When it comes to complementary and alternative medicine, few physicians find themselves without some malpractice exposure. Doctors who practice CAM have direct exposure, but even physicians who don't practice CAM could be exposed if they fail to find out what CAM regimens their patients are using on their own.
According to a report published by the Mutual Insurance Company of Arizona (Phoenix) for the Arizona Medical Association, 42% of U.S. adults reported using alternative therapies within the last 12 months. These include chiropractic, massage therapy and herbal remedies. Ninety-six percent of those individuals also saw a medical doctor in the same time period. But less than 39% discussed their alternative therapies with their medical doctor.
An estimated 15 million Americans are taking prescription drugs and herbal remedies concurrently and may be at risk for interactions or side effects, the 1999 report says.
"What the medical community has been doing with CAM recently is formalizing an understanding of an entire range of modalities that our patients have always been interested in," says Stephen Straus, M.D., director of the National Center for Complementary and Alternative Medicine at the National Institutes of Health, Bethesda, Md. "These days, our patients are very informed, although not always with correct information."
One challenge, Straus says, is that much of the evidence and research for CAM treatments are less robust and more diffuse than for more mainstream approaches. Another is that patients can access these therapies on their own without physician permission.
Get the patient history
Taking a comprehensive history is an important risk management tool, says Karen Connell, assistant manager of risk management services for Mutual Insurance Company of Arizona and author of the report.
And yet, a physician's own behavior can contribute to an information gap, according to Julian Whitaker, M.D., of the six-physician Whitaker Wellness Institute, Newport Beach, Calif.
"Most patients don't talk about their own CAM practices with their allopathic physicians because the physicians' responses are usually disdainful," says Whitaker. "Rather than dealing with that negative bias, they don't even bring up the topic."
Says Connell, "We encourage our physicians to ask about things that patients may be taking in a way that 'normalizes' it." For example, she says, they can begin with, "Many of my patients use alternative therapies or take some herbs," to make patients feel comfortable discussing CAM.
Some large practices create a form for their physicians to use for taking medical histories and for other types of patient data collection.
"In such cases, these forms should have questions or areas that will prompt the physicians or nurses to ask patients about complementary and alternative care treatments, medications, herbs and so on," Connell says.
The practice also should create some type of tickler system so that, if a patient does not return for treatment as a result of going to an alternative practitioner, the physician can follow up with the patient.
The physicians desk references for herbal medicines and nutritional supplements as well as The Natural Pharmacist are three ready sources of information about interactions. If a physician finds that a patient is involved with a CAM treatment or supplement that the physician believes is not safe, he or she should share this information with the patient.
"This can be done verbally, by providing a pamphlet or other written literature, or by directing the patient to a reputable Web site with information on the concerns about the supplement or treatment," notes Connell.
Physicians also should advise the patient about interactions between drugs they are prescribing and any CAM supplements the patients might be taking, urging the patient to stop taking the supplements while taking the drug if there is a suspected dangerous interaction.
"Again, the admonitions should be documented," she adds.
Practicing with CAM
Martin Dayton, M.D., D.O., of the Dayton Medical Center in Sunny Isles Beach, Fla., has been practicing CAM since the 1960s. Besides treating patients with mild medical concerns, he also uses certain CAM treatments for patients with cancer and heart disease. However, in most cases, he integrates CAM procedures with conventional procedures.
"I think this integrative approach is much more powerful than CAM or conventional procedures alone," he says.
As a way to protect himself, Dayton first explains to the patient what procedures he is recommending, along with his qualifications and experience in those procedures. He also explains what conventional treatments are available.
"I then have the patient sign a consent form for the procedures that I plan to do," he states. "If a patient prefers one certain treatment over one that I recommend, I will respect that patient's wishes, provided that I don't think that their preferred treatment would do more harm than good."
Whitaker, who has been practicing CAM for 27 years, uses a number of therapies in his practice, including IV vitamin therapy, nutritional support, acupuncture and chelation therapy. He utilizes three strategies to protect himself.
"First, every patient signs an arbitration agreement, so if they have a beef with me, it can be arbitrated by three judges," he states. Second, they sign a comprehensive informed-consent document. "Third, and the most important, is that we strongly stress patient service and patient care," he emphasizes. "In my experience, the majority of problems physicians have with patients are not related to what is done, but how the patients perceive the willingness of the physician to provide good patient care."
For most physicians practicing CAM, says Whitaker, the major liability concerns are not related to patients, but to administrative actions from state boards.
"For the most part, the patients are happy," he observes. The best protections he has found are two of the three he uses directly with his patients: informed consent and good patient care.
"In sum, anytime you are discussing CAM treatments or supplements with patients, be sure your recommendations and decisions represent what you believe to be defensible positions," Straus says.
William Atkinson is a freelance writer living in Carterville, Ill.