Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, August 09, 2007

The Real Issue With CAM

All kidding aside, I've been thinking about CAM (complementary and alternative medicine, also called Integrative medicine by those who feel that makes it more acceptable) a lot lately. Obviously much debate centers on efficacy of unproven treatment modalities, although it can certainly be said that there is no such thing as 'alternative' medicine; there is only medicine that has been proven to work, and medicine that hasn't. While it is important to consider evidence, efficacy, and even plausibility, that's not what I'm talking about.

The real issue with CAM is unmet needs.

When people get hurt or sick, they seek medical attention. Their needs, generally speaking, are for an accurate diagnosis and effective treatment that isn't too unpleasant or expensive, from a friendly-enough doctor with acceptable facilities. When these needs are met, there is no impetus to seek out any kind of alternative care. The system works; everyone is happy

Often enough, though, all of those needs are not met completely. The doctor was brusque (although the diagnosis was right and the treatment worked) or the staff was rude (but the doc was great.) Or they couldn't make a diagnosis (but the symptoms resolved on their own) or the suggested treatment was too expensive (but the diagnosis was right and the nurse was wonderful.)

Different people attach more or less importance to each of these elements; that is, they have different needs. Some people need to understand their diagnosis in greater detail than others. Some people want to know about every single possible treatment option, even those that may not be appropriate for them, because they just want to know. Other folks just say, "Just tell me what to do to get better and I'll do it." Different doctors meet different patients' needs differently in different situations. When one or more of those needs are not met by "conventional medicine" the patient may look elsewhere for relief; to have their needs met.

A patient with vague complaints of fatigue, pain and malaise may go through multiple investigations at the hands of numerous doctors and emerge without a satisfactory diagnosis. Without a diagnosis, treatment options may be limited. Symptomatic care may or may not be tried. Mental health treatment may be recommended; that recommendation may be accepted or rejected. It's easy to see patients' frustration build as their need for diagnosis, relief, validation, whatever, are not met. So they turn elsewhere: the chiropractor; the LLMD; the Reiki master; the acupuncturist.

Each of these practitioners manages to meet patients' needs. They diagnose invented conditions, but they provide a diagnosis. They perform treatments that have no scientific plausibility, but "at least they're doing something." They often spend long periods of time with patients, listening and providing validation that "something's wrong" even if the doctors could never find out what. They meet the patients' emotional need to be heard. They may not provide accurate diagnosis or effective treatment, but they are certainly meeting needs; otherwise they wouldn't exist.

Take another patient diagnosed with cancer. His primary need is for a cure, although sometimes we can't do that. Failing that, we must meet his need for hope; hope that pain will be managed, that he won't be abandoned; all of his emotional needs. If another can be cured, she needs to know that she can tolerate the treatment; that the vomiting can be treated; that she won't be too tired to take care of her kids; again, mainly that her emotional needs will be met. Even when we cannot cure, we can often do a decent job of meeting patient needs.

So when we can't, is it any wonder they turn to laetrile? To diet cures? To all manner of alternative treatments that meet their need for hope, even if not their desire for a physical cure.

Why do doctors turn to providing "alternative" care? What makes them do the mental somersaults required essentially to renounce their scientific training (in the name of "open-mindedness", they tell themselves)? Sometimes, perhaps, it's from disillusionment with patients' poor responses to what they've been taught they have to offer, but I'd wager that far more frequently the underlying motivation is economic.

An alternative (or complementary; or integrative) practice is a cash practice. It's a golden opportunity to ditch the insurance slavemasters, while convincing oneself that one is still helping people; albeit only those who can afford one's services.

Some of us -- those of us who truly understand the science as well as the art of medicine -- couldn't imagine that financial need would ever trump our integrity to the extent required to open an alternative practice, but for many others, when the physician's need to earn a living wage is not met by practicing conventional medicine, turning to CAM is often an economically viable option.

If conventional medicine were able to meet all of our patients' needs all of the time, and if all physicians were able to earn whatever amount of money required to meet their needs, there would be no such thing as CAM.

Researching new medical modalities is important. Who knows which alternative therapies are simply not proven "yet"? It is also important to debunk junk science when it represents a clear danger to patients. However as we go around and around with the debate, perhaps some of our energies would be better spent trying to improve the job we do of meeting our patients' needs. Then there wouldn't be a need for CAM.

8 Comments:

At Wed Aug 08, 08:16:00 PM, Anonymous Anonymous said...

