Articles

A Guide for Confronting Patients

I sometimes lecture on science-based medicine to my colleagues and one of the most common questions I get is how to deal with a patient who expresses belief in unscientific treatments. The dilemma for the physician is that professionalism requires that we do not confront patients regarding their personal beliefs. We are there to inform and advise, not preach. And yet proper medical care is often hampered by unscientific beliefs on the part of patients.

David wrote previously about a case he reviewed in which a woman with a very treatable early stage of breast cancer opted for “alternative” treatment rather than the standard treatment, which carries a > 93% good outcome. As a result her cancer progressed horribly – but she clung to belief in CAM despite its obvious failure in her case. This story highlighted the fact that giving patients proper medical advice sometime requires confronting their false beliefs.

Unscientific and bizarre medical practices are in vogue and are increasingly infiltrating the medical system through a combination of misguided political correctness, stealth, and apathy. This is exacerbating the dilemma for science-based practitioners who are caught between the imperative to do the right thing in accordance with evidence-based guidelines and the default respect for the patient and the desire to maintain a therapeutic relationship.

In my experience, however, these two goals do not have to be mutually exclusive. An uncompromising but non-judgmental approach works very well.

Cross-Purposes

One of the more challenging aspects of ethical clinical practice is to balance various ethical and practical concerns that are at cross-purposes. For example, the need to give patients informed consent includes the requirement to give them a realistic sense of their medical condition. If a patient has a terminal illness, they need to be told so. Gone are the paternalistic days when a doctor would lie to a patient to protect them.

It is even more important to inform a patient of the consequences of their medical decisions. If a patient refuses a recommended treatment and they are likely to die without the treatment, they need to be told so in no uncertain terms.

At the same time we don’t like to scare patients unnecessarily and cause undue stress. Therefore we won’t tell a patient that we think they may have cancer when it is still uncertain. It’s better to wait for the test results.

But what if a patient declines to take a test that will indicate whether or not they have cancer? Then it may be necessary to inform them that the purpose of the test is to look for things that are potentially serious and treatable. If they still refuse, you may need to break down and inform them that they may have cancer and the test is needed to rule it out.

In other words – part of the art of medicine is knowing how much information to give a patient in order to help them make the right decision. Or, at the very least, if they are about to make a risky decision it becomes necessary to inform them in stark terms why the decision is risky. The desire to protect the patient from unnecessary stress takes a back seat to giving them the information they need to make an informed decision.

Confronting Beliefs

Along the same lines, health care providers should not confront the personal beliefs of a patient, but what if those personal beliefs are motivating them to make very bad medical decisions? Then, in my opinion, it depends upon the nature of the beliefs. Religious beliefs should be completely out of bounds. It is not the place of the physician to validate or refute personal religious beliefs.

Non-religious ideological beliefs are the same. The point is that the physician cannot impose their value system onto their patient.

That doesn’t mean that nothing can be done within the confines of professional ethics. If a patient refuses a life-saving intervention because of their religious beliefs it is reasonable to make sure that they fully understand the consequences of their decision. It is also reasonable to suggest that they consult with family members. You may even offer to refer them to a support group or even counseling.

This can be done in a completely non-confrontational and non-judgmental way. You can respect their religious belief and their right to make their own decisions, but just advise them to take advantage of available support structures in making such a huge decision.

Confronting Claims

I think where most of the confusion comes in is confusing the approach to personal values or ideological beliefs with the proper approach to medical claims. While beliefs and values are out of bounds, any factual claims are fair game – regardless of their motivation.

First it is important to recognize that patients who are in a doctor’s office have already made the decision that the expertise and experience of that physician is worthwhile. By consulting a physician a patient is tacitly giving that physician permission, even the obligation, to provide their unvarnished medical opinion. In fact, holding back on giving an honest medical opinion is a throwback to the old paternalism – it in essence says that the patient is incapable of handling the honest opinions of their doctor and they need to be coddled to some extent. In reality, in my opinion, failure to give an honest opinion is misguided and harmful – and I suspect may be designed to protect the physician from an uncomfortable confrontation more than the patient.

It is far better to be unapologetic in stating that one is a science-based practitioner (this article is written for the science-based practitioner) and that one’s medical advice is based upon the best scientific evidence available. I find that when patients come to my office, that is exactly what they want. They are very happy to get my honest opinion, even if it directly contradicts what they believe. I don’t dance around the issue at all.

