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Jay Udani, MD

JAMA. 1998;280:1620.

Residents and other physicians may wonder whether alternative medicine offers new hope to patients or if such therapies constitute quackery. The notion of alternative medicine as quackery has been reinforced by a once commonly heard definition that equates alternative with any medical treatment not taught in accredited US medical schools. That definition is no longer valid, as more medical schools have added nontraditional courses in response to growing public interest in alternative therapies.

The change in attitudes toward these therapies can be seen in the change in language used to describe them; the terms now current imply a relationship between the different approaches to medicine. The word alternative is often replaced by the words complementary and integrative. Complementary implies that these modalities are performed as an adjunct to, and not simply in place of, conventional western medicine. The newest term, integrative medicine , implies an even closer relationship—one in which western and alternative modalities are used together. Proponents of integrative medicine are creating clinics at which a physician evaluates a patient, makes a medical diagnosis, and then recommends a combination of therapies that may include pharmaceuticals, herbs, acupuncture, or even a massage.

Use of alternative medicine among the general population has skyrocketed in the last decade. Studies show that the percentage of people in the United States using alternative therapies has risen from 34% in 1990 to 69% in 1998.^1-2 Patients spend more out-of-pocket money on alternative medicine than on visits to their primary care physician.¹ People are using alternative medicine for several reasons: they may have grown up with it as folk medicine, they have chosen a holistic lifestyle, or they have had a negative experience with conventional western medicine.

Fortunately, people still like their physicians. The majority of alternative therapies are used as an adjunct rather than as a replacement for conventional medicine. Only 4% of Americans use alternative therapies exclusively, and only 15% think these therapies are more effective than western medicine.³

The main reason physicians distrust alternative medicine is because most of these therapies have not been studied well. Research into alternative therapies is difficult for several reasons. Dietary supplements cannot be patented, hence companies that produce herbal products have no incentive to fund expensive research studies. Some have argued that traditional research cannot take into account all of the variables that are important to alternative therapies such as a person's "energy pattern." Nonetheless, research can assess meaningful patient outcomes.

Although the research is still scant, physicians must recognize that alternative medicine is not just a fad and recognize that our patients may already be using alternative therapies. We must be willing to discuss these therapies with patients. If we dismiss a patient's interest in an alternative therapy, the patient may choose to use it without the physician's knowledge. If, instead, we discuss the efficacy of an alternative therapy in a balanced manner, we are more likely to gain the patient's trust and respect. If we lose that trust, our patients may choose to get their health care advice from sales clerks at holistic stores.

Even while keeping an open mind toward these therapies, physicians must demand that alternative therapies meet the same rigorous scientific standards as western medicine. Physicians should review the literature on alternative therapies, which is scarce but growing. The burden is truly on clinicians to explain to patients the importance of science over anecdotal evidence.

In addition to keeping an open mind, adventurous physicians might even try an alternative therapy such as acupuncture, meditation, or Tai Chi. Evaluate your experiences and the literature in a critical, unbiased fashion for the benefit of yourself and your patients.

Fellow, Health Services Research and Integrative Medicine
Cedars-Sinai Medical Center
Beverly Hills, Calif

REFERENCES
1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med. 1993;328:246-252. FREE FULL TEXT 2. Alles W. National CAM survey results. Presented at: Conference on Complementary and Alternative Medicine: Scientific Evidence and Steps Toward Integration; September 18, 1998; Palo Alto, Calif. 3. Astin J. Why patients use alternative medicine: results of a national study. JAMA. 1998;279:1548-1553. FREE FULL TEXT

Prepared by Ashish Bajaj, Department of Resident Physician Services, American Medical Association

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