Whether providing or referring patients to alternative treatments, physicians need to remain mindful of their professional obligations, potential medico-legal risks
As Canadians' access to health information expands, so does their interest in complementary and alternative medicine (CAM). CAM refers generally to a group of diverse therapeutic treatments, products, and practices that are intended to complement or serve as alternatives to conventional medical practice (i.e. practices that are commonly taught in medical schools and provided in medical practices and hospitals). The range of treatments considered CAM include natural health products, chiropractic treatment, acupuncture, meditation, yoga, Reiki, and homeopathy.1
The boundary between CAM and conventional medicine is neither fixed nor absolute. Many Canadians complement conventional medical care with one or more of these alternative approaches. Some Canadian physicians practise CAM, either as a primary focus or as a complement to conventional medicine, and some form professional affiliations with CAM practitioners. It is important for physicians to ensure that patient safety is properly managed in these situations.
Discussions with patients about alternative medicine
Physicians must respect the autonomy, health goals, and treatment decisions of their patients, including the decision to pursue CAM instead of, or as an adjunct to, conventional medicine. Discussing CAM without judgment or trepidation helps in obtaining a full impression of a patient’s personal practices. As patients may be reluctant to reveal their use of CAM, a physician might consider proactively asking patients if they are using CAM. A thorough history is also important so that symptoms and potential interactions with conventional treatments can be assessed and monitored.
When patients ask about CAM, physicians should respond in a professional manner and within the limits of their knowledge, skill, and judgment. If possible, physicians should assist patients in making informed decisions about CAM therapies by providing information about known benefits and side effects, and known interactions with the patient’s existing treatments. If a physician believes that an alternative therapy may be harmful to the patient, it is important that this information is shared with the patient.
Physicians should inform their patients when they do not have sufficient familiarity with the CAM to provide information about the risks and benefits. The physician may also consider whether consulting with, or referring the patient to, another practitioner who could provide that information would be appropriate. All discussions with patients about CAM should be recorded in the patient’s medical record.
Providing alternative medicine
Physicians who provide CAM must do so in accordance with a recognized and accepted standard of practice, and within the limits of their skill and knowledge. Physicians should familiarize themselves with applicable policies of their medical regulatory authority (College) to ensure they fulfill their professional obligations.
Whether a physician provides CAM or conventional therapy, similar standards apply regarding taking a history, conducting an appropriate examination, rendering a reasonable diagnosis or differential diagnoses, and documenting informed consent. Any CAM provided by a physician should be based on reliable scientific evidence that confirms the therapy’s safety and efficacy in the patient’s circumstances. Some Colleges require physicians who provide CAM to include specific information in the consent discussion, such as informing the patient of the strength of evidence and scientific reasoning that supports the decision to offer CAM, reasonable expectations for the efficacy of the CAM, and a description of how the therapy compares to conventional treatment.
Physicians providing CAM could be exposed to the risk of liability or College sanction if it results in harm to the patient. It is important to the defence of such a claim or complaint that there be evidence that the physician met the standard of care and that the patient was properly informed of the benefits, effects, and risks of the therapy, and made an informed treatment decision. Detailed records of the rationale for the CAM recommendation, assessments conducted, diagnosis made, and informed consent discussion are therefore essential.
Alternative medicine and social media
Physicians using social media or other mass communication media have an obligation to ensure that the information they share about CAM is supported by credible, scientific evidence. Physicians should be mindful that, by expressing support of any CAM, they could influence the public to adopt certain practices even though doing so in their particular circumstance may be harmful. Physicians should avoid providing personalized medical advice to individuals through social media, and should be aware of and follow their College’s guidance concerning social media use and advocacy.
Professional affiliations with CAM practitioners
The integration of some CAM into conventional medical practice is becoming more commonplace. Some hospitals have created clinics or divisions for integrative medicine to study, monitor, and recommend practices that are not typically considered conventional, but that might complement rather than replace conventional medicine.
Some physicians may be interested in forming a professional affiliation with a CAM clinic or practitioner. Patients might view such an affiliation as an endorsement of the safety or effectiveness of the CAM. Before forming a professional affiliation with or referring a patient to a CAM practitioner, the physician should consider if the practice is based on scientific evidence, and whether it creates more risk to patients than a conventional therapy. Physicians should ensure they fulfill any professional obligations imposed by their College when affiliating with CAM clinics or practitioners, including with respect to potential conflicts of interest. Ultimately, physicians are not generally held responsible for care provided by another health practitioner who is not the physician’s employee or under their direct supervision.
Physicians working in hospitals or clinics where CAM are available may consider referring patients to those practitioners if it is in the patient’s best interests and there are policies that clearly define roles, responsibilities, and accountabilities within the healthcare team. For example, the policy might specify that the ultimate decision to proceed with CAM will be made by the patient following an informed consent discussion with the CAM practitioner. The policy might also require the CAM practitioner to communicate the patient’s decision regarding CAM to the referring physician. The policy should clarify that accountability rests with the CAM practitioner to assess the benefits and risk of the therapy in the patient’s particular circumstances, and to obtain informed consent. Patients should be informed of the separate roles and responsibilities of members of the healthcare team in this respect.
Physicians might be requested by CAM practitioners to order bloodwork or other testing for their patients. Physicians are under no obligation to order tests or investigations that have been requested by other practitioners. Physicians receiving such requests should make their own assessments regarding the appropriateness and need for the test or investigation in the circumstances of each patient.
The bottom line
Physician-patient communication is particularly important when a patient is considering CAM. Whether providing CAM, working in affiliation with a CAM practitioner, or referring a patient to CAM, physicians should be mindful of their own scope of practice, as well as the patient’s particular circumstances.
College of Physicians and Surgeons of Ontario. CPSO;1997 Nov. Advice to the profession: Complementary and Alternative Medicine [updated 2021 Sep; cited 2021 Oct 28]. Available from: http://policyconsult.cpso.on.ca/wp-content/uploads/2020/11/Complementary-and-Alternative-Medicine-Draft-Advice-Document.pdf