Most experienced clinicians already know to avoid dismissive, insulting, or judgmental statements. In confronting unscientific medical beliefs, it is easy to do so. Simply confine your opinions to the scientific evidence. For example, if a patient asks me about acupuncture for migraine headaches I simply tell them that I have reviewed the published literature which does not support the use of acupuncture for migraines. I therefore do not recommend it. I am then happy to discuss the evidence with the patient as much as they desire. But almost always patients appreciate the fact that I have taken the time to actually read the literature and they respect my opinion. They may not follow it – but that is their choice.

Sometimes patients ask me about treatments that I believe to be fraudulent and exploitive – for example I am frequently asked about whether or not it is worth it to fly to China to get stem-cell therapy. In these cases I tell my patients, in a very factual and dry manner, that such clinics are fraudulent. What evidence we have shows that their treatments are not safe and that they do not work. In my opinion the people operating the clinic are committing fraud to steal money away from desperate patients. To do anything less is to fail to properly inform a patient.

I have even confronted the beliefs of patients that vaccines have caused their child’s autism – in some cases hardcore true believers. I validate the patient’s concerns and acknowledge the evidence that is out there. I reassure them that I simply want to give them the best advice I can, that I have read the literature thoroughly and then I give them my scientific opinion. It is often helpful to explain to patients how I approach evidence and my philosophy of science-based medicine. The response is almost universally positive.

Conclusion

Physicians and other clinicians should not be afraid to defend the scientific basis of good medicine and to explain to patients that we are scientific practitioners. In my experience there is still a great deal of basic respect for science in the public. As long as you take a thoughtful, professional, and evidence-based approach to your opinions, patients will respect them, even if they disagree with them.

It is profoundly misguided and harmful to fail to confront pseudoscience or bad science in medicine out of fear of offending a patient. Such fears are overblown and misplaced.

Given the medical environment today, clinicians are obligated to have a working knowledge not only of science-based medicine but of the unscientific practices and claims with which their patients may be faced. We are obligated, as part of good practice, to know the literature and the nature of unscientific claims and to help our patients navigate through them. Otherwise we are throwing them to the wolves.

Posted in: General, Medical Ethics

Leave a Comment (42) ↓

42 thoughts on “A Guide for Confronting Patients

  1. vinny says:

    So what will you do when antivax walks into your office with a laptop and start showing all the patients in your waiting room articles from his whale:to site. Will you:
    1. Call the police and have him arrested.
    2. Go into the waiting room and attempt to debate him.
    3. Ask your nurse to usher him into an examination room and perform administer a restraining dose of haldol.
    4. Alert nearby county psychiatric ward that their patient has escaped and have wait for orderlies to pick him up.
    5. Run into the waiting room with a weapon and kill him, and destroy his laptop.
    6. Offer some vitamins that are being referenced at the whale:to site, at a “discount” to those in your waiting room.
    7. Embrace antivax in a bearhug and wait for him to pass out, then take nude photographs of him and post them to sciencebased medicine.
    8. Force him into the dungeon and place him into a chain him to the wall.
    9. Wait for him to leave and not answer his provocation.
    10. Go golfing.

  2. vinny says:

    sorry for the typos as I was revising some of the above options.

  3. weing says:

    I just had a long discussion with a patient who is considering going to the Burzynski Institute. I gave her my biased EBM view. I hope she continues treatment with her oncologist.

  4. RickK101 says:

    Perhaps along with the usual tattered copies of “Time” and “People” physicians should also keep copies of “The Skeptical Inquirer” and “How We Know What Isn’t So” laying around the waiting room.

    Seriously though, I definitely think physicians must be armed with the sort of evidence that sways different patients. Some people ONLY respond to the sort of anecdotal, human interest stories they hear on Oprah. So in addition to studies and statistics, physicians should have cases of real people for whom placebo treatments (CAM) has failed. Dr. Gorski’s case is an excellent example.

    Different people respond to different types of data. For example, when buying a car, my mother in law put much more weight on the experience of her hairdresser than on Consumer Reports statistics. She’ll glaze over if a doctor starts talking clinical trials. But she might respond very well to a nurse saying “this is the drug I’d want my mother to take in your situation.”