Very upsetting. Why not become a Wall Street broker?

 
At Wed Aug 08, 08:45:00 PM, Anonymous RJS said...

Some of us -- those of us who truly understand the science as well as the art of medicine -- couldn't imagine that financial need would ever trump our integrity to the extent required to open an alternative practice, but for many others, when the physician's need to earn a living wage is not met by practicing conventional medicine, turning to CAM is often an economically viable option.

If I owned my own pharmacy, I suspect I would have difficulty building wealth, because there is no way that I could (in good conscience) sell half of the shit that you can buy OTC. Because I know it sells hope, not a cure.

It still cracks me to recall the look on this woman's face when she asked me if some homeopathic remedy was "the one that works." I said "No, you're better saving your money and drinking some water for all the good that's going to do you, because homeopathy is complete BS."

It's like I'm supposed to expound upon the wonders of the junk we sell simply because I am employed by a company whose sole purpose is to make money.

Sorry, my integrity is more valuable than that.

--

On topic, it never ceases to amaze me how often people just need someone to listen to them. I suspect a good 80% of the population needs a therapist, if only just to have some "me" time.

I, on the other hand, have a blog and an ego that allows me to talk about myself and pretend that people care with no problems at all. ;)

There's a reason the thrust of Dale Carnegie's famous book is listening.

 
At Wed Aug 08, 10:05:00 PM, Blogger Beach Bum said...

An interesting and thought-provoking post. Thank you. My initial reaction was a cliche, "don't throw the baby out with the bathwater."

As a medical student who practices Yoga, and who has gone to alternative practicioners, I have a somewhat more inclusive view of such things. But then again, I'm an artist. My operatic technique did not start to fall into place until I had started practicing Yoga, and going to a Shiatzu practitioner. The physical awareness and energy balancing required to be able to sing with a classical technique was something that these practices enabled me to achieve. But what it did for me had less to do with fixing an existing problem, and more to do with improving my existence and performance.

Having said that, I hate "junk science" with a passion, and think that the vast majority of the "alternative" mumbo jumbo out there is snake oil.

I wonder whether disciplines such as Yoga and Acupuncture must have some basis in reality since they've stuck around so long. Just not, perhaps, a western reality. Then again, I don't believe in drinking tiger penis concoctions, so maybe I'm a bit more narrow than I want to admit.

Western Medicine is pretty good at finding out a problem, and fixing it. It's very reactive, and tends to prefer its problems be concrete. Where scientific medicine is weak is in the area of vague concerns and general feelings of non-wellbeing. And although it's getting better, it still sucks at dealing with the mind-body connection.

 
At Wed Aug 08, 10:16:00 PM, Blogger A Kipp said...

I must admit, I've been reading your blog for quite some time now, and this is the very first time I strongly disagree with what you've said.

There are hundreds, if not thousands, of people in the US providing very real medical care to patients, but not using the Western model. Acupuncture has been around for thousands of years, and multiple studies have been done that correlate the acupuncture model of health and disease and Western medicine's model. Similarly with herbs; there is a study at the CDC (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5630a5.htm) that is looking at a drug from wormwood, which is a traditional herbal treatment for malaria, and has been for hundreds of years.

That's not to say there aren't lots of people out there looking to scam people out of their money, especially by taking advantage of someone in a vulnerable state. But I think we miss the opportunity to learn so much more about health and disease and the human body if we throw out all of integrative medicine. Yes it's a great source of money because insuarance companies rarely accept it, yes it seems hokey and completely against what we, as allopaths, are trained to do. But many of these fields have a history longer and more rich than Western medicine, and are not mere "inventions" of the quack down the road.

 
At Thu Aug 09, 06:33:00 AM, Blogger #1 Dinosaur said...

kipp: I'm not saying "throw it all out." I'm pointing out that it's meeting unmet needs. And although I think we should try to do a better job of meeting our patients' needs with "conventional" medicine, I really don't think we'll ever completely succeed. Therefore I do believe there will always be a market for CAM.

BTW, some of your points about acupuncture are wrong: there is no research "correlating" it with scientific medicine, and although it may have been around for thousands of years (a claim some doubt) the Chinese themselves have been discarding it wholesale with the introduction of "Western" (ie, effective) medicine. (Link here.)

 
At Thu Aug 09, 12:32:00 PM, Blogger Dr. Smak said...

Dr. Dino,

Once again, you have hit the nail on the head. Where the hell did you get such an accurate hammer?

CAM is here to stay, for the reasons that you have outlined. Though I think that >99% of it is a crock of hooey, I'm much more measured in how I discuss it with my patients. Categorically dismissing it alienates and belittles the patients whom I'm already not helping to the degree they need, whether the unmet need is medical or non-medical. A placebo effect can be a powerful thing.

Besides, some of these patients are very 'high maintenance', and it aids in doctor fatigue to share the wealth. If they're going to go anyway, I may as well know about it and keep them engaged the medical world that I practice in.

Dr. Smak

PS I think I want to be you when I grow up.

 
At Thu Aug 09, 02:14:00 PM, Blogger Lynn Price said...

This is a great topic, and I can only hope that I’m treated without rancor as I was on Panda’s site when he had the same discussion.

The term ‘integrative medicine’ isn’t used to make it seem more acceptable, Dino. It’s a clarification to those of us who have witnessed how nicely alternative modalities play alongside allopathic medicine. Example: the doc who uses chemo, biofeedback, Reiki, or mediation for their patients in an effort to treat the cancer and the side effects of chemo.

The same can be said for the term ‘alternative medicine.’ It’s a clarification that acknowledges the differences between allopathic and non-allopathic practices.

When people get hurt or sick, they seek medical attention. everyone is happy. Often enough, needs are not met. The doctor was brusque (although the diagnosis was right and the treatment worked) or the staff was rude (but the doc was great.) Or they couldn't make a diagnosis (but the symptoms resolved on their own) or the suggested treatment was too expensive (but the diagnosis was right and the nurse was wonderful.)

Personally, I think you’re oversimplifying the debate and making rudeness the most common denominator. In truth, using alternative methods end up being far more expensive because, except in small cases, insurance doesn’t cover the treatment, and it becomes an out of pocket expense. I’ve met plenty rude docs, but that would never sway me away from seeking medical treatment. I would only seek alternative methods if science hit a dead end.

When one or more of those needs are not met by "conventional medicine" the patient may look elsewhere for relief; to have their needs met.

What’s wrong with this? Sometimes the conventional medicine isn’t good for us. We menopausal women have been told that HRT’s make us prone to cancer. I could see the results of my being on HRTs, and they were exceedingly uncomfortable, so I discontinued their use. By taking natural products (that docs aren’t allowed to prescribe), my hot flashes are few and far between, and I’m waltzing through menopause. I’m under the watchful eye of a professional in the alternative field, and he’s the first one to say, “Go seek medical help.” I agree that this is the perfect blend of integrative medicine and that’s because I did my homework. The problem is that many aren’t smart about their uses of alternatives and forgo all allopathic medicine. This was actually the foundation for one of my main characters in my book.

The main problem I’ve found through my research is that there are three kinds of docs; those who have an innate suspicion of alternative medicine, those who are willing to recognize possible benefits, and those who actively have integrated alternative uses in their practice. The first group has already made up their mind and declines to do any research, or had a bad experience (such as my main character). The second group are the fence riders (and by far the majority) who don’t really care one way or another. My own doc fits in this category. The third group is growing in numbers. Respected docs such as Mehmet Oz and Andrew Weiss have been influential in this advancement. The Continuum Center for Health and Healing in NYC, which is based out from Beth Israel, has grown in stature over the years.

Another issue that I’ve seen brought up is how hospitals are giving way to integrating alternatives in the interest of making big bucks. I don’t buy this, because it’s incumbent upon the medical professionals to offer results. If patients utilize the alternative choices and receive no benefit, it’s going to die very quickly.

It's easy to see patients' frustration build as their need for diagnosis, relief, validation, whatever, are not met. they turn elsewhere: the chiropractor; the LLMD; the Reiki master; the acupuncturist.

The only problem I have with this scenario is if the patient leaves the doctor all together. No one should ever leave their doc. On the other hand, if a doc tells a patient there’s nothing more they can do, what options are left to the patient? The doc who has integrated alternatives like Reiki or the acupuncturist into his practice (and I’m not suggesting he has these people on hand, but rather has recommended names), then he offers his patient a wider choice in which to find relief.

Each of these practitioners manages to meet patients' needs. They diagnose invented conditions, but they provide a diagnosis, perform treatments that have no scientific plausibility, but "at least they're doing something." spend long periods of time with patients, listening and providing validation that "something's wrong". They meet the patients' emotional need to be heard. They may not provide accurate diagnosis or effective treatment, but they are certainly meeting needs; otherwise they wouldn't exist.

