By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

Many patients use traditional or non-prescribed remedies that range from putting aloe on minor skin infections to taking herbals or antioxidants for late-stage cancer. Numerous studies have shown that very few who do (considerably less than half) ever discuss these remedies with their healthcare providers. To learn more about this phenomenon and how healthcare providers can help, I spoke with two physicians. One is David Rosenthal, MD, medical director of the Zakim Center for Integrative Therapies at Dana-Farber Cancer Institute in Boston. The other is Giang T. Nguyen, MD, an instructor in family medicine and community health at the University of Pennsylvania. Nguyen works with his community’s Asian immigrant population and does research in the area of health literacy and cultural concerns.

Rosenthal and Nguyen say it is important for healthcare providers to know about all treatments, prescribed or not, that their patients are or could be using for a couple of reasons. The first is the potential for dangerous interactions with certain combinations of drugs or therapies. The second is to be able to talk with patients about additional therapies that could supplement the ones they are receiving. So I asked why conversations about “other therapies” don’t take place as often as they should.

The reasons vary. Some cultures, for instance, emphasize respect for those in authority, which often includes healthcare providers. Nguyen says patients from such cultures may feel that talking about other therapies they might be using would show a lack of respect for or trust in the provider. Rosenthal says that some patients may feel their providers are simply not interested in outside therapies. Other patients, for a variety of reasons, may feel the need to keep information about other therapies private.

Both Nguyen and Rosenthal say it is not just patients who do not initiate conversations. Some providers simply are not aware of all the various remedies patients might try, or if they are, they may not know what questions to ask. To keep treatments effective and safe, healthcare professionals need to ensure these conversations not only start but also proceed smoothly. Here are some ways to make that happen.

Know the range of possibilities.

Rosenthal speaks of “integrative therapies” as an umbrella term. It refers to medical treatments and combination of treatments drawn from both Eastern and Western traditions. According to Rosenthal, there are three types of integrative therapies that healthcare professionals should be aware of, either because patients may be pursuing them on their own or may need to be informed about their potential benefit. The three types are:

• Physical activity. This includes yoga, tai chi, and qigong among others.
• What you put in your mouth. This includes a wide range of foods and drinks, antioxidants, over-the-counter remedies, supplements, herbs, and botanicals.
• Complementary therapies. This includes acupuncture, massage, music therapy, mind-body awareness, and energy therapies such as Reiki.

Unless professionals are studying to become integrative medicine practitioners, they are unlikely to know a lot about the many different therapies. One way to find out more is from research in journals. Nguyen cautions, however, to read the studies carefully. Data can be hard to interpret, he says, especially when the sample size is small.

Keep an open mind.

No matter how knowledgeable you are about integrative therapies or other types of non-prescribed remedies, there invariably will be times when patients mention treatments that are unfamiliar. Rosenthal and Nguyen agree that providers cannot possibly know everything there is to know. Saying, “I don’t have experience with that kind of treatment. Now that you have mentioned it, I will try to find out more,” lets the patient know you have an open mind and it is okay to share information with you.

Then, Nguyen says, it is important to do your homework. A good place to start is with centers for integrative medicine in academic medical centers.

Open-ended questions are good conversation starters.

To get the conversation going, Nguyen asks open-ended questions. For instance, with a patient who has chronic back pain, Nguyen might ask, “What are you doing now for this condition?” If the person only mentions ibuprofen but Nguyen senses he has been doing more, he will probe with additional questions such as, “Are you doing anything else for your back pain?” As long as the questions are exploratory rather than accusatory, many patients soon feel sufficiently comfortable to add that they are doing yoga, taking herbals, or going to the chiropractor.

Appreciate each patient’s worldview.

Rosenthal sees many patients with advanced cancer who can benefit from integrative therapies that might help control their disease. If he is the first to suggest such treatment to a patient, he tries to explain it from the person’s point of view so the patient can more easily see the purpose of the therapy is to “improve the quality of your life while you are fighting cancer.”

Nguyen likewise tries to present information in context of the patient’s understandings. When explaining a new diagnosis of diabetes to a person who believes that disease results from an imbalance of Yin and Yang, he may apply the concept of balance to start a conversation about options. “What’s happening,” he may say, “is that an imbalance is making your sugar levels too high. That’s why I’m prescribing this therapy.”

Finally, Nguyen points out it is easier to talk about non-prescribed treatments when providers have made the effort to establish relationships with the patients they see.

Ways to learn more:

Giang T. Nguyen, MD, is an instructor in family medicine and community health at the University of Pennsylvania. He co-authored an article with Marjorie A. Bowman, “Culture, Language, and Health Literacy: Communicating About Health with Asians and Pacific Islanders” published in the March 2007 issue of Family Medicine.

David Rosenthal was the Medical Director of the Zakim Center for Integrative Therapies at Dana-Farber Cancer Institute in Boston.

Another excellent resource about cultural considerations in healthcare is the award-winning book by Ann Fadiman, The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures first published in 1997 by Noonday Press, NY.

Helen Osborne, MEd, OTR/L, is president of Health Literacy Consulting. Her column appeared regularly in On Call. You can contact her by e-mail at Helen@healthliteracy.com.