The article by Bridget J. Bernstein and Teresita Grasso comes at a time when complementary and alternative medicine (CAM) is on the minds of health-care workers and the public alike. The authors focus their study on the aspects of CAM that are most relevant to the role of the clinical pharmacist. Clinical pharmacists are key sources of information for cancer patients and their families, and they greatly influence how the prescribed treatments are perceived. The US Food and Drug Administration has identified at least 104 deaths directly related to "natural" supplements, which further supports the importance and timeliness of this study.
It is not unusual for consumer magazines with wide circulations to cover similar stories. However, the recent coverage of CAM, as in a story published simultaneously by the New Yorker and U. S. News & World Report is a reflection of the importance and mass appeal of complementary and alternative medicine. Interest in CAM has grown well beyond the intense but always ephemeral attention of the mass media. The National Library of Medicine’s PubMed online database has over 220,000 references, abstracts, and full-text articles on CAM.
CAM has only recently gained the somewhat sluggish and resentful attention of the premier medical institutions. Paradoxically, as managed care has significantly limited an individual’s choice of physicians and settings, consumers are driving the CAM engine by stepping outside of the health-care system and spending their own dollars. In 1999, the US Congress’s General Accounting Office estimated CAM-related consumer spending to be in excess of $31 billion.Language Problems
The article by Bernstein and Grasso provides a helpful literature review of the importance of CAM, for an intended audience of "health-care professionals, especially pharmacists." The authors cite the National Institutes of Health’s Office of Alternative Medicine definitions of complementary and alternative medicine. The information provided by their survey is also helpful but falls prey to many of the same language problems identified in their article. The terms "complementary" (therapy used in addition to conventional treatments) and "alternative" (therapy used instead of conventional treatments) are used interchangeably, despite the fact that all patients in the sample were receiving medical care (left undefined) at a South Florida Hospital.
The authors acknowledge that the sample was small (96 or 100, depending on who is actually included) and comprised primarily of whites and Hispanics (91 of the 99 who responded to the race question). However, the data are presented in a somewhat confused manner. The reader has to work hard to extract what can be valuable information. For example, the authors note, "80% of patients reported using some type of CAM; 81% took vitamins . . ." and, "No correlation was found between the use of CAM and age, gender, ethnicity, or education. However, 65% (n = 52) of college graduates and 90% (n = 72) of whites reported using vitamins, herbal therapies, and/or relaxation techniques."
The patient questionnaire is also problematic. Complex terms are used but not defined, and it is impossible to decipher what is part of normal self-care (such as taking a daily multivitamin) and what is actually being used with the intent of enhancing immune function or as an antineoplastic agent. Given that patients in the sample were being cared for at a hospital, the term alternative used throughout the article and in the questionnaire should probably be replaced with complementary. There is also inadequate explanation as to why prayer, for example, was excluded from the questionnaire. (Perhaps only those agents that most relate to the practice of clinical pharmacy were listed.)
Given the intended audience, a discussion of practical information that would aid pharmacists in protecting patients from dangerous complementary and alternative agents would have been helpful. Also, pharmacists should be encouraged and taught to routinely ask patients if they are taking any agents in addition to their prescribed medicines. Such a dialog could reveal essential information for the treating health-care team. Hopefully, the investigators will pursue this strategy in a follow-up study.
Overall, the study is helpful in beginning to identify which CAM therapies cancer patients are currently using. Some other areas that were alluded to but not adequately discussed follow.Why So Many People Use CAM
As with the early hospice movement, CAM has evolved in a closely parallel but distinctly nonintersecting orbit with that of established medicine. Hospitals are now scrambling to develop credible CAM programs that attract patients and managed-care contracts, but they have not been able to figure out how to pay for these services. This is a significant problem for hospitals and universities confronting dwindling reimbursements, aging populations, and fiercer competition for educated patients with resources. Virtually all CAM programs use existing staff (who perform these services in addition to their regular assignments), or refer to outside practitioners over whom they have little quality control. The few CAM programs that actually do have full-time staff are supported primarily by research grants or philanthropy.
Health-care professionals, especially physicians, express confusion over why CAM is so important to patients and families, given the lack of scientific support for almost all these interventions. For many patients with serious (but potentially curable) or life-threatening diseases, even an undefined vague sense of hope is much more real and meaningful than the objective scientific "certainty" of statistics. The lack of connection to a health-care team that has too little time to spend with them and no opportunity to see them as people, creates a sense of vulnerability and exposure that is intolerable to many people.
Patients want to benefit from the best that science has to offer, but they also need to feel a human connection to those on whom they feel so utterly dependent for their survival. The ability of people to pin their hopes of healing and recovery on another human being predates the scientific methods by many millennia. Patients who actively use CAM are, in part, yearning for their physician to also be a shamanto have magic beyond science. In this role, it is a vague evolutionary memory of an atavistic relationship now long gone from objective consciousness that controls the sense of abandonment, fear, and exposure. Perhaps this is no longer possible in any health-care system.Conclusions
Science represents the best system for developing new knowledge and overcoming problems, but it is not an instrument for healing the separation and sense of exposure that people feel when they become ill. Only a sense of connection to other people or a higher undefined power can do that. Perhaps it is time for organized medicine to cross the schism it created when curing a disease became the gold standard, and the messy business of caring for a person was relegated to the status of a social problem.
If the example of hospice is any clue as to how institutions will respond to the unmet needs of patients and families, sell your biotech stocks and invest in coffee and shark cartilage.