Pharmacy ServicesLiability issues for practicing physicians in the area of alternative medicine are quite broad. Legal authorities like Michael J. Cohen, JD, point out the presence of conflicting licensing, regulatory, and malpractice considerations because of the evolving nature of complementary/alternative medicine. Relatively little has been scientifically proven concerning the efficacy and safety of CAM treatments. Also, such treatments are viewed as “non-standard” care. There is concern about having sufficient safety and efficacy data, such as contraindications to make informed recommendations to patients.

Physicians lack knowledge about the interactions that can occur when a patient “self-medicates” versus when he ingests medications that are prescribed.¬†In addition, they may be uninformed about which complementary remedies a patient is using. Patients taking these agents may require additional precautions before surgery and anesthesia. Examples include complementary therapies, which can affect clotting dynamics or cause additive sedation prior to surgery. This reinforces the need to ensure that health histories elicit information about the patient’s use of herbal remedies. Physicians also need to advise patients to discontinue all herbal remedies for a relatively long period prior to surgery. Physicians can be held liable for the unintended consequences resulting from their patients’ use of CAM products regardless of whether they (the physicians) are aware that the products are being used.
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Doctors and pharmacists must educate patients about the differences between conventional and alternative medicine and about the pharmacological similarities between conventional and alternative treatments. Patients must be made to understand that these therapies affect the chemical balance in their bodies just as prescription medications do. These therapeutic substances also have differing bioavailabilities, pharmacoki-netics, elimination times, allergenic properties, and side effects that must be measured and evaluated.

Physicians who sell vitamin and herbal products in their offices may be considered to be selling “drugs” for purposes of legal liability. We recommend that physicians who support or distribute

CAM remedies contact their malpractice carriers to determine whether their coverage will be affected. The American Medical Association (AMA) expects an increase in the threat of liability if there are economic variables in some CAM-related decisions made by the physician. Examples include selling herbal products to augment stagnant or declining incomes. The AMA gives scant guidance for CAM because “there is little evidence to confirm the safety or efficacy of most alternative therapies.”

Physicians at Exeter University in the United Kingdom are taking a course entitled “Familiarization in Complementary Medicine.” The course has been well received, and primary care physicians are indicating that they have gained useful information regarding complementary therapies. However, concerns have been voiced regarding poor communication with CAM practitioners, and doubts of competence have been reinforced by a lack of identifiable qualifications.
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Physicians must be aware of the possibility of “failure to warn” liability if they do not advise their patients of the untoward effects of some alternative remedies that they may be taking. This exposure may include therapies that the physician becomes aware of as well as therapies actually recommended by the prescriber. If the patient is seeing an alternative practitioner with a bad legal or medical record, the physician might be held liable for failing to warn the patient. However, physicians may also be held liable for withholding information about an alternative method that might be helpful to patients if that remedy has been found to be a useful treatment for a particular disease.

TRENDS IN THE U.S.

Cushman et al augmented the 1997JAMA study by surveying four focus groups of African-American and Hispanic women in New York City. This was a pilot study for an eventual nationwide survey of women of various ethnic backgrounds.

Few differences in primary health concerns emerged across demographic lines (ethnicity and household income). Herbal medicine was the most common remedy. Younger women expressed more reservations regarding alternative therapies than did older women, and they were skeptical about CAM practitioners. Older women in these groups often preferred CAM practitioners for a variety of reasons, such as payment terms, their use of methods that have been handed down from generation to generation, language differences, and other cultural issues. Survey participants judged the effectiveness of CAM treatments similarly to conventional ones in terms of assessment of how they feel and assessments of how they look to others. Most younger women studied relied on health assessment by regular doctors whether or not they used CAM.

A follow-up study in the Journal of American Medical Women’s Association¬†amplified this issue. This study, in conjunction with Latina Magazine, studied CAM use in Hispanic women. In this study, another important factor was raised. More than 60% of the subjects indicated that their physicians had never asked them if they were using CAM. Forty percent of the subjects indicated that they never voluntarily reported CAM use. Patients sometimes felt intimidated by their physicians and perceived a sense of disapproval with regard to their physician’s views on the use of CAM. As we can see, this is a problem, particularly when one considers drug-CAM interactions and the potential dangers of procedure-related adverse events.

CONCLUSION

A number of issues have been raised regarding the use of CAM in a variety of populations. In summary, the following items should be explored further:

  • educating traditional practitioners about CAM and related cultural issues
  • developing better evidence-based scientific evaluations of CAM modalities and individual therapies
  • learning more about adverse reactions between conventional therapeutic agents and CAM remedies
  • improving understanding among traditional practitioners of the prevalence of CAM use
  • improving CAM history-taking as a part of the conventional history and physical examination
  • developing a history-taking instrument that would effectively elicit complementary therapies during patient and family interviews with conventional practitioners
  • obtaining detailed CAM histories

It is clear that CAM usage poses a high level of responsibility for pharmacists. Pharmacists are best positioned to reduce the fear and reluctance on the part of patients to “confess” to their physicians that they are using CAM to augment their prescribed therapies because they are more likely to obtain the required information from their patients. Pharmacists are also best prepared to integrate this information into the patient’s history and to determine the effect of CAM therapy on the patient’s regimen of conventional medicines and other interventions.
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Surgeons, anesthesiologists, cardiologists, and gastroen-terologists are among those who utilize these pharmacist services, when available, to determine patient suitability for various procedures. Pharmacists can greatly enhance their value to the health care system by increasing their knowledge of CAM and by using the CAM monographs and databases that are available. A significant business opportunity exists for pharmacists who can integrate conventional and complementary patient care.