These are very general accusations, and you do the honest practitioners a grave disservice. The same argument can be made for docs who over-prescribe medication and then prescribe more meds to alleviate the symptoms of the previous meds. They don’t order tests, and basically ignore their patients until they either die or go elsewhere.

Yes, there are assholes out there who are more concerned with taking a buck rather than practicing often very ancient forms of therapy. This is the primary concern I have about alternative medicine, and that’s why I’m such a proponent of getting it where it belongs, under a doc’s watchful eye. The docs I researched with were terrific gatekeepers for their patients and got them the various forms of therapy they needed in conjunction with providing their medical needs. In this scenario, therapist and doc are in constant communication.

Why do doctors turn to providing "alternative" care? What makes them renounce their scientific training (in the name of "open-mindedness")? I'd wager that far more frequently the underlying motivation is economic.

Dino, you're guessing here. Have you talked to docs who have integrated alternatives into their practice? If not, you're painting with a pretty broad and cliche brush. I researched with numerous respected docs while writing my book, and they would never dream of renouncing their scientific foundations. Why is the notion of being open-minded a strange notion? In a field where medical miracles are happening every day, yours seems to be a rather limiting opinion. Can anyone say that they definitively know how the human body heals? Is there no accounting for the power of the mind and spirit in the healing process? No, you can’t put the human spirit under a microscope, but are you so quick to discount its power in the healing process? These ideas don’t interfere (or shouldn’t) with medical care, but the docs I interviewed believed that there is a huge benefit to curing the mind and the body – that the two are synonymous. If a Republican and Democrat can have a happy marriage, why can’t science and alternatives?

If conventional medicine were able to meet all of our patients' needs all of the time, there would be no such thing as CAM.

Dino, even in a perfect world docs will never be able to meet all their patients’ needs because docs depend solely on medicine and surgery. What about the kid I researched who had Type 3 neurofibromatosis? His doc had gone as far as he could go with his medical and surgical protocol; the meds were no longer helping, and the surgeries were becoming more invasive and dangerous. He recommended an acupuncturist who hangs his shingle out at the hospital. The only reason the mother acquiesced was because it came from the doc. With treatment, the kid’s tumors abated and he got off nearly all of his meds. The doc is still scratching his head, but he acknowledged there was nothing more he could medically do. I have tons of stories of this nature.

and if all physicians were able to earn whatever amount of money required to meet their needs, there would be no such thing as CAM.

CAM has zip to do with doctors’ earnings.

Researching new medical modalities is important. Who knows which alternative therapies are simply not proven "yet"? It is also important to debunk junk science when it represents a clear danger to patients. However as we go around and around with the debate, perhaps some of our energies would be better spent trying to improve the job we do of meeting our patients' needs. Then there wouldn't be a need for CAM.

Or perhaps, with research, medicine would discover that there is a place for CAM. I agree that it’s a rat’s maze trying to discern what modalities are deemed good and what sucks. This is what prevents CAM from being accepted as a whole and is one of the basic arguments of one of my main characters. But it’s pretty hard to find acceptance when there are docs who dismiss its efficacy without doing the research and only listening to the bad stories and their own personal biases. Given that premise, a case could be made for the dangers of medicine. Both are equally ignorant.

I understand and agree with docs’ concerns about alternative medicine’s accountability. After all, this isn’t a “science” that can be slapped under a microscope and analyzed. “Yesiree, there’s the spot that Reiki did a fabo job.” Can’t be done. The only byproduct of these practices are whether the patient’s outcome had a positive effect. Do they feel better? Are they able to get out of bed and go to work after a rousing schedule of chemo? Do they still vomit hourly? All my research with docs and patients have shown me that alternative methods are very effective in this sort of treatment.

The problem I see is fear. Too many patients become frightened and grasp at straws in an effort to find answers to their medical maladies. They leave the medical arena, which is inherently dangerous. If the medical profession were more amenable to CAM and adopted some of these modalities in their practice, they could keep their patients where they belong; in the doc’s office and medically safe.

 
At Sun Oct 12, 10:21:00 AM, Anonymous Dr. Val said...

Great post, Dino. And yes, my "reader take" at KevinMD was essentially a revisitation of this same idea. It's true that the message is repetitive - but as you know, if people only needed to hear a message once to change a behavior, we'd all be out of a job. :) I think you will enjoy my next post at Science Based Medicine (to be published on Thursday morning, October 16). Please look out for it. Glad we're on the same page! :)

 

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