Physician - Patient Communication & Patient
Empowerment
Participants' experiences with their physicians regarding
supplements were usually described in negative terms. They
commented that many physicians are closed-minded about the
usefulness of supplements and have poor knowledge of supplements
and nutrition in general. Many participants felt they were
treated badly by physicians who did not want to discuss
supplements, and some reported arguments about the usefulness of
such products. The best experiences were usually characterized
by ambivalence, wherein the physician said to continue using a
supplement if the patient felt comfortable with it. On the
positive side, one participant described how his physician
worked with him to treat his high LDL level using a dietary
fiber supplement.
The participants acknowledged the value of
physicians' diagnostic skills and expressed a desire for a
partnership with their physician that emphasized disease
prevention. They hoped that more physicians might combine their
conventional medical practices with knowledge of alternative
treatments, such as dietary supplements, and improve their
knowledge of nutrition. They also emphasized the need for
physicians to be better listeners, remain open-minded, and be
more humanitarian.
Discussion
In many ways, the health food store customers in this study
were ideal patients. In addition to the motivation to be
healthy, they were educated, well read about health matters, and
wanted to maintain responsibility for their own health care.
Physicians would be well served by acknowledging this in a
positive manner. The physician and patient could then ideally
enter into a healthy dialogue about the patient's use of dietary
supplements and other modalities to achieve wellness. By
rewarding patients with open-mindedness, patient-centeredness,
and scientific information, the physician empowers the patient
and strengthens the physician-patient relationship.
Evidence-based medicine--randomized double-blind
placebo-controlled studies--remains the gold standard by which
effective treatments can be determined. Nevertheless, Stead[16]
recently estimated that physicians are able to use
evidence-based medicine only 25% of the time. The other 75% of
medicine is empirical, and often based on trial and error (ie,
the personal response of the individual patient). Physicians
often say, "Try this and see if it helps. If not give me a call,
and we will try something else." Evidence-based medicine is
important, but it is time-consuming and often lags behind
discoveries that individuals and groups may make through trial
and error. For example, consumers' use of large doses of vitamin
E has to a large extent been validated as having some
effectiveness in the prevention of heart disease,[17] prostate
cancer,[18] and Alzheimer's disease.[19]
These customers of health food stores generally determined
the effectiveness of a given dietary supplement through an
experimentation method that is quite subjective. However, it
should be acknowledged as having some validity. We may not know
if the patient's feelings of wellness are due to placebo effect
or have a biomedical basis. An important objective has been
accomplished if the patient feels better, regardless of the
mechanism. Astin[20] has shown that relief of symptoms is one of
the 2 most important reasons patients choose alternative
medicine modalities.
Despite their desire for more guidance regarding dietary
supplements, focus group participants did not often seek advice
from their physicians. The fact that most participants felt
uncomfortable discussing their use of supplements with their
physicians, and some even stopped visiting their physician, is
important information for health care providers. Physicians
should welcome an open dialogue about supplements and be able to
disagree with patients' beliefs without being disagreeable. The
participants in this study wanted reliable information about
supplements amidst a lot of confusing claims. They wanted a
partnership with their physicians, who they hoped would be more
knowledgeable about dietary supplements and nutrition in
general. Unfortunately, the majority of medical schools in the
United States have been teaching very little about the medicinal
use of herbs and dietary supplements. Many physicians,
therefore, are not very knowledgeable about this topic, and some
may be prejudiced about the use of such products.
Limitations
This study was limited to a small population of health food
store customers who volunteered to participate in the focus
groups. The participants are not necessarily representative of
the general population. However, they demographically resembled
other consumer populations who made use of alternative medicine
as well as allopathic medicine.[2,9,10]
Conclusions
Minimally, physicians should respect their patients' right to
take supplements, acknowledge this right, encourage continued
physician-patient communication, and have a willingness to learn
about supplements--even from their patients. The participants in
our study expressed respect for the medical profession's
diagnostic and technologic skill. Good relationships are clearly
possible. Physicians who are open-minded, patient-centered, and
willing to allow patient experimentation with dietary
supplements without condemning their efforts are likely to be
able to form good therapeutic relationships.
