and ask the patient to maintain the symptom diary.
“Make the patient the pilot and you become the copilot,” he said. “It's their data with their symptoms.”
If you refer for CAM, see the patient after the initial visit to the CAM provider and review that person's recommendation. “This is the thumbs-up, thumbs-down conversation that we don't have with patients often enough,” he said.
“Physicians who practice this way will be in much higher demand in the marketplace, because [patients] will be able to have an honest conversation with an educated clinician who does care about CAM and does understand the literature,” he explained.
If the CAM therapy works, “then it feels like you participated with them in this exploratory journey,” Dr. Eisenberg said.
“It's about shared decision making. The patient feels listened to [and] safe, and the patient-physician relationship is tested,” he said.
If the CAM therapy fails, patients, “are still very grateful for the opportunity, and you can go back together to square one and ask, 'What can we try now?'” he said.