The need for a multidisciplinary, patient-centred approach.
THE NATURAL HEALTH PRODUCTS MOVEMENT IN HEALTH CARE
In 2004, a five-month-old baby arrived at a Toronto-area hospital for EEG testing.(1) Her visit to the lab ensued from an arduous battle between her father – a homeopathic practitioner who had taken her to a colleague for a remedy to control episodes that he had, correctly, diagnosed as seizures – and a neurologist who had admonished dad for his choice of treatment. The neurologist had told dad to relinquish the homeopathic strategy in favour of conventional antiepileptic drugs (AEDs), or the baby would not be allowed access to the hospital’s EEG service, or other testing.
As the remedy had reduced baby’s episodes in number – from several to one or two per day, a course similar to that seen with conventional AEDs – dad had persisted in his conviction to continue with it. Calling upon legislation which supports the right of a competent patient – or the patient’s representative – to choose alternative treatments (2) and the neurologist’s obligation to discuss all alternatives to conventional treatments and support the patient’s choice for them (3), dad had won access to testing – and subsequent monitoring – for his child, without having to accept treatment with conventional AEDs.
2004 was also the year that saw the initiation of the efforts, by Canada’s Natural Health Products Directorate (NHPD), to survey, for licensure, all natural health products (NHPs) being sold in Canada based on their safety and efficacy. The directorate was formed in response to the public’s growing tendency to turn to treatment alternatives, such as natural health products. Consumer surveys have since shown that people choose NHPs believing that they are as effective, less harmful and will produce fewer side-effects than conventional pharmaceuticals.(4)
The NHPD also strives to improve product labels in terms of their descriptions of ingredients, dosages, risks, etc. Its mandate is to ensure that those products which are permitted on the market are safe and that consumers have adequate label information to make decisions regarding their use. This mammoth undertaking is scheduled for completion in 2010. Despite the ongoing progress of the NHPD, many unlicensed products are still sold in Canada.
CHIROPRACTORS AS THE GATEWAY TO WELLNESS
As we have seen, there is ongoing controversy in medical circles, regarding the use of NHPs. For patients, this results either in unwarranted hesitation, or a full-scale plunge into their use, often unassisted and in the form of self-diagnosis and treatment. (5) Patients who do wish to consult with a professional over the use of NHPs are faced with confusing information regarding who the appro-priate practitioners are in this area. This quagmire, where the public is forced to figure out answers for themselves, leads to use of NHPs in a manner that is inefficacious, at best, or dangerous in unfortunate – if rare – cases. This is, clearly, contrary to the notion of patient-centred health care.
Chiropractors are often approached by patients with questions about, or requests for, NHPs and many DCs provide various supplements, etc., within the framework of their practices. As a professional group, chiropractors are properly trained, and magnificently positioned, to guide patients with health and wellness choices and, therefore, could be a valuable resource for direction regarding NHPs. However, given the profession’s overall commitment to substance-free practice, it
may, in fact, be against chiropractic’s fundamental grain to be advising patients toward remedies of any sort.
Furthermore, questions arise – from members of the profession itself – regarding whether a chiropractor has sufficient training in the prescribing and distribution of NHPs to be considered a primary source in this area. (6)
But, even if a chiropractor chooses against NHPs within his/her treatment paradigm – a choice that any practitioner retains – questions from, and health situations of, patients arise, obligating the DC to address the issue in a fair and patient-centred manner. To deny the value of NHPs, thereby sending a patient away to pursue them without knowl-
edgeable guidance, may not be prudent. In fact, as we have seen, legal and ethical considerations for practitioners in Canada – including those set by the Canadian Chiropractic Association – dic-tate that this course is not preferred. (7)
The solution, for chiropractors, involves a bifid strategy:
• The development of networks with practitioners of other disciplines – where training and experience are aligned with access to a growing body of evidence in favour of NHPs – who can guide patients in the safe, efficacious use of these substances, and
• ongoing education to increase general knowledge of natural health substances, particularly those that are pertinent to skeletal health.
SO, WHICH PRACTITIONERS SHOULD I NETWORK WITH?
NHPs may produce adverse effects if administered in inappropriate dosages and may be contraindicated if other substances are being taken. Only proper screening by a qualified professional can ensure that the patient receives the right treatment at the right dosage for his/her individual needs. When it comes to any substance, whether supplement or drug, a pharmacist appears be a good resource person to start with. But, is this the case with NHPs?
At the University of Toronto, Prof. Heather Boon, a pharmacy researcher and Complementary and Alternative Medicine (CAM) advocate, is currently investigating the role of pharmacists with respect to NPHs. Boon told Canadian Chiropractor: “The study asks the question, ‘should pharmacists be advising patients on NHPs or declare this area to be outside of their scope and look to delegate it to other licensed professionals?’” Boon emphasizes that, even if pharmacists retain NHPs within their scope of practice, they will continue to look to other practitioners as experts to whom patients should be triaged for specialized care. “It may be,” she continues, “that pharmacists will figure they have enough to deal with and will call upon licensed professionals, such as homeopaths or naturopaths, to be the primary advisors regarding these products.”
A problem arises when one tries to determine which NHP-competent professional – for example, naturo-paths, homeopaths, traditional Chinese medi-cine practitioners, etc. – is actually licensed, since professional regulation status for these disciplines varies from province to province. Although reference guides exist to help with this– see “A Q&A with Dr. Philip Waddington, ND” at ww.cndoctor.ca – the information changes as regulation legislation develops.