Acknowledgements
The authors would like to acknowledge the Wisconsin Research
Network for its financial support, the Medical College of
Wisconsin for providing support for a medical student summer
research project, and Chris McLaughlin for her editorial work.
References
[1.] Marwick C. Growing use of medicinal botanicals forces
assessment by drug regulators. JAMA 1995; 273:607-9.
[2.] MacDonald S. Herbal alternatives. Cincinnati Inquirer
February 11, 1998; El, E5.
[3.] Porter DV. Dietary Supplement Health and Education Act
of 1994 (Public Law 103-417). Report for Congress. Washington,
DC: Congressional Research Service, 1994.
[4.] Schneider B. Ginkgo biloba extract in peripheral
arterial diseases: meta-analysis of controlled clinical studies.
Arzneimittelforschung 1992; 42:428-36.
[5.] Linde K, Ramirez G, Mulrow CD, Pauls A, Weidenhammer W,
Melchart D. St. John's wort for depression: an overview and
meta-analysis of randomized clinical trials. BMJ 1996;
313:253-8.
[6.] Eliason BC, Doenier, JA, Nuhlicek DN. Desiccated thyroid
in a nutritional supplement. J Fam Pract 1994; 38:287-8.
[7.] Centers for Disease Control. Adverse events associated
with ephedrine containing products: Texas, December 1993 to
September 1995. MMWR 1996; 45:689-93.
[8.] Philen RM, Ortiz OI, Auerbach SB, Falk H. Survey of
advertising for nutritional supplements in health and
body-building magazines. JAMA 1992; 268:1008-11.
[9.] Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins
DR, Delbanco TL. Unconventional medicine in the United States:
prevalence, costs and patterns of use. N Engl J Med 1993;
328:246-52.
[10.] Eliason BC, Kruger J, Mark D, Rasmann DN. Dietary
supplement users: demographics, product use and medical system
interaction. J Am Board Fam Pract 1997; 10:265-71.
[11.] Eliason BC, Myzkowski J, Marbella A, Rasmann DN. Use of
dietary supplements by patients in a family practice clinic. J
Am Board Fam Pract 1996; 9:249-53.
[12.] Krueger RA. Focus group: a practical guide for applied
research. Sage Publications: Newbury Park, Calif, 1988.
[13.] Morgan DL, Krueger RA. The focus group kit. Volume 1-6.
Sage Publications: Thousand Oaks, Calif, 1998.
[14.] Crabtree BF, Miller WL, eds. Doing qualitative
research. Research methods for primary care. Volume 3. Sage
Publications: Newbury Park, Calif, 1992.
[15.] Miller WL, Crabtree BF. Qualitative analysis: how to
begin making sense. Faro Pract Res J 1994; 4:289-96.
[16.] Stead EA. Dr. Stead on doctoring: advice to emerging
physicians. Pharos 1998; 61:20-2.
[17.] Stampfer MJ, Rimm EB. Epidemiologic evidence for
Vitamin E in prevention of cardiovascular disease. Am J Clinic
Nutr 1995; 6(Suppl): 1365S-9S.
[18.] Heinonen OP, Albanes D, Virtamo J, et al. Prostate
cancer and supplementation with alpha-tocopheral and
beta-carotene: incidence and mortality in a controlled trial. J
Natl Cancer Inst 1998; 90:440-6.
[19.] Sano M, Ernesto C, Thomas RG, Klauber MR. A controlled
trial of selegilime, alpha-tocopheral, or both as treatment for
Alzheimer's disease: the Alzheimer's Disease Cooperative Study.
N Engl J Med 1997; 336:1216-22.
[20.] Astin JA. Why patients use alternative medicine. JAMA
1998; 279:1548-53.
Submitted, revised, February 16, 1999.
This paper was previously presented at the 1997 Wisconsin
Primary Care Research Forum and Eleventh Annual Wisconsin
Research Network Meeting, October 24-25, 1997, Appleton,
Wisconsin.
From the Department of Family & Community Medicine, Medical College of
Wisconsin (B.C.E., J.H.), and the Department of Family Medicine, University of
Wisconsin (L.M.), Milwaukee. Requests for reprints should be addressed to B.
Clair Eliason, MD, 341 Maple Terrace, Oconomowoc, WI 53066.
COPYRIGHT 1999 Dowden Health Media, Inc.
