Tips for doctors and patients
It is an exam room like any other—gray-green walls, fluorescent lighting, thin white paper spread on the exam table. But on this exam table sits a covered bowl decorated with dragons chasing each other’s tails.
The doctor, stethoscope around her neck, observes as the patient opens the container. Inside is a dark brown Jello-like blob. The patient tells the doctor that he obtained it from a Chinese herbalist; the physician pokes at it gingerly with her finger.
“Doesn’t look very appetizing,” she offers. The patient, an elderly gentleman suffering from irritable bowel syndrome, ignores her.
“Will it help me?” he asks plaintively. And, like many allopathic physicians across the country, she can only reply: “I have no idea.” But she realizes that she must learn, because being asked about herbal medicine is not a rare event in her clinic.
And such queries are likely to become more common. According to a survey by Prevention magazine, about one-third of all adults living in the United States use herbal remedies, creating a $3.2 billion market for botanicals. And the number of herbal remedy users is growing by 15 percent annually.
Patients’ reluctance to talk about their use of herbal remedies may be linked to the decreasing but ever-present perception that herbal medicines are something akin to “snake oil.” It may also be tied to a belief that medical doctors don’t know much about herbs, which, unfortunately, is often true. Western medical training ignores herbal remedies (although that’s changing). And, because of busy schedules and mounds of medical reports to read, doctors often don’t have time to study them.
Yet like the doctor above, more and more physicians are finding that they must learn. But how? Based on my experience, the question needs answering. As a family physician practicing in Albuquerque, New Mexico, I found myself constantly trying to answer patients’ questions about herbal remedies. I had to scramble for answers. Because of my frustration, I decided to seek out other health professionals for advice. This is what I’ve found. It’s helped me; whether you’re a doctor or a patient, perhaps it will help you.
When Tieraona Low Dog, an herbalist and medical doctor who practices in New Mexico, was a medical student, she interviewed patients of a family physician whose clientele was primarily Hispanic. She found that forty-five of fifty patients were simultaneously using herbs and visiting the medical clinic for conventional medical care.
“Almost without exception, they felt that herbs were safer and cheaper and they wished doctors knew more about herbs so they could recommend which ones to use,” Dr. Low Dog reports. Patients sought the medical doctor’s recommendations because they wanted assurance that the herbs and conventional medicines wouldn’t clash. But, despite this strong desire for information, “they were afraid to say anything to the doctor because they were afraid he might be mad at them . . . and they didn’t think he knew anything about herbs,” Dr. Low Dog writes.
Further, many of the Hispanic patients she talked with said they felt that using herbs was an intimate part of their heritage. If the conventional medical doctor dismissed the remedies, they told Dr. Low Dog, they would feel as if their culture had been rejected.
Using herbal remedies may be tied to an individual’s heritage, but it may also be tied to a desire to save money. Dr. Craig Ottenstein of Albuquerque is convinced that bringing herbal alternatives into the mainstream would be a financial boon to many. Dr. Ottenstein has worked with one HMO to help incorporate alternative medicine into its health plan.
“There are so many studies coming out suggesting that substituting herbal products for conventional medicines is cost-effective [as well as] clinically effective,” Dr. Ottenstein says. For example, Claritin, an antihistamine, is on HMO lists of high-cost drugs. “If some of these patients could get by on stinging nettle for their seasonal allergies,” Dr. Ottenstein says, “it would save a great deal of money.”
Although Western medicine started out as herbal medicine (the United States Pharmacopoeia was the “Bible” of medical doctors during the 1800s), the scenario is quite different today. Current medical research attempts to define diseases by molecular mechanisms, then tries to fight the disease with drugs developed to target the illness. This “silver bullet” approach demands purity and standardization of pharmaceuticals. On the other hand, herbs hold many active chemicals—not a single silver bullet, but a plethora of potential activities—and standardization and purity of product in the case of herbal remedies is far from an exact science, much to many doctors’ dismay. This dismay may lead to distrust and, ultimately, a dismissal of herbs’ potential to heal.
Despite such hurdles, some health-care providers have successfully bridged both worlds. David Schwindt, a medical doctor practicing in Albuquerque, has a deep respect for herbs and prescribes them regularly. He says that combining his Western training with herbal knowledge allows him to give his patients ideal care—an integrated approach. When one medical approach fails, he says, the other steps in to fill the gaps.
“I see people who come in with a Western diagnosis, but are having toxic side effects from their medicines, so I help them titrate down the Western pharmaceutical with herbs . . . with a Western understanding of how the herb works,” Dr. Schwindt says.
He has prescribed the nonaddictive herb valerian, for example, to wean people off their benzodiazepines and dandelion to substitute for potassium-wasting diuretics.
Perhaps because Dr. Schwindt is trained in Western medicine, he evaluates herbal remedies by their active ingredients, rather than relying on testimonials and observations of an herb’s effectiveness gathered over the years, as some herbalists do.
“Many herbalists don’t know a lot about Western medicine, and that is a shortcoming,” he says. “There is an advantage to knowing how both work.”
Sometimes the fact that an herb doesn’t fit the silver-bullet model poses some problems, he says. For example, laboratory research may tell him that an herb contains a specific compound, yet it may not show how that compound works with other groups of compounds to produce a different effect in a patient.
Dr. Low Dog was raised in a Native American/Anglo family where herbs were just part of life, she says. She started out as an herbalist and midwife with a very large practice, but soon realized that she couldn’t help people with serious health problems. Frustrated by the helplessness she felt before very sick children, very sick elderly people, and people dying of cancer, she decided to go to medical school. Today she prescribes herbs about 80 percent of the time, she says, but she also knows when to call upon Western pharmaceuticals.
