Originally published March 2012
As Canadians' access to health information expands, so does their interest in complementary or alternative medicine, including natural health products. The boundary between conventional medicine and complementary and alternative medicine is neither fixed nor absolute. Therapies once considered to be "alternative" may have since evolved and been adopted by conventional medical practice, while others do not have the necessary scientific support and are consequently considered unproven.
A recent survey1 of healthcare consumers confirms that, while Canadians prefer conventional medicine, 1 in 4 use alternative methods at times. Meanwhile, more than two-thirds2 of physicians are regularly asked by patients about natural health products (NHPs).
The response of physicians to complementary and alternative medicine (CAM) is also changing, with gender, age, and culture influencing attitudes to alternative forms of health treatments. A recent survey estimates that 38% of physicians recommend at least some NHPs to their patients.3
Still, there is much debate in the medical community about how best to handle CAM practices, and how to ensure risks and patient safety are properly managed.
What is complementary and alternative medicine?
There is no single definition of what is included within CAM. For most Canadians, CAM is used in conjunction with conventional medicine, rather than an alternative.
CAM most often refers to a group of diverse medical practices and products that fall outside the norms of conventional medical practice. The range of treatments currently considered by most to be CAM can include homeopathy, naturopathy, traditional Chinese medicine (TCM), osteopathy, acupuncture, massage therapy, and reiki.
Given public interest in CAM, many medical regulatory authorities (Colleges) have created guidelines and are providing information about non-conventional practices to help support physicians in their daily practice. The aim is to enhance patient safety by discouraging physicians from prescribing ineffective and unproven therapies (e.g. therapies that are not supported by scientific evidence) or engaging in unprofessional conduct (e.g. conflicts of interest, such as charging inappropriate fees for uninsured services or NHPs).
Some Colleges, for instance in Ontario, define three types of practices that encompass CAM, including physicians who practise conventional medicine, but have patients that pursue CAM; physicians who practise CAM, either as a primary focus or as a complement to conventional medicine; and physicians who form professional affiliations with CAM clinics and therapies.
When patients seek alternative medicine
Physicians should respect the autonomy, health goals, and treatment decisions of their patients. Patients have the right to make decisions about their health in accordance with their values and preferences, including the right to pursue complementary or alternative forms of health treatments.
When patients ask about CAM therapies or natural products, physicians should respond in a professional manner and within the limits of their knowledge, skill, and judgment. Often patients may be reluctant to reveal their use of alternative therapies to physicians, but this information could be important to the effectiveness of conventional treatments and in preventing negative interactions and adverse events. A physician may consider asking a patient if they are using CAM therapies, including NHPs. This may be especially important as some symptoms may be related to CAM therapies, and drug interactions can occur with homeopathic (?NHPs) and conventional medications. If the physician does not have the knowledge required to comment on the therapy, including determining the potential for adverse reactions, the physician should let the patient know and make a note of the conversation in the medical record.
While physicians are under no obligation to prescribe complementary and alternative therapy which they feel is not medically indicated or supported by scientific evidence, physicians prescribing, recommending, or providing CAM must do so in accordance with a recognized and accepted standard of practice. Physicians should consult their respective College policies to ensure they are meeting these obligations. Governments may also regulate the use of particular CAM therapies.
Whether providing conventional or alternative medicine, physicians have a general duty to do no harm to their patients. To this end, physicians' professional, ethical, and legal obligations require them to act within the limits of their knowledge and provide care which is within the scope of their clinical practice and supported by current scientific evidence.
Providing advice to patients about CAM
Physicians may be asked by their patients for information about complementary practices, including recommending or suggesting NHPs or remedies or a referral to a CAM practitioner.
In these instances, physicians should consider providing information to allow patients to make informed choices. In some cases, it may be appropriate to consider consulting with or referring the patient to others when doing so is in the best interests of the patient and where there is no reason to believe that the patient would be exposed to harm.
If a physician believes that an alternative therapy may in fact be harmful to the patient, it is important that this information be shared with the patient. While providing information to a patient does not mean that a particular therapy is being endorsed or ordered, these conversations should be noted in the patient's medical record.
The role of consent
While physicians are increasingly concerned about their liability in the event that patients are harmed by treatment received from CAM, in general the risks associated with such claims are less likely if the physician is not actively involved in the provision of CAM therapies.
When a physician refers a patient to a complementary or alternative therapist, orders the therapy, approves the requested therapy, recommends a certain complementary therapy, or provides information to the patient about the benefits, effects, and risks of the therapy, the physician may be held accountable. However, each independent practitioner will be held responsible for the care he or she provides. For example, it is unlikely that the referring physician will be held responsible for the negligence of the CAM practitioner.
Consent is an important aspect of integrating complementary and conventional medicine. Physicians who authorize or recommend CAM therapies should obtain informed consent from the patient. The consent discussion and rationale for making the recommendation should be noted in the medical record. Whether a physician recommends or offers a complementary or conventional therapy, the same standards apply regarding taking a history, conducting an appropriate examination, rendering a reasonable diagnosis where possible, outlining the risks and benefits of available and scientifically supported treatments for the specific condition, documenting thoroughly, referring if needed, and obtaining appropriate consent.
Affiliations with CAM practitioners
Some CAM therapies are in the process of being integrated into the mainstream. Many medical clinics, for example, now offer massage therapy or chiropractic services. Some hospitals have created clinics or divisions for integrative medicine to study, monitor, and recommend practices that are not typically considered conventional, but might complement rather than replace conventional medicine.
Some physicians may consider forming an affiliation with a CAM clinic or therapy. Patients might view such an affiliation as an endorsement or recommendation of the safety or effectiveness of the CAM practice. Before forming a professional affiliation, the physician should consider if the practice is based on scientific evidence and whether or not the practice entails more risk than a conventional intervention or therapy. There should be a reasonable expectation that the CAM therapy will be clinically effective.
Physicians working in hospitals or health centres where CAM therapies and practitioners are available may consider referrals if policies which clearly define roles, responsibilities, and accountabilities within the healthcare team are in place. For example, a policy may specify that the ultimate decision to proceed with a CAM therapy will be made solely by the patient, taking into account the informed consent discussion with the complementary therapy provider and any comments made by the healthcare team. The policy should be clear that accountability rests with the individual providing a CAM therapy.
The clinic or hospital may require the patient or substitute decision maker to sign a waiver absolving the hospital or clinic of any liability. These waivers should include physicians and members of the medical staff.
While CMPA assistance is always discretionary and decided on a case-by-case basis, generally a member would be eligible for assistance when the member is engaged in medical professional work.
The bottom line
Considerations with respect to CAM and natural health products include the following:
Physicians considering using or recommending CAM to their patients should know how alternative medicine is governed in the jurisdiction in which they practise, including reviewing any applicable guidelines or policies issued by their College.
When discussing alternative treatments with patients, physicians should document this discussion in the patient medical record.
Physician-patient communication is important when considering alternative medicine. Physicians should encourage their patients to inform them if they are using complementary or alternative medicine or natural health products.
Physicians are under no obligation to offer complementary or alternative therapies, although it may be helpful to have reliable information on CAM products and therapies most likely to be the source of inquiries from their patients.
When in doubt, members should call the CMPA for advice or guidance. The CMPA's experienced medical officers are an excellent resource for members.
Deloitte Center for Health Solutions, "2011 Survey of Health Care Consumers in Canada – Key Findings, Strategic Implications."
Medical Post, May 18, 2011. "38% of doctors now suggest natural health products: survey."