  5. Vinny,

    I know you’re being funny – but to clarify: If someone barged into my office to spread misinformation to my patients –
    1 – they are not my patient, I have no professional obligation to them (beyond generic obligations to society)
    2 – He does not have the right to use a private office as a venue to preach or sell anything
    3 – I would have an obligation to provide a comfortable and safe environment for my patients, and would therefore immediately have him removed.

  6. durvit says:

    I find that when patients come to my office, that is exactly what they want. They are very happy to get my honest opinion, even if it directly contradicts what they believe. I don’t dance around the issue at all…

    I am then happy to discuss the evidence with the patient as much as they desire.

    This may be a UK/US difference but in the UK it is unlikely that most patients would ever have that long an appointment with a consultant neurologist (or a family doctor, come to that). I don’t have a feeling for how many patients would be able to discuss their ideas about (say) environmental allergies; heavy metal toxicity; food allergies; geopathic stress; chronic lyme disease etc. as contributors to their symptoms with their neurologist/specialist/family doctor.

    I don’t want to end up in the s**m filter for including the links but I am interested in how you handle patients whom you believe to have a functional neurological problem. Some of the literature indicates that functional neurological symptoms are present in up to 30% of referrals, even to a tertiary level setting. You might have a scientific rationale for explaining to someone why you consider that their symptoms are functional rather than otherwise but some of the literature indicates that telling that to patients is not received well – nor do some patients accept it.

  7. I think RickK101 and Vinny too :-) are on to something. We all learn and react differently and are swayed by different things. I personally wish doctors would not place women’s magazines and publications like Prevention in their waiting rooms.

    Years ago I went to some trouble to find a very competent, qualified, evidence-based internist for my mother, the only kind of doctor I’d ever see myself. My mother didn’t like him because he was “dry”. She didn’t remain his patient for long.

    She found another internist who she did like very much. IMO, the treatment she got from him was correct but there were strange glitches. When at the age of 78 she collapsed into a chair and appeared to have trouble breathing, I phoned him to ask if I should get her to the ER or his office. His office was very close. The ER far and it was rush hour in the NYC suburbs which would have been a problem for an ambulance as well as for me. He said, “I don’t know if it is an emergency. I can’t see her. You can. You have to decide yourself. If you want, I can meet you at the ER.” I said I’d take her to the ER myself and let them call him if they thought they needed him. When I got back to her, the emergency had past. Her breathing was normal again, but I still took her to the ER.

    She told me that while she was hooked up to a monitor, the good doctor came in and told the nurse he was discharging her. The nurse responded, “Okay, Hot Shot, but maybe you better look at this first.” She had congestive heart failure. He kept her in the hospital. I insisted that she be seen by a cardiologist even thought her internist was most annoyed at that. Seems she had decided she was urinating too frequently and decided to go off her diuretic without telling me or him about it.

    Several years later after we had moved away we heard that the MD had died. He was only in his 50s. My mother said, “He probably died of cancer.” When I asked her why she thought that, she said because he smoked. Turns out she had heard from her friends that he smoked and decided that he was the doc for her since if he smoked he couldn’t possibly tell her not to, and he didn’t. He kept an ashtray on his office desk, something my mother appreciated very much.

    Now if you asked someone what criteria they used to choose an MD, would you ever expect anyone to respond, Oh, I’ll only go to one who smokes? I sure wouldn’t.

  8. overshoot says:

    I just had a long discussion with a patient who is considering going to the Burzynski Institute. I gave her my biased EBM view. I hope she continues treatment with her oncologist.

    And if she does go to Burzynski, will there ever be any record of how it all turns out?

    I doubt it. I doubt it very much.

    Burzynski and the like run on amnesia. There are no records of their “patients” aside from those who are chosen for advertising. There are no long-term follow-ups. We get the famous examples of the “terminal cancer patients, cured! Here to speak to us tonight on television.” Most of whom, following their miraculous cures, were dead within a month. That part didn’t make the news, but the video clips are still circulating.

    If (and I hope with you that she chooses wisely) your patient does go the Burzynski route, please at least try to get permission to follow up and document her outcome. One isn’t much — but it’s frankly better than what we have now.

  9. HCN says:

    vinny, just tell AntiVax that a satanic ley line runs through the waiting room… that will make sure he leaves post-haste.

  10. Dealing with so-called functional symptoms is a complex topic for another post. I don’t want to give a quick answer to it.

