Taking an Integrated History: Asking About Traditional and Complementary Therapies

Earlier articles in this library explained why Integrated Functional Medicine asks about every form of care a patient uses. This article is about how. Asking well is a skill, and the difference between a practitioner who asks “Are you taking anything else?” and one who asks specific, respectful questions can be the difference between an incomplete picture and a complete one, and sometimes between safety and harm.

The disclosure gap

Surveys in several countries have found that a substantial proportion of patients who use herbs, supplements or complementary therapies do not tell their doctors. The most common reasons are that the clinician did not ask, the patient did not think it was relevant, or the patient expected disapproval. Patients using traditional medicine from their own culture may also assume that clinicians trained in modern medicine will not understand or respect it.

The disclosure gap is largely a problem of how, and whether, the question is asked. That makes it correctable.

How to ask

Normalise

Signalling that such care is common and that the question is routine reduces fear of judgement. For example: “Many people use supplements, herbal remedies or other therapies alongside their regular medicines. It helps me to know about all of them so I can make sure everything works well together.”

Be specific

General questions miss much. Specific prompts help patients remember:

• vitamins, minerals and other supplements;
• herbal teas, tonics and preparations;
• traditional medicines, such as Ayurvedic, Chinese, Unani, Siddha, homeopathic or other remedies;
• products bought online, at a health shop or from overseas, or sent by family;
• sports, weight loss, energy and muscle building products;
• creams, oils and cosmetics used on the skin, including skin lightening products;
• special diets, fasting or detox programmes;
• practitioners: physiotherapists, chiropractors, osteopaths, acupuncturists, naturopaths, homeopaths, traditional practitioners, counsellors, coaches.

Ask about practitioners and practices, not just products

“Besides me and your doctor, who else is helping you with your health?” often uncovers care that product questions miss.

Show curiosity rather than judgement

Asking what the patient hopes a product or therapy will do, and whether it seems to help, conveys interest and provides useful information about their beliefs and goals.

Ask again

Patients start and stop products frequently. Asking at every visit, particularly when new symptoms appear or medicines change, keeps the inventory current.

The brown bag review

Asking patients to bring every product they take, prescribed and non prescribed, in a bag to the consultation is one of the most effective ways to obtain an accurate inventory. Photographs of labels are a practical alternative. Seeing the actual product reveals ingredients, doses and manufacturers that patients may not remember, and sometimes duplicates or combinations they were unaware of.

What to record

For practitioners, record the type, training and registration where relevant, the treatments provided and how often, and whether the patient is willing for you to communicate with them.

Identifying high risk situations

Once the inventory is complete, certain combinations and situations warrant particular attention:

• products used instead of necessary conventional treatment;
• high risk medicines, such as anticoagulants, immunosuppressants, antiepileptics, antiretrovirals, chemotherapy, lithium and insulin;
• pregnancy and breastfeeding;
• children and frail older adults, including products given by carers;
• upcoming surgery;
• products from unregulated sources, traditional herbo mineral preparations and skin lightening creams;
• unexplained liver or kidney test abnormalities, anaemia or new symptoms.

Cultural humility and language

For many patients, traditional medicine is part of family, culture or faith. Cultural humility, an attitude of openness and willingness to learn rather than an assumption of expertise, helps. Using the patient’s own terms for their care, asking them to explain unfamiliar practices, and working with professional interpreters rather than relying on family members for sensitive discussions all improve the quality of the history.

Using the information

The integrated history is not an end in itself. Its purpose is to allow the practitioner to evaluate each form of care, identify risks, build on what helps and coordinate with other practitioners. The inventory feeds directly into the timeline, where start dates may align with symptom changes, and into the matrix, where products and therapies can be mapped to the systems they target.

An illustrative consultation

A 63 year old man with type 2 diabetes and hypertension attends for a review. When asked generally, he says he takes only his prescribed medicines. The practitioner then explains why she asks about everything and offers specific prompts. He mentions a bitter gourd juice his wife prepares daily, a herbal powder from a traditional practitioner for his blood sugar, a joint oil he massages into his knees, and weekly visits to a practitioner for back pain. He has been having occasional shaky episodes before lunch.

She records each item in detail, notes that 2 products may add to the glucose lowering effect of his medicines, and with his permission contacts his physician, who adjusts his treatment. The joint oil is low risk. His back pain practitioner is added to his care team list. The shaky episodes stop. 5 minutes of well structured questions made his care visible, and safer.

Asking is the intervention

Much of the safety and coherence of integrated care depends on a simple act done well: asking about every form of care, specifically and respectfully. It is the practical foundation of Integrated Functional Medicine.