Complementary and Alternative Medicine: If You Don’t Ask, They Won’t Tell

The use of traditional medicine along with complementary and alternative medicine (CAM) is widespread. CAM is defined by the National Center for Complementary and Integrative Health as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine” (1). CAM therapy is used by almost 40% of adults in the United States, with American Indians using these approaches most commonly (around 50%), followed by white adults (approximately 43%). Around 12% of children and adolescents use CAM, primarily those whose parents also use these treatments. Generally, individuals who choose CAM approaches are seeking ways to improve their health and well-being or to relieve symptoms of chronic illness—especially chronic pain (2). Others may choose CAM as a component of a holistic health philosophy. In the United States, most users of CAM also receive conventional allopathic care (3).

Studies suggest that many conventional health and mental health care settings are unaware of the CAM practices of their patients (4). This may be particularly problematic when herbs or other biologically active CAM treatments may result in adverse interactions with some prescribed allopathic medications (5–7). Physicians are often poorly trained in homeopathic, naturopathic, herbal, massage, chiropractic manipulation, and diet therapies, as well as other CAM treatments, and thus may not consider these when taking a medication history (3, 6, 8). For example, in one study of oncology patients (5), it was estimated that between 11% and 95% of the patients receiving cancer treatment also used CAM treatments, yet between 20% and 77% did not disclose their CAM use to their oncologist. It has been estimated that less than 40% of all patients disclose their use of CAM to their primary care physicians (8). The most common reasons endorsed for nondisclosure were the doctor’s lack of inquiry; the patient’s anticipation of the doctor’s disapproval, disinterest, or inability to help; and the patient’s perception that disclosure of CAM use is irrelevant to their conventional care (5). Another study of cancer patients (9) suggested that CAM users have a higher desire for control and are more desirous of being actively involved in their health care decisions than those who have not used CAM.

Patients may choose CAMs for a combination of social, cultural, philosophic, and personal factors that often differ among ethnic groups and disease types (2, 3, 8–10). Interestingly, physicians tend to utilize these modalities about as often as the rest of the public (3). CAM therapies have been noted to offer patients “a participatory experience of empowerment, authenticity, and enlarged self-identity when illness threatens their sense of intactness and connection to the world” (10, p. 1061). The treating physician will be most helpful when she/he opens a dialogue aimed at understanding the broad range of personal, cultural, spiritual, and philosophical motivators for CAM use (11). In this regard, a multicultural orientation accentuating cultural humility is essential. Cultural humility has been defined as “the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client” (12, p. 354). A culturally humble physician makes a lifelong commitment to self-examination, has a greater awareness of personal limitations, and is dedicated to understanding and addressing power imbalances in the doctor–patient relationship that interfere with optimal care (12, 13). Cultural humility of the psychotherapist has been found to relate significantly to the patients’ ability to develop a strong therapeutic alliance and their ultimate clinical improvement (12). The attitude of cultural humility and genuine interest in the full variety of health practices of one’s patients is the most potent antidote for patients’ lack of disclosure of CAM.

The most effective method of learning about a patient’s CAM use was for the physician to directly inquire about it (11). Physicians often underestimate the prevalence of CAM use in their patients and may forget to inquire. In addition, lack of sufficient understanding to discuss the CAM practices therapeutically may disincentivize a clinician from asking. Physicians may assume that asking a patient what they are currently taking includes herbs or other nonprescription medications. Patients may not have that same interpretation. Clinicians who communicated support of the patient’s efforts toward self-care, without directly supporting a CAM that has not been proven to have efficacy and safety, formed a stronger alliance. Advising against the use of CAM or a chastising attitude tended to decrease the likelihood of the patient informing their doctor of their CAM use—although it often did not alter it (4).