We should always ask our patients about unconventional treatments

Self-treatment with medicines and therapies outside of mainstream medical practice, including herbal medicines and supplements, folk remedies, homeopathy, acupuncture, chiropractic therapy, and massage therapy, is a growing trend in the United States. Forty percent of Americans have used an unconventional therapy, and of those, fewer than 40% have informed their regular physician about it.¹ In many cases, patients do not disclose their use of unconventional therapies simply because the doctor does not ask about them,² rather than out of fear of their physician's disapproval.

Similarly, the use of foreign drugs that are banned in the United States is often not disclosed to physicians. Taylor and colleagues report the results of a patient and provider survey in San Diego that found that more than a third of surveyed Hispanic patients had used the banned antipyretic drug dipyrone, whereas nearly three fourths of surveyed physicians were unaware of the drug's indications or adverse effects. This study provides valuable information about a non-English-speaking population group that has been largely underrepresented in most national surveys on the use of unconventional therapies. It would be interesting to know how many of the 76 users of dipyrone had reported their use of this drug to their clinic provider.

At first glance, it seems inappropriate and incongruous that the patient survey was conducted in a community clinic setting where all of the patients were Hispanic and uninsured or receiving Medicaid, whereas the provider sample was taken from mailing lists of professional member groups in San Diego, whose patients were mostly non-Hispanic. However, the use of unconventional therapies is distributed across all sociodemographic groups, and providers are likely to encounter such patients in all clinical settings.¹

A recent survey of family practice clinic patients showed that the use of alternative therapies was significantly associated with self-perceived poor health and high educational level.³ Often, these patients have a chronic illness, such as cancer, low back pain, or anxiety. In fact, many people who use unconventional therapies are “shopping around” for health care and have the financial resources to pay for therapies not generally reimbursed by health insurance. They may see several nonphysician practitioners or travel outside of the United States for medicines banned by the FDA. In addition, I searched the Internet using the search term “dipyrone” and found many web sites from which the drug could be ordered and shipped to the United States—so you do not need to go outside this country to get hold of a banned drug.

The use of alternative treatments does not generally reflect dissatisfaction with conventional medicine, but rather a desire to find treatment alternatives that fit with personal values and cultural beliefs about health care.⁴ Increasingly, a new health care paradigm is being embraced, one that blends conventional medicine with alternative remedies and practices based on individual motivational and spiritual attitudes toward health.

Physicians can best guide their patients by inquiring with a tone of neutrality about all health care practices, including natural remedies, self-care therapies, and practitioner-based treatments, and listening to their patients' perspectives on health, illness, and conventional medicine. Although the goal of the encounter is shared decision making, physicians must be able to advise patients about potentially harmful therapies such as dipyrone. Busy practitioners cannot be expected to be knowledgeable about all of the unconventional therapies reported by their patients. Fortunately, several books and journal articles have been published recently that provide comprehensive information on advising patients on the use of alternative remedies.^4,5,6 No longer is a “don't ask, don't know” policy toward unconventional therapies appropriate, because more people are individualizing a health care plan that necessitates proactive management by the primary care provider.