  11. weing says:

    overshoot,
    I was able to give her an anecdote. Not my patient, but the husband of one of my childhood friends had metastatic colon cancer a few years ago. I recall receiving requests for donations so that he could go to Burzynski. (I refused to donate) His disease progressed to its inevitable end unabated.

  12. azinyk says:

    David Gorski’s story would make a great pro-scientific-medicine television ad, I think. The idea would be kind of like the Yul Brynner anti-smoking ad, where a person speaks from beyond the grave, regretting the previous behavior. You could show the person vital and happy before getting sick, and crippled and miserable after using alternative medicine.

    Unfortunately, a lot of people are true believers until the end, so they wouldn’t participate in making such an ad, but there’s a lot of potential for a weepy ad made by the orphans or spouse left behind – that’s how they do anti-suicide ads. Victims who are now suing their practitioners, like Sandra Nette, who was paralyzed by her chiropractor, would also be good candidates.

    It would also be good to see an ugly CAM practitioner driving his Mercedes or laying on the beach while sinister music plays. I think an acupuncturist doing the perp walk would probably be too much – it would portray them as the underdog. The real doctors should be physically attractive, friendly and smiling, but not have any diplomas showing or be wearing glasses, which would make them look elitist.

    I don’t know what organization would fund such an ad in the United States, but in countries with publicly-funded health care, it seems like something the NHS or Health Canada should be doing. I know there’s some interest in this, because Richard Dawkins dedicated a whole hour of his “Enemies of Reason” documentary to this kind of thing. People who are credulous wouldn’t sit down to spend an hour watching a skeptic, but a thirty-second ad, played several times a day, might get through to them.

  13. Harriet Hall says:

    A quick and simplistic answer for the problem of functional symptoms: I used to tell patients the tests indicated that their body was physically normal, but the way it was “functioning” was causing symptoms. It wasn’t something we could “fix” with surgery or a pill, but we could help them cope with the symptoms and try to minimize the impact on their life.

  14. overshoot says:

    I recall receiving requests for donations so that he could go to Burzynski. (I refused to donate) His disease progressed to its inevitable end unabated.

    I’m sorry to hear that. It’s bad enough when it’s someone we know only casually; I lost my oldest childhood friend to GI stromal cancer a few years ago.

    What really gripes me is that none of these cases seem to be recorded anywhere so there’s no data on Burzynski that we can use for patients like yours.

    Why, we might ask the alties who tout woo-icine, did bleeding and purging persist as the standard of care for centuries?

  15. coryblick says:

    Great article. I’m curious as to what differences might be present in a guide to confronting colleagues?

    Often times patient perceptions are led astray by clinician beliefs. This adds a dimension of conflicting expert advice and cognitive dissonance for the patient upon being confronted as was described. Not that cognitive dissonance is a bad thing, just it is usually uncomfortable and quite likely to result in the patient toward choosing the path of least resistance, which quite often is back to the clinician with unsupported beliefs.

    Cory Blickenstaff

  16. Wicked Lad says:

    Dr. Novella wrote:

    For example, if a patient asks me about acupuncture for migraine headaches I simply tell them that I have reviewed the published literature which does not support the use of acupuncture for migraines. I therefore do not recommend it.

    But my sister-in-law used to get these wicked migraine headaches, see, and she went to an acupuncturist, and….

    Seriously, thank you for the fine post.

    Last night I was listening to the 3rd anniversary episode of The Skeptics’ Guide podcast. (I know! I’m sorry! I’m way behind in my podcast listening!) Your brother had been to Horror Con and was horrified that credulous woo had invaded his hobby. You groused something like, “Imagine if they invaded your professional field.” No one picked up on that–at least in the edited version of the podcast–but I immediately thought of your good efforts on this blog.

    Keep up the great work.

  17. overshoot says:

    You groused something like, “Imagine if they invaded your professional field.” No one picked up on that–at least in the edited version of the podcast–but I immediately thought of your good efforts on this blog.

    You learn to cope. In my field (engineering) we call the woo-addicted “management.”

  18. Fredeliot2 says:

    What about a science based patient encountering health care professionals that suggest CAM. This has happened to me and I was shocked. I responded by citing Dr. Novella blog and podcasts, although, I don’t think it had much effect.

  19. Harriet Hall says:

    “What about a science based patient encountering health care professionals that suggest CAