Boston, June 2 -- Some patients who use alternative medicine after treatment for breast cancer are having more mental distress than those who do not turn to alternative therapies, According to an article in the New England Journal of Medicine. Seventy-percent of the women in the study had let their doctor know that they had turned to some form of alternative medicine. In an editorial, Dr. Jimmie C. Holland from the Memorial Sloan-Kettering Cancer Center in New York, notes that the Boston findings are indeed a sign that women are turning to alternative medicine therapies "to alleviate their distress." "These results contrast starkly with the widely held image of the woman who seeks help from alternative medicine as self-assertive, psychologically strong, and well-adjusted," she notes. Holland said that this study "exposed a fault line in our medical care system." She agrees that doctors "should ask routinely about the use of alternative medical treatments," not only because their use might complicate conventional cancer therapy, but also because "the use of such treatments may identify distressed patients.
[New Engl J Med 1999;340:1733-39, 1758-9]
Health food stores are bad places to ask for medical advice, according to a survey by a British consumer organization. Using a scripted set of health concerns, researchers visited 30 health food stores, 25 of which gave them misleading or inaccurate advice. In some cases, store employees recommended products that would have been dangerous for real shoppers. A news item from The Times of London describes the recent survey. Many products sold in health food stores are untested for safety or effectiveness. For example, the University of Texas Southwestern Medical Center at Dallas tried to verify claims of an oil called MCT which many health food stores offer as an alternative to olive or canola oils. Although MCT was supposed to lower cholesterol, the researchers found that cholesterol increased in volunteers who used the oil. U.S. consumers are on their own when it comes to dietary supplements and remedies from health food stores. Congress revoked the authority of the U.S. Food and Drug Administration to police supplements and "natural" remedies for safety and effectiveness. To find out if such products might worsen a medical condition or interact with medications, talk to a doctor or pharmacist, not the health food store clerk.
[By Jeff Johnson in HealthScout.com with permission]
Beijung (July 20) Xinhua-- China will hold a nationwide qualifications test for medical practitioners next year. Wu Mingjiang, an official with the Ministry of Public Health, said that this test is a measure for improving the overall level of doctors, and safeguarding patients. "The Law of the People's Republic of China on Medical Practitioners" implemented this May said that only those who pass the qualifications test and are registered have the right to practice medicine. The latest regulation issued by the Ministry of Public Health states that both medical practitioners and assistant medical practitioners will be tested. The test will be divided into four categories: clinical practice, Chinese medicine, stomatology and public health. They will also be both written and practical. Wu said that his ministry will complete the preparation work for the test by the end of this year. Those who pass the test will be awarded certificates as medical practitioners, which will become one of the two necessary certificates for people practicing medicine in China, the other one being a license. The ministry will set up a test committee, with Minister Zhang Wenkang as its director. [Copyright 1999, Comtex]
An Editorial in the AMA News (8/2/99) entitled "Room to wiggle" is how one AMA alternate delegate described the AMA's new policy on physician sales of health-related products. Then again, as the Council on Ethical and Judicial Affairs report and recommendations strongly suggest, what may be best is to think twice before wiggling at all. At issue is the final category of products to be addressed by the AMA in the context of physician office sales. CEJA has articulated policy on doctors' sale of prescription drugs (discouraging it) and on nonhealth-related goods (a ban, save for inexpensive items to support community organizations -- candy bars to help a school sports team, for example). The sale of nonprescription health-related goods -- often vitamins, dietary supplements and skin creams -- presents special concerns. Claims of effectiveness often come from manufacturers and so may be overly optimistic. Also, traditional product safeguards may not apply to these items. Dietary supplements, for example, aren't required to have an FDA imprimatur. Meanwhile, these sales carry the same inherent and considerable risk of conflict of interest that taint the other categories -- more, most likely, than with nonhealth-related items. A patient may find it easier to resist an offer to buy soap flakes at the doctor's office than to say no when a doctor suggests a course of action for good health, then endorses a specific product to achieve it and just so happens to have it available for sale at the reception desk. Add to that the trust and reliance that is a normal part of the patient-physician relationship and the potential for straining that relationship is obvious. This even though there is every reason to believe that the overwhelming number of physicians involved will be scrupulously honest. The doctors who do sell these items contend that they are providing a convenient patient service, that this is how to get what they believe are the best products into patient hands. Many also frankly say that they need the money at a time when the screws are being put to physician income. By that view, those physicians who would block such sales are ignoring the realities of practice today, not only building a castle in the air but expecting their colleagues to live there. The contentiousness of the situation is reflected in the close balloting on the AMA house floor: The CEJA recommendations passed by a margin of only six votes. The recommendations themselves were scaled back somewhat from a more comprehensive ban proposed last year. Bowing to physician concerns that some leeway was needed, the recommendations are not absolute, although they do establish some basic requirements to lessen the potential for problems. One is that the products should have a real scientific basis for claims of effectiveness, such as peer-reviewed research -- not manufacturer hype. Another is that physicians are told they should not get involved as exclusive distributors. CEJA's report points out that distributorships exclusively through physician offices create a monopoly and a captive patient consumer population. They put the patient in the position of "purchase the product from [the] physician or forgo the recommended treatment." CEJA recommends that physicians should encourage companies offering exclusive distributorship deals to make their products more accessible (and, in a corollary of sorts, CEJA tells doctors that products that have the same medical benefit and are generally available from drug and health food stores should not be sold at physician offices except under certain circumstances). Once a product clears these hurdles, the recommendations address two scenarios in which such goods might appear for sale. If a physician wants to make a health-related product available as a patient service, the doctor can sell it at cost, or provide it free, and thereby remove the potential conflict of interest. But in situations where a physician feels it is necessary to sell at a profit, then that doctor should clearly and meaningfully disclose the financial relationship with the manufacturer or supplier. How many physicians will try to turn the modest wiggle the report appears to allow into a full-blown rumba? Only time will tell, although CEJA has already started receiving requests for clarification of the policy. But if in this case the letter of the recommendations is unclear to some, the spirit seems very clear indeed.
NCAHF Comment. Physicians who think it is ethical to sell health products to patients should examine the American Chiro-practic Association's official "Therapeutica" pillow at amerchiro.org/hot_topics/therapeutica.html, "...not your standard feather or cervical pillow." But one "...designed and tested by doctors of chiropractic to allow for proper spinal alignment during sleep and to achieve a unique look and feel." Retail price: $60 (cost to chiros: $28.80 less 10% for five or more). Is this what MDs want?
[This text is preliminary to a longer paper in preparation on this topic. I would appreciate any comments, suggestions, corrections or criticisms you may have to offer. Bill Burley - 9 September 1999. Email to: firstname.lastname@example.org]
Today there are three major systems of naming herbs, including medicinal herbs. Because these three systems are widely used, often by quite different groups of writers or practitioners, there is considerable confusion as to the "correct" names of herbs. Many books and prescriptions or OTC preparations do not include a "crosswalk" or index of the names to help the consumer more easily determine which herbs are being discussed or consumed. The situation is especially difficult with respect to herbs used in traditional Chinese medicine (TCM).
Vernacular or Common Names
For obvious reasons, these names are most widely known and used. Many have a fascinating etymological history, in addition to having an interesting history of use as medicines. They may be written in any language or typescript. English common names today often derive from Old English or Anglo-Saxon, but many "English" names also derive from other languages such as Latin, French, Chinese, Norwegian, Sanskrit, Greek and indigenous or native languages such as Cherokee, Mayan or Yanomamo. Names often heard today in America and other English-speaking countries include comfrey, garlic, evening primrose, red clover, St.John's wort (wort is OE for plant), saw palmetto, red clover, licorice, devil's claw, chicory, borage, wormwood, and rosemary. Chinese herb names my be variations on these names or they may be original Chinese common names translated into English. Also, the transliteration of the Chinese characters into Pinyin, Wade-Giles, or other systems may further complicate the use of these common names. Frequently, the common names simply are changes or corruptions of a name in another language. For example, English "dandelion" is derived from French "dent de lion." English "fennel" is derived from Old English, but was originally from Latin "foeniculum,: from "foenum" for hay. Similarly, English mullein derives from French moulaine. Tansy, a vernacular name used for several different plant species, derives via old French from the Greek athanasia, for immortality, presumably due to the health-inducing effects of some plant in ancient Greece. Knowing this history of the names helps us understand why there is so much confusion in the use of plant names for herbal medicines.
A second system of names for medicinal herbs derives from the old medical practice of using the Latin, particularly in Europe in the Middle Ages. This naming system is also called pharmaceutical, homeopathic, or commercial Latin. Unfortunately, it is a well-intentioned but very inadequate naming system which still is found widely in pharmacopoeias, some medical texts and research papers, homeopathy, and especially in the popular herb books, prescriptions and patent formulas of Chinese herbal medicine. Examples of herb names under this system include: Cuscutae, Curcumae, Plantaginis, Asari cum Radice, Fructus Citri Sarcodactylis, Cimicifugae, Fructus Zizyphus, Radix Dipsaci, and Semen Sterculiae. Although sometimes it is possible to determine exactly which plant species is being referred to in this system, the latinized name is incomplete or insufficient and can lead to confusion over which plant species is involved.
From the examples above, "Cuscutae" clearly refers to a plant in the botanical genus Cuscutae but it does not indicate which species may be involved. Botanists currently recognize about 145 species in this genus. Similarly, "Cimicifugae" refers only to the botanical genus Cimicifuga, which contains about 18 species in the buttercup family, the Ranunculaceae. It could be referring to Cimicifuga racemosa, known in American vernacular as black cohosh, or perhaps to some other species. Lastly, "Radix Dipsaci" obviously refers to the root (radix) of a species in the genus Dipsacus, but it is unclear which of about 15 species of Dipsacus is meant here.
This system of latinized names sometimes is an improvement over the system of common names, but often it is even less clear and informative than using the common names. When looking for herb information in the older literature, particularly in the older editions of the pharmacopoeias and materia medicas, one must be careful to examine the latinized name and to note whether it is possible to determine precisely which species is being considered. Frequently there is no clear indication.
Names in Botanical Latin
For more than 200 years, scientists and botanists have recognized this difficult problem of the plethora of plant common names, many names for the same plant species, and one species having several common names. To get around this confusion, a comprehensive botanical Latin naming system was developed and now functions under the rules and recommendations of the International Code of Botanical Nomenclature. The Code is updated every six years, most recently this year (1999) in St.Louis, Missouri. This is the ONLY naming system which reliably and uniquely refers to a particular herb species and to no other plant. It is the only naming system which is universally understood and used by botanists and researchers worldwide. The names are based on specific plant material preserved in herbaria. They are accepted or rejected under very specific rules of priority, validity, orthography, etc. Because of its utility and clarity, ultimately this is the only naming system which always must be used in referring to herb species. Other systems can be used also, of course, but they should be "crosswalked" and cross-indexed with the botanical Latin names. Any research paper or reference book that uses only a vernacular name such as "ginseng" or an incomplete latinized pharmaceutical name such as "Cortex Moutan Radicis" is immediately suspect, and the information or results in that source are nearly worthless if the species cannot be determined with accuracy. Worse, these incomplete names can be misleading or dangerous if a reader or herb user assumes that some other herb species is being referred to. Herb names in botanical Latin must be written in very precise ways, for reasons which often seem arcane or even silly but which are agreed upon because they have been found necessary to avoid confusion.
A full explanation of the nomenclature system is not possible here, but the following notes may be helpful. The botanical Latin name is always in two, sometimes three parts (binomials and trinomials). The first part is the name of the botanical genus and always is written with an initial capital letter. The second part is a word which identifies a particular species in that genus, and it is never capitalized today. Thus the binomial name Tanacetum parthenium, or feverfew in English, refers to one species in the genus Tanacetum. Tanacetum vulgare is another species, or European tansy, now a common roadside weed in America and elsewhere. The binomial name sometimes is abbreviated, such as T.parthenium, if the generic name has been written previously and is clearly evident. Research continues on the plants and their evolutionary relationships. Because of this, unfortunately, there are some Latin name synonyms to deal with, but under the procedures of the International Code, this difficulty can be overcome in systematic fashion. As throughout modern science, the system over time is constantly improving and is self-correcting. Errors get weeded out and corrected. Technically, the full botanical name for an herb species includes the name of the author or botanist who first described the species and subsequent authors who may have created a new name for that species, in a different genus.
Thus we have Panax quinquefolius L, one species of "ginseng" first named by Linnaeus, and that name is still accepted today for American ginseng. Crataegus laevigata (Poir.)DC. refers to a species of hawthorn originally described by Poiret in a different genus but later classified in the genus Crataegus by deCandolle. The reason is it necessary to include this author citation in the Latin name is that it is the only way to be sure exactly which species (or taxon) is being referred to. Today, the best and most authoritative herb books and references include this full botanical Latin name plus author citation for any herbs being discussed in depth. Lastly, the Latin name of the herb should be set off in italics (if your typescript software allows this!) or in bold, or both.
Where Do We Go From Here?
This problem of the confusion of herb names is becoming better known throughout the herbal medicine community, and eventually the problem will be ameliorated or minimized as mistakes become evident and as the botanical Latin is included in more reference material. Meanwhile, however, I recommend the following guidelines:
Traditional Chinese herbal medicine presents special name problems, however, because of the long-standing tradition of using Chinese common names written in Chinese characters, the difficulty of transliteration of these characters (several systems in use), and the common practice of herb substitution. In Chinese prescriptions and patent formulas, often another herb with supposedly similar drug action will be substituted for the herb named on the label, without informing the consumer of this substitution. This serves only to make it more difficult or impossible for the consumer to know which herbs are in the bottle or prescription. Clearly, any research involving the use of Chinese herbs must be carefully scrutinized for this potential substitution problem.