Talking with patients about complementary alternative medicine

There are various practices that fall under the term complementary alternative medicine (CAM). While some practices are most definitely “complementary,” others may overlap with another field or are used regularly in traditional medicine, which sometimes leads to confusion amongst patients and their physicians about whether there is a true benefit to the CAM modality a patient is using. The most common forms of CAM encountered by mainstream physicians include alternative medicine practices such as acupuncture and naturopathy; physical therapies such as chiropractic care, massage, and physiotherapy; dietary and herbal supplements; and mind/energy interventions such as reiki, meditation, and hypnosis. My general approach to CAM, for myself and for my patients, is based on the principle of “do no harm.” This can be loosely interpreted based on how you define harm. Is harm defined literally, as something that is negatively impacting the health and well-being of the person. Or can harm be caused when a person participates in something that doesn’t bring them any benefit, even if they believe it does. This is where the definition takes on a bit of creative interpretation. In my practice, whether I believe there is benefit does not factor in; If the patient genuinely believes there is a benefit, and there is clearly no harm, then I usually don’t take the issue any further. However, one harm that I take very seriously is the harm that may exist from false advertising and questionable cost associated with the CAM treatment the patient is using. When I feel strongly that this harm might exist for a patient undergoing CAM, I encourage the patient to reflect on and understand the objective and subjective proof of benefit, which is something they may not have thought about before. This is where the definition takes on a bit of creative interpretation. In my practice, whether I believe there is benefit does not factor in; If the patient genuinely believes there is a benefit, and there is clearly no harm, then I usually don’t take the issue any further. However, one harm that I take very seriously is the harm that may exist from false advertising and questionable cost associated with the CAM treatment the patient is using. When I feel strongly that this harm might exist for a patient undergoing CAM, I encourage the patient to reflect on and understand the objective and subjective proof of benefit, which is something they may not have thought about before. I consider people in my practice, those experiencing infertility, to be a somewhat vulnerable population. They are not vulnerable in the traditional sense of the medical definition. However, their vulnerability presents in their extreme desire for pregnancy and the limited proven interventions outside the setting of medicalized fertility treatments. It is not surprising, therefore, that by the time patients find themselves in my consultation room, they are trying a variety of different CAM modalities. And not surprising is the number of times I am asked if the modality/supplement/practice they are participating in is known to improve their chances of pregnancy. Read Dr. Mills on: New Year’s resolutions starting to fizzle? Currently, in the field of fertility treatment, there is very little high-quality scientific evidence to support a benefit of most CAM. Because of this, I find myself having this “benefit vs. harm” conversations multiple times per week. I feel like I have almost perfected my stock response, which goes something like this: “Unfortunately, there haven’t been any (or many) studies looking specifically at the benefit of your therapy/supplement. This is mostly because it is very difficult to get ethical approval to do these kinds of studies on people, especially those who are trying to get pregnant. How do you feel that this intervention is working for you?” If they ask, I will go on to tell them which interventions or supplements there may be evidence to support (based on their individual histories). And, I do this in almost the exact way I describe the evidence behind the various fertility treatments we offer. My favourite example for this is the role of acupuncture in fertility care, as almost everyone asks about it. I start by telling patients that there is limited good quality evidence to support the benefit of acupuncture, and I will proceed to describe what evidence there is and why it’s not “good quality.” From a scientific perspective, the study groups are too small to accurately detect a true difference (if there is one); there are multiple confounding effects that are difficult to control for, not the least of which is the patient’s cause of infertility; and there are also multiple outcome measures, including implantation rate, clinical pregnancy rate, and live birth rate that vary between studies. Overall, the limited evidence suggests a slight benefit for the use of acupuncture on the day an embryo is transferred, but in no other aspect of IVF treatment. Finally, the relationship between acupuncture and better embryo transfer success rates is not well understood making it difficult to extrapolate to other areas of fertility treatment. Benefits and harms I don’t stop with the fertility-related scientific evidence though—because many patients are still left confused at this point. I continue to describe other well-established, non-fertility-related benefits of acupuncture, including the benefits for relaxation, stress reduction, and stimulation of the central nervous system. All these benefits may have an overall positive effect on people experiencing infertility or undergoing fertility treatments, even if there is no study to prove it. Then for completeness’ sake, I point out the potential harms of acupuncture. Although quite limited (in my opinion), these include a false understanding of the true impact (which I have already tried to address), and the associated cost, especially if not covered by private insurance. Read Dr. Mills on: When self-care is self-preservation After this quick but thorough discussion about the evidence surrounding a CAM practice, including a quick 101 on how we evaluate evidence in medicine, and the proven or potential benefits and harms, most patients can make a relatively informed decision for themselves as to whether they want to continue with said practice. Thankfully, I have found that most patients are happy to continue with treatments that make them feel good and that may have benefit (like acupuncture) and less likely to continue with the interventions or practices that are costing them a lot of money without a known benefit (like supplements I’ve never heard of before). I have come to appreciate this approach to discussing CAM options with patients because I believe patients find it non-judgemental and logically presented. They feel educated about why healthcare practitioners should or shouldn’t recommend treatments, they are given the opportunity to process the information themselves, and they feel supported in continuing something that they believe is helping them (or discontinuing something they believe is not helpful), regardless of my personal opinion on the matter. While I can never know for sure, I do hope that by presenting information in this fashion, patients will start asking themselves or even their alternative health practitioners the same questions when offered a treatment modality. If we are encouraging practitioners and patients to use evidence-based practices, regardless of that evidence, it is important that people learn how to ask the right questions and evaluate the answers with the right perspective.

Talking with patients about complementary alternative medicine

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Ginevra Mills

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