“I certainly am not going to take a child who has a 103° temperature and a rip-roaring otitis media [ear infection], and looks acutely ill, and treat him with echinacea,” Dr. Low Dog says. “I’ll treat him with antibiotics.” She notes, though, that despite her from-birth training in the use of herbal remedies, there is a problem—the current “big business” of herbs has produced remedies that are very different from those her grandfather knew.
“People were generally using teas, things that grew in their garden and around their homes that their grandmothers and great-grandmothers had used,” she says. “[Now] we are using things that have been imported from China, India, Europe, all over the United States with very poor quality control. . . . My grandfather used herbs, but he used what grew around him, what had been used for the last 200 years. He would be overwhelmed with all of this.
“As herbalists,” she continues, “if we are going to use herbs to treat conditions and expand our materia medica to the far ranges of the globe, we are going to have to take on that responsibility—to make sure the medicine we use is good.”
Scott Shannon, M.D., is a child psychiatrist and holistic practitioner in Fort Collins, Colorado, and a member of the board of the American Holistic Medical Association. He became interested in phytomedicine years ago, after he met Andrew Weil at the University of Arizona in Tucson. He’s enthusiastic about the potential of herbs to heal.
“The safety history of herbs has been so extraordinary over the last ten years of intensive use . . . especially when compared with the side effects of conventional medicines,” Dr. Shannon says.
But, like Drs. Schwindt and Low Dog, he doesn’t favor herbs over Western drugs or vice-versa. He uses them to complement one another. For example, as a psychiatrist, he finds himself prescribing the newly popular St.-John’s-wort to quell mild depression and Ginkgo biloba to help improve blood flow to the brain (to help the antidepressants work more efficiently), but he never suggests that his very mentally ill patients use St.-John’s-wort.
“Mood disorders are on a spectrum,” he explains. “The mild to moderately ill do well with a holistic approach. But the very ill do often need the conventional medicine.”
Awareness is a two-way street. Medical herbalist Amanda McQuade Crawford, a founder of the National College of Phytotherapy in New Mexico, says that Western herbalists must be sensitive to the fact that their patients most likely have been brought up in the Western medical tradition, and an awareness and acceptance of this is crucial to effective treatment.
“It is important that the modern herbalist who works clinically, especially in the Western paradigm, understands that we are in the Western world and that many of our clients are on standard medications,” she says. “Some of them want us to help them get off their medications because of side effects or potential long-term problems. Some are requesting that they reduce their doses [of the conventional pharmaceutical] or get off them. It is important for us to know what herbs would be appropriate and what potential interactions there are.”
McQuade Crawford says she counsels her patients to tell their other health-care providers about their herbal plan, including its therapeutic aims, the herbs she has prescribed, and their dosage.
Dr. Lin Bin is a doctor of Oriental medicine practicing in New Mexico and was a medical doctor in China. Her knowledge of both types of medicine has given her an awareness of the lack of communication between the providers of different health-care plans.
“We [alternative practitioners] aren’t quite sure what medicines the patients are getting and the Western doctors aren’t sure about what herbs we are prescribing,” she says. But, in combining therapies, “one needs to keep in mind the basic constitution of the patient. A patient with asthma and hypertension on ephedra could get worsening blood pressure and increased central nervous activity leading to insomnia.”
She also discourages self-medication, saying that patients need to consult a qualified health-care practitioner to ensure that they don’t do themselves more harm than good. For example, while ginseng is a popular herbal remedy, it isn’t good for everyone, she notes. One of her patients used ginseng along with other herbs to try to correct biweekly menstrual periods. Instead, Bin says, the patient bled irregularly for five months, then finally sought professional care.
Back in the exam room, the doctor continues to poke at the brown blob in the dragon-decorated bowl. The patient gives the doctor a piece of paper with a list of the five ingredients in the formula. She doesn’t recognize tortoise, honeysuckle flower, loosestrife, or tickclover, but she does know licorice; from medical school, she remembers that excessive ingestion of this herb is a bad idea for some people.
“Well, it might raise your blood pressure, but maybe not,” she tells her patient. “I understand that in formulas, some of the side effects are balanced out, so it is possible that these other herbs might counteract that effect. Anyhow, the dose of licorice might be low enough to not cause problems.” Frankly, she has more questions than answers—and her patient feels that if he takes the concoction, he’s taking a risk.
Because the doctor is hesitant about recommending that her patient try the formula, together they decide on a plan of attack. He will receive regular blood pressure checks while using the herbal preparation to make sure there is no change in his blood pressure. Meanwhile, she will contact the Chinese herbalist who put together the formula so that she can learn more about the other ingredients and so that she and the herbalist can work together to help heal this patient.
If the herbal remedy helps relieve his irritable bowel syndrome, it will be a relief for her, too. Like many diseases, his illness has no clearly defined cause in Western medicine’s eyes, so there is no silver bullet to quell the alternating bloating and abdominal discomfort that he suffers. A lack of a silver bullet is not rare in Western medicine (think of the common cold), but it brings up a point that many of those I spoke to make: Western medicine, in many cases, is begging for new answers. Integrative care—drawing upon the best of both worlds—may be just what the doctor should order.
Sylvia Wittels, M.D., received her degree from the University of Arizona Medical School. She practices in Albuquerque, New Mexico, where, she says, she always asks her patients whether they’re using medicinal herbs before she diagnoses and prescribes.
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