Doctors Flunk Supplement Quiz

New study reveals just how ‘in the dark’ physicians really are when it comes to supplements.

By
Joanna Cosgrove
Online Editor

Although Americans are taking more dietary supplements than ever, a recent study found that doctors know surprisingly little about over-the-counter (OTC) vitamins and herbs. The study, “Physicians’ Understanding of the Regulation of Dietary Supplements,” (Archives of Internal Medicine, 2007; 167: 966-969, Ashar et al), surveyed 355 physicians, 90% of them residents at 15 internal medicine programs around the country.

Each physician took a brief online test assessing their knowledge of supplement regulations, followed by an online tutorial and a second quiz to measure what they had learned. Baseline knowledge of dietary supplement regulatory issues was poor. The total average pretest score was only 59% (986/1675). But the average score rose to 91% (1526/1675) after completion of the curriculum. (See sample question below.)

With regard to specific content areas, prior to the testing, one-third of the physicians surveyed did not know supplements do not need to be approved by FDA, or that safety and efficacy data are not required as a condition of sale. One-third of doctors also did not know that the quality of supplements is not regulated, while 60% were unaware that adverse reactions to them should be reported to FDA.

Lead study author, Bimal Ashar, Ph.D., assistant professor, Department of Medicine, director, Advanced Medicine Clerkship, and medical director, Johns Hopkins’ Executive Health Program in Baltimore, MD, said he and his team were not surprised by the results, given how little emphasis is placed on dietary supplement teaching in medical schools or in residency training. He added that the solution to this ongoing problem is muddled by a combination of issues.

“Medical schools and residency programs do not put much emphasis on dietary supplements (and alternative medicine). Things are changing, but there is a great deal of variability in what is taught. I also think that it is difficult given the conflicting studies regarding supplements and the limited knowledge of pharmacologic effects of supplements,” he explained. “A number of supplements may be effective for certain conditions but not knowing how they work limits the ability to teach and learn about these substances. There may be some physicians who are dismissive about supplements in general but I think that is changing.”

Loren Israelsen, executive director, United Natural Products Alliance (UNPA), Salt Lake City, UT, offered a keen viewpoint in light of these findings: “Doctors have very few incentives to learn, study, know about and advise patients with respect to supplement use. Why? They’re not reimbursed for it, they don’t have drug sale reps knocking on their doors to brief them, and it’s really outside of their educational practice.”

Mr. Israelsen continued, saying that conflicting information about supplements puts physicians in an ethical and professional bind. “In a world of uncertainty (in doctors’ minds) about quality, safety, science and efficacy of supplements and interactions, why would they recommend something that could get them in trouble? If they prescribe three or four drugs or if the patient is already on drug medications and they use a supplement and a problem develops, they [the doctors’] get blamed. Their license is on the line and they don’t want to get reprimanded by their colleagues. So in short, there is simply no cultural mandate or imperative for physicians to be fully engaged in preventative and nutritional medicine.”

The study concludes with the suggestion that: “An online didactic module may improve knowledge and potentially enhance patient-physician communication regarding the use of such products.” Dr. Ashar asserted that the supplement industry is certainly welcome to complement ongoing physician education efforts by helping fund and disseminate good research. “It is easy for physicians to dismiss the use of supplements by saying ‘there is no good data to support this.’ But if high quality studies are done, that line becomes untenable,” he said.

Mr. Israelsen concurred but cautioned that physicians’ busy schedules might boil even the most well-intentioned supplement education down to a question of incentive—a conundrum that must be addressed in partnership by both the medical and the supplement communities. “Where do they find the time and how do they work their way through the thicket of information about quality products and all of other things these people need to know about? The burden rests on both sides,” he said. “We all know that patients are very interested and would like to be using supplements, but if a doctor doesn’t even have the language or the basic knowledge they will look dumb in the eyes of a patient. They may grill patients about supplement use but then what? The patient tells them they are using four or five supplements, then the doctor has to go to step two, which requires a level of knowledge that most [doctors] do not have so they default. We in the industry have got to do more to provide the kind of continuing medical education that doctors would find interesting and useful.”

Sample Question

A 34-year-old gentleman is brought into the emergency room by ambulance after suffering a cardiac arrest. He is accompanied by his wife who states that he has been taking a new supplement over the last week to help him lose weight and build muscle. Which of the following statements regarding adverse event reporting of dietary supplements is correct?

A. It is the professional duty of physicians to report the event to the product manufacturer since they (manufacturers) are legally required to disclose these events to the FDA
B. It is the professional duty of physicians to report the event through the FDA’s Medwatch system, the same system used for adverse event reporting for drugs
C. It is the professional duty of physicians to report the event to the American Dietary Supplement Council hotline
D. It is the professional duty of physicians to simply document the potential adverse event in the chart, since there is currently no adverse event reporting system for dietary supplements