Medical doctors (MDs) are regulated in every province but most physicians are not versed in NHPs. Patients should, therefore, be reminded that MDs are under obligation to inform, when they are not the best source for advice in this – or any other – area, and to refer out to other professionals (8) who might be better suited to advise on, and prescribe, NHPs.
When referral is indicated, to whom, then, should the chiropractor send a patient for NHPs?
Dr. Scott Wilson, DC, owner of PhysiomedHealth Inc. multidisciplinary wellness clinics in Toronto says, “I like to align myself with naturopaths and other professionals, whom I come to know and trust, within the geographical area of each of my clinics. That way, when patients want advice on NHPs, I have someone that I can send them to so they’ll get the best advice.”
Gabriel Braun is a registered homeopath in Ontario where, in June 2007, Bill 171 granted homeopathic medicine the status of a regulated health profession. (9) Braun states that supplements, and other NHPs, are indicated for one of three reasons: as a preventive measure, for maintenance of good health or in situations where a particular pathological state warrants their use. He cautions that decisions regarding prescribing NHPs – including the dosages that are given – must be rooted in training and clinical experience but supported by relevant patient information that is collected through intake forms especially suited for this purpose.
“You have to ask the right ques-tions,” Braun notes, “and come at [the patient]… in context. Practitioners’ skills are invaluable to carefully establish the needs of the patient… Appropriate therapy must be followed and all potential complications avoided.”
From a national or provincial standpoint, there is no official policy, or legislation, regarding chiropractors offering NHPs through their practice. However, within their Codes of Ethics and Conducts, various provincial chiropractic associations actually delineate restrictions regarding NHPs and chiropractic clinics. (6)
Dr. Wilson agrees that chiropractors can be sources for some NHPs but cautions: “If you’re going to sell NHPs in your office, you have to make them a standard component of care and know how to prescribe them for each patient. And, when you feel it is indicated, do not hesitate to refer out.”
EASY-ACCESS INFORMATION SOURCES FOR NHPs
Dr. Wilson also feels that all chiropractors should maintain an NHP information resource, written or on-line, that they are familiar with and trust, for patients who ask about them.
For chiropractors who may be researching specific NHPs, there are several sources available. The libraries of many chiropractic colleges – CMCC included – offer online NHP references that are available through membership. Also, the NHP industry itself can become a point of reference as manufacturers of NHPs are often associated with practitioners, including chiropractors, whose role it is to advise on the use of these products in various situations. Finally, the Canadian Interdisciplinary Network for Complementary and Alternative Medicine Research – www.incamresearch.ca – contains an NHP compendium.
THE CALL FOR PATIENT-CENTRED COLLABORATION
In our national milieu, then, we have the following situation: on a retail level, NHPs are still “The Wild West” (10), regulation of practitioners is a work in progress and mixed signals, regarding NHPs, are the only signals reaching Canadian consumers at this time.
It becomes clear that, now, more than ever, patients should not be left on their own to pick supplements and remedies off the shelves, like so much candy, but should be guided in their use. Chiropractors are equipped with the knowledge, and resources, to offer direction to patients, in this area, and are called upon, through legal and ethical frameworks to do so, when indicated.
An open, multidisciplinary ap-proach will foster an atmosphere for gaining patients’ trust and will allow chiropractors to emerge as practitioners who are also a resource for information within a patient-centred health-care network.
Without hesitation, Braun admits, “I have my limitations and, hence, I refer patients to other practitioners. I pray that the time will come when we can all work together.”
Dr. Wilson echoes this sentiment but offers it from a chiropractor’s perspective, “If you do not feel comfortable [prescribing, selling or advising on NHPs], then your best bet is to refer the patient to another qualified practitioner.”•
1. Case illustration – author’s personal experience.
2. Practitioner-Related Legal and Ethical Issues, in Health Law and Ethics in Relation to the Use of Complementary and Alternative Health Care and Natural Health Products: An Invitational Roundtable (December 1-2, 2001), Health Canada website, http://www.hc-sc.gc.ca/dhp-mps/pubs/complement/hle-des_12-01/hle-des_12-01_4_e.html.
3. Health Care Consent Act, 1996, S.O. 1996, c. 2, Sch. A, Section 11 (1,2,3)
4. Baseline Natural Health Products Survey Among Consumers, March 2005. Ipsos-Reid Survey available online through Health Canada, Section 1:
5. Ibid, Section 2.
6. Page, S.A. An audit of health products and services marketed on chiropractic websites in Alberta and consideration of these practices in the context of chiropractic codes of conduct and ethics. Journal of the Canadian Chiropractic Association, Vol. 51, No. 2, June 2007, 91-98.
7. Informed Consent in Clinical Guidelines for Chiropractic Practice in Canada, 1996., www.ccachiro.org/client/ cca/cca.nsf/web/Glenerin%20Guidelines.
8. CMA Code of Ethics (Update 2004), CMA Policy, Canadian Medical Association, http://policybase.cma.ca/PolicyPDF/PD04-06.pdf.
9. Bill 171, 2007, An Act to improve health systems by amending or repealing various enactments and enacting certain Acts, website of the legislative assembly of Ontario, www.ontla.on.ca/web/bills/bills_ detail.do?locale=en&BillID=519.
10. Robert McMaster, consumer advocate and NHP vendor in the province of Ontario – communication with author.
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