Dr. George and colleagues in the manuscript, Beliefs about Asthma and Complementary and Alternative Medicine (CAM) in Low-Income Inner City African American Adults, provide an intriguing and challenging mirror for conventional practitioners into the real world experience of poor black women with chronic asthma.1 Several key themes emerge from this report, and many more questions.
Increasingly taught in medical schools is the need for cultural competency in treating patients. Through a structured 1-hour interview, the researchers delve into these patients' beliefs as to why they have asthma and what they believe will help. This time intensive knowledge acquisition is essential to partner with any patient with chronic illness, yet so difficult to obtain. Can we completely know if conventional medical care is effective, unless we have confidence that the patient has fully divulged what they are “really” doing for their illness, compliance, and alternatives? I found myself curious as to how much of the information obtained by these interviews was new to the treating medical practitioner. An important piece of this research would have been to reveal how much of the gleaned knowledge was a “surprise” in the health care record (again perhaps documenting patients' reluctance to disclose CAM practices).2
The essential importance of full disclosure by patients to their health care providers, and provider's obligation to pursue such information from patients, is further highlighted in this study by 2 specific examples. Three different potential safety risks are identified (oral camphor, Echinacea, and high-dose cough lozenges) as well as potential delay of treatment in life threatening episodes owing to beliefs around prayer or CAM. Trust as a theme in this quantitative analysis is seen as critical to compliance by patients. It is reported, because of repeated comments, that these patients did put high trust in their health care providers. Yet, if trust were optimal, compliance of inhaled corticosteroids might be anticipated to be higher than documented in this analysis. A fascinating reflection on the link between trust in the government and trust in conventional medicine is implied in regards to a flu shot. Particularly in this population, but perhaps a broader belief, is the notion that conventional medicine is a “product” of government, and CAM is not. Rather, CAM is a product of culture. The implications of the belief of conventional medicine as an arm of government, particularly in an administration struggling for public support, are quite far reaching.
A third theme emphasized are the reasons why patients use CAM. The predominant usage of over-the-counter botanicals and mind-body techniques observed in this study, rather than utilizing CAM professionals, is likely related to the socioeconomic group studied and lack of discretionary funds for treatments such as acupuncture. Alternative to the author's conclusion, the frequency of CAM usage in this population may be higher than documented in previous reports owing to the fact these patients all have a severe form of a chronic illness, unlike the random public surveys reported in the past. Furthermore, conventional medicine defines a paradigm of asthma as “incurable,” which is most difficult to accept for a young person, faced with years of daily medications and their real or potential side effects and expense. Self-administered CAM gives such a patient a sense of control over their illness, and empowerment that they can help themselves, rather than simply following conventional medicine's standard advice. There is no confidence that conventional medical practitioners will recommend an “integrative” approach including CAM if conventional treatments are not meeting shared goals, i.e., does your pulmonologist recommend prayer and sublingual lobelia for acute asthma exacerbations in addition to your prescription medications? Thus, the patients feel they must rely on self-treatment or the advice and support of friends and families for a complete treatment plan. It is likely there are gender differences in these beliefs, social support and conclusions as documented in CAM usage through previous surveys.3 Inclusion criteria stated that prescription coverage was required. What interview results might be obtained in a similarly chronically ill population without prescription coverage?
The paper limits discussion as to the potential benefits for the patients of their beliefs. What do we understand about the therapeutic potential of believing something is helpful for a chronic illness, such as laying on the linoleum floor or having your mother's church friends pray for you or lay hands on you and call upon the Divine? Is there a therapeutic, harmful or placebo effect in the use of onion potions for asthma?4,5 What is the benefit on course of illness when a patient feels hope for a cure versus anticipating the illness will negatively impact their quality of life forever? How essential is it for patients to feel control over their therapeutic decisions, or at least feel it is shared decision making between their health care provider and their beliefs? Dr. George's thoughtful discussion forces us to ponder such questions when treating the ever-growing numbers of chronically ill patients, particularly those that feel vulnerable in society in general.
Current medical doctors define “conventional medicine” and “evidence-based medicine” as close synonyms in contrast with CAM. The public we serve defines “medicine” in much broader terms based on their beliefs, financial options, and health care access. Linked with the availability of medical information, plus the trust and access issues raised earlier, the past decade's emphasis on scientific support and methods in determining effective medical practices has not appeared to narrow the gap in how our public determines effective healthcare. The more we can strive to understand each patient's definition of “medicine” and not assume they agree with our current view, the greater our ability to improve his or her health condition. The key to cultural competency includes our ability to understand the patients' beliefs, as well as our knowledge of our own strong beliefs (i.e., government does not control medicine?), and thus the chasm that may lie between these 2 worldviews impacting communication, compliance, disclosure, and therapeutic results.
Each generation of physicians looks back at the prior generations and realizes how little they knew compared to the present body of scientific medical knowledge. Examples such as “what causes a myocardial infarction?” provide proof of a medical condition we could clearly explain and define 25 years ago in medical school and now seems quite perplexing. The next generation will be no different, respecting the leaps made by scientific inquiry of great minds as well as how silly some of the historical concepts now appear. What do we really know about causality of asthma? Is there a mechanism for a mind–body connection or “stress” in asthma exacerbations? What will the next generation of physicians come to understand about triggers and controls of inflammation and the immune system? Ultimately this report again impresses on us as physicians that particularly in the care of chronically ill patients, when we cannot offer a cure, we must be ever humble and accept that “we do not know what we do not know,” as frightening as it is to face patients with that acceptance. Our scientific knowledge with an inquisitive and open manner will lead us to the most effective therapeutics, particularly in a health financing system that will allow us the time to know our patients.