Once an environment of trust and shared decision-making has been established with more effective communication with the patient, the motives for the use of herbal medicine during conventional oncology treatment can be examined. So, let me just first ask you about the treatment how it's going, how you're feeling. Well, I guess it's okay. Prostate cancer is a treatable disease, and I trust my doctors. I guess putting everything together will be victorious formula. Something like that. I don't know. It's your words. I kind of work by evidence and numbers. So, I read about prostate cancer and I guess it will be fine. The question "why are you taking herbal remedies during chemotherapy?" should be asked in a non-judgmental way, since the patient could potentially see this as an attack on their healthcare beliefs. As a judgment that they have turned to alternative medical practices, and that the healthcare practitioner asking the question objects to the use of non-conventional medical practices. Patients need to understand that the question "why are you using herbal remedies during chemotherapy" is intended to better understand their health belief model. How they perceive concepts of health and healing; and to identify their unmet needs and expectations which may have been one of the reasons why they sought out non-conventional medical therapies in the first place. It is also important to understand whether the use of herbal medicine is reflective of a positive need of the patient as part of the cultural and societal norms which often have a high affinity to traditional practices which incorporate the use of natural therapies as part of the health belief model, or whether the use of non-conventional medicine arose from a negative experience with conventional care with unmet needs and expectations, with unresolved physical, emotional, and spiritual concerns. Dr. Elad Schiff addresses the challenges facing patient healthcare practitioner communication on the use of herbal medicine from an ethical perspective, emphasizing the physicians need for commitment to patient's safety. Many studies have shown that patients are fearful to reveal herbal use to their physicians. They think that physicians will oppose, but they still want to do that because that's the way the health philosophy goes. So, if physicians understand that this is for patient safety, if they will ask the patient in a judgmental way about herbal supplements and the patients will not reveal that, then they are endangering the patients. Therefore, we have to educate physicians. We have shown that in a one-hour educational sessions, we can educate physicians how to ask the question non-judgmentally regarding drug and supplement use. And physicians understand that morally, it is their role to ask in a non-judgmental way, and that way they will keep the patient safe. In order to expand your knowledge on how to improve healthcare practitioner-patient communication in integrative care, we recommend that you watch the full interview with Professor Heather Boone from the University of Toronto in Canada. I think two things come to mind right away. One, the question I get asked the most is "can you help me find an oncologist who'll be willing to talk about these things with me?". You're given that diagnosis, you want to try everything. You want to do everything possible to help yourself get better. So, I think it's only natural that people are looking for a wide range of therapies. The challenge in this whole field is there's so much we don't know. So, I think what's really important is to keep in mind if we know that there's evidence that something might work, if we know there's evidence something won't work or be harmful, or if it's in the middle bucket and that is we just don't know. A lot of complementary alternative therapies are in the middle. I think it's very important for both patients and for clinicians not to pretend they know when we don't know. Be honest, when we don't know, and help patients on that journey to either participate in trials if they're available, or to help them to gauge whether it is working for them even if there is not a study to say if it works in general, I think that's really important. So, what are patient's expectations when they seek complementary medicine? One of the things that the patients in our studies talked a lot about was that when they go to see a traditional practitioner or a practitioner of integrative medicine, that person often spends a lot more time with them. They feel supported in ways that unfortunately our conventional Western-style medicine doesn't support them. They tell stories about having seven minutes with the physician and an hour or two with their natural pathic doctor or their traditional Chinese medicine practitioner. That very human contact and support is something that's very important to them over and above whatever therapies the practitioner may recommend. Can you compare patients expectations with the camp provider versus their oncologist? They have different expectations with the two realms? They do have different expectations. They do expect more personalized care with an integrative medicine provider. I think though, if you talk to patients, they'd actually like all of their providers to have that kind of perspective. It's our healthcare systems, which mean that our oncologists often don't have the time, they would love to be able to spend an hour with the patient. But the way the system is designed, the way they're reimbursed, it's impossible for them to spend that much time. I really think we need to think about how we organize healthcare as a whole, to think about the good things that are part of integrative medicine that should be available to all patients, and then oncologist should be able to deliver ultimately. In order to identify the many challenges which are related to communication gaps between healthcare practitioners and patients in designing an integrative medicine treatment plan, we will present a case scenario. Jasmine is a 45-year old married female patient who was undergoing adjuvant chemotherapy for localized breast cancer. She was referred to our integrative oncology clinic by her oncologist for treatment of the side effects of her treatment. The therapeutic interaction with the integrative physician begins as soon as Jasmine enters the consultation room and the dialogue ensues. During which it becomes apparent that in addition to her chemotherapy regimen, she tells you that she is taking a number of herbal supplements as well. If she does not make any such disclosure, you could take the initiative and ask her whether she has previously, currently, or is considering using herbal medicine. Or whether she has consulted with an herbal practitioner for this purpose. In order to describe such a practitioner, you might need to use terms such as traditional, alternative, homeopathy, naturopath, nutritional consultant, or other titles. You may also ask her if she has consulted with an herbal consultant or healer, and whether she is currently taking any herbal remedies, supplements, eating certain foods or abstaining from others. In your conversation with Jasmine, you may continue and ask her what the reasons are for her use of herbal medicine in conjunction with the conventional oncology treatment. A number of explanations may be given such as her unmet needs, concerns, and expectations; or else her health-belief model which may differ greatly from that of her oncologist. After conducting an in-depth assessment of her quality of life related concerns, which should include both directed questions about her symptoms as well as filling out patient-reported outcome measure questionnaires or PROMs, you can now address her interests in using non-conventional modalities such as herbal medicine for her symptoms. For example, you may suggest that she try using ginger root to reduce her chemotherapy-induced nausea and vomiting. You can refer her to the online resources such as PubMed, and show her the evidence supporting the use of herbal remedies such as ginger at the same time discussing the risks of this practice, which include toxic effects of some herbals, and negative herb-drug interactions. After sharing this information with Jasmine, you can then recommend that she add ginger to her supportive cancer care treatment regimen, which may already include conventional antiemetic drugs, as well as other disciplines such as psycho-oncology, for example. After she has been given the relevant information on the benefits and risks of integrative and herbal medicine, a treatment plan can then be co-designed with goals which are clearly defined and realistic. If Jasmine was interested in alleviating the nausea caused by her chemotherapy regimen, as well as other outcomes such as improving appetite, reducing anxiety, additional integrative medicine modalities such as acupuncture or meditation might be added to the treatment program in addition to the ginger supplement. The design of the treatment plan can include other integrative medicine consultants such as an herbalists who could advise Jasmine on the use of other herbs. Or else an anthroposophic physician who can prescribe Mistletoe Viscum album injections for symptom relief. While discussing the treatment options and co-designing the integrative treatment plan, it is also important to be aware of the potential gaps in communication which may negatively affect the patient-centered design and implementation of the therapeutic process. Despite the initial excitement at the beginning of most treatment regimens, whether conventional or not, patient adherence tends to decline with time. It would thus be helpful if you would first ask Jasmine whether she is familiar with ginger root, and then whether she has ever used it as a medicinal remedy. If so, if she used it in the roof form as an herbal tea, as a dry powder, or a capsule. It is important to examine the context in which the ginger remedy had been used as a spice for food, as a traditional herbal remedy, or for other reasons. The next set of questions should relate to any preferences she may have partaking the herb. Is the taste or smell too strong? Is the capsule the preferred route for taking the herb because of its taste or smell? Finally, you can ask Jasmine whether she thinks that she'll be able to adhere to the dose and frequency of the herbal remedy as recommended.
