The official policy of the military to not ask regarding sexual preference was intended to reduce discrimination and harassment on this basis. Recent press coverage indicates that the opposite has occurred with an increased number of cases of discrimination and harassment related to sexual preference being reported. A similar process is occurring in the medical field with respect to the use of complementary/alternative medicine (CAM). According to the Eisenberg study (NEJM 1-93) one in three people are using CAM. While 83% of those using CAM also use Western allopathic medicine (WAM) 72% do not tell their physicians. This breakdown in communication can and does result in several adverse consequences. 

Unrecognized Interactions 
Not knowing what else our patients are doing can be potentially disastrous. A patient I saw who had atrial fibrillation with rapid ventricular response is a perfect example of this problem. The patient's tachyarrhythmia had been well controlled with digoxin but he ended up in the emergency room on several occasions with tachycardia and a low digoxin level despite taking generous doses of the medicine. On questioning he was taking a milk thistle (silymarin) supplement to "cleanse" his liver. This herbal product does in fact cause enzyme induction which can speed the metabolism of several medications. Upon stopping the milk thistle supplement his digoxin levels remained therapeutic and he ceased making trips to the ER. There are many other vitamin or herbal supplements which can enhance or diminish the effectiveness of prescription medications and thus cause potentially dangerous situations. "Don't ask, don't tell" is clearly not in the best interest of the patient. 

Contraindications
There are often situations where patients need to be protected from bad advice or contraindicated interventions given by CAM practitioners without medical training. A patient I saw with metastatic prostate cancer had refused the conventional anti-hormonal treatment recommended by the urologist. After a CAM practitioner using muscle testing (applied kinesiology) determined what supplements were best for the patient he came to see me for further advice. The number one ingredient in the supplements recommended to the patient was bovine orchic extract - high in testosterone and further stimulating the growth of his prostate cancer. Upon my advice he stopped the inappropriate supplements and I was able to persuade him of the benefits of conventional medical therapy where physicians practicing only WAM had not been able to. Clearly "don't ask, don't tell" did not serve the best interest of this patient. 

Non-Compliance
"Don't listen if you're not heard" describes the attitude of the above patient. Once a physician listened to the patient, then, and only then, was he able to hear the necessary medical advice. There are countless numbers of patients who are cynical, or fearful of WAM. If as a physician you disrespect the belief systems of patients you only make them less likely to follow your advice. If on the other hand you respect their beliefs, listen to their concerns and address their fears they are much more likely to hear what you have to say - and that might even save their lives! 

Legal 
Our litigious society likes to place blame or assign liability to the deepest pocket, (often physicians and their liability insurers), when there has been a bad outcome. Woe to the physician if a bad outcome occurs as a result of a CAM interaction, contraindication or complication that the physician failed to ask about or inform the patient about. CAM practitioners generally have "shallower pockets" and are often viewed more sympathetically by patients because they spend, as a rule, much more time with patients than physicians do.

Imagine the following conversation between the plaintiff's attorney and a physician who had a bad outcome because he/she didn't ask about the use of CAM. " So Dr., you're aware that one in three Americans use CAM and yet you didn't include this in your history just as you would ask routinely about substance abuse, sexual preference, or even OTC medication use?" The physician confidently replies, "I don't have any training in CAM and there's no proof that these therapies are effective." The lawyer toys with the physician, "I didn't ask you as to your medical school training nor your belief in the efficacy of CAM. Please answer the question I asked." The physician angry with the lawyer's tactics retorts, "CAM is irrelevant to the practice of medicine." The lawyer smiles and changes topics, "Dr. do you believe in staying current through the use of CME?" The Dr. uneasily responds, "Yes," knowing he is being set up. The lawyer moves in for the kill, "Dr. there are several CME conferences each month around the country on CAM, peer reviewed medical journals on CAM and medical texts on CAM written by physicians for physicians. Have you availed yourself of any of these resources?" The physician meekly mumbles, "No." "Thank you Dr.," says the lawyer who then proceeds to paint an unfavorable picture of the physician who didn't care to get educated on something that affects one in three Americans and further describe how the plaintiff is the unfortunate victim of the doctor's indifference. 

Lack of Needed Research 
The objection that CAM lacks adequate data to support its use should be balanced by the report of the government Office of Technology Assessment which concludes that 70 to 80% of what we do in WAM has not been adequately proven. Virtually everything that is done clinically needs to be put to the test including both WAM and CAM. Who is better qualified or better positioned than Family Practice physicians to do the necessary outcome studies? We shouldn't complain that there is no data since it is up to us to provide the data! Passively complaining that research is needed will accomplish nothing. Family Practice is the only specialty I know of that can be defined in terms of integration and inclusion. All other specialties can be defined in terms of fragmentation and exclusion. Family Practice physicians are in the best position to do the necessary research to see how WAM or CAM makes a difference in our patients' lives. 

Conclusion
"Don't ask, don't tell" clearly is not in the best interest of the one third of Americans who use CAM. As physicians we not only need to ask about the use of CAM but must also be prepared to talk intelligently about it. There are many reputable resources of credible information for physicians on the subject of CAM. By becoming informed we can help patients make safe choices in the use of CAM. By monitoring and studying the clinical outcomes we will be providing the much needed data which will help us determine when CAM interventions are beneficial. If not us, who? If not now, when?