Don’t ask, don’t tell: A hazard for both patients and their caregivers

Always ask about supplement, herb use

The military has a "don’t-ask, don’t-tell" policy, but if you take this into your medical practice, you may be setting yourself — and your patient — up for a big headache.

A growing body of scientific and anecdotal evidence shows harmful interactions between some herbs and supplements and pharmaceuticals. Medical and legal experts advise health care professionals always to ask their patients about the use of herbs, supplements, and other complementary and alternative medicine (CAM) therapies as part of a routine patient history.

The failure to do so could result in serious complications for your patient and potentially expose you to malpractice liability as well, says Michael Cohen, JD, lecturer on medicine at Beth Israel Deaconess Hospital in Boston. Cohen is the author of Complementary and Alternative Medicine: Legal Boundaries & Regulatory Perspec-tives (Baltimore: Johns Hopkins Press; 1998).

"Ignorance creates risk," says Cohen. Not only should health care professionals comply with all federal and state laws (which may vary), if a patient is injured and a lawsuit ensues, the failure to ask about herb and supplement use could be considered "below the standard of care." That is a legal term that means the patient was not given proper care according to the medical standards of the day.

"A good conversation with the patient, noted on the chart, potentially reduces your liability if a patient fails to tell you about herb or supplement use and then has an interaction," says Cohen.

Those good, open conversations with patients are sometimes difficult, and many patients fear being ridiculed, so they are reluctant to tell their doctors, nurses, or dietitians about their use of herbs or supplements.

The key to developing the trust of your patients is to be informed, says Manchester, CT, cardiologist Stephen Sinatra, MD, FACC, FACN, assistant clinical professor of medicine at the University of Connecticut School of Medicine.

Americans spent an estimated $15.7 billion on nutritional supplements in 2000. At least one-third of Americans report using at least one form of alternative medicine, and one-third of those consult CAM providers, with more than half of them paying entirely out of pocket for their services. Surveys show the most common disease conditions addressed by CAM therapies are back problems, anxiety, headaches, chronic pain, and cancer or tumors. Although 83% reported being under the treatment of a conventional physician, 72% who used CAM therapies did not inform their doctors. In addition, 18.1% of all prescription drug users, 15 million people, reported in 1997 that they took prescription medications concurrently with herbal remedies and/or high-dose vitamins.1-3

"Clearly, the modern physician needs to listen to the voice of the public and at least try to become acquainted with alternative methods as part of continuing medical education," Sinatra says. "The modern physician has got to jump into the arena just now and delve into the information available about vitamins and herbs and supplements," he adds.

It almost can be assumed that patients are using some type of CAM therapy, since more than 80% of Americans have used some sort of CAM therapy in the past year — most of them vitamins, herbs, and supplements. That makes it incumbent for health care professionals to learn about all types of CAM therapies and not to dismiss any of them as "knee-jerk reactions," says Sinatra. "Any health care professional who fails to ask all the questions is at risk, and so is the patient."

That means patient information and history forms should not stop with questions about medications a patient is using; they should specifically mention herbs, vitamins, and supplements. Many patients swear by the efficacy of the herbs or supplements they may be taking, but paradoxically they also view them as "natural" and therefore not worthy of mention to a health care professional.

Beware of interactions

Numerous interactions have been noted, particularly between herbs and pharmaceuticals. For example, St. John’s wort has been shown to interact negatively with selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, some blood pressure medications, some antivirals, digoxin, loperamide, some birth control medications, immunosuppressive drugs, and warfarin.

Ginkgo biloba has been associated with increased blood clotting time, may interfere with cyclosporine, and may raise blood pressure. Garlic is also an anticoagulant, so it may interfere with the actions of warfarin and other anticoagulants.

"You need to assume your patients are using some of these therapies, and they may be giving them great benefits. You need to explain to them that, like any other medication, they could be harmful if combined improperly with other medications," Sinatra says.

Leaving your personal biases outside the door is the first step to developing a rapport with your patients that will bring out all the information you need to make a professional diagnosis and write a prescription, says New York City physician James Dillard, MD, DC, CAc, assistant clinical professor of medicine at the Columbia University College of Physicians and Surgeons. "It needs to be simple and conversational —and most importantly, nonjudgmental," he says.

"You don’t need to go over the top. Be offhand and relaxed. Take a generally professional attitude, but be warm and friendly. This question shouldn’t be any different than any other question you’d ask a patient," Dillard explains.

It’s all part of developing that relationship of trust that should be part of any physician-patient, nurse-patient, or dietitian-patient relationship. "You’d ask any patient if he has pain or a family history. This doesn’t have to be a big deal, but you just have to do it," says Dillard. "If you don’t, you’re a bad doctor," he adds.

The bottom line for all three experts interviewed for this article: Always ask.

[For more information, contact:

Michael Cohen, JD, Beth Israel Deaconess Hospital, Boston. Telephone: (617) 267-0723. Web: Integrative Medical Arts Group Inc., Beaverton, OR. Integrated BodyMind Information System and The IBIS Guide to Drug-Herb and Drug-Nutrient Interactions. Telephone: (503) 641-6541. Web:]


1. Eisenberg DM, et al. Trends in alternative medicine use in the United States 1990-1997: Results of a follow-up national survey. JAMA 1998; 280:1,569-1,575.

2. Eisenberg, DM. Advising patients who seek alternative medical therapies. Ann Intern Med 1997; 127:61-69.

3. Eisenberg DM, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993; 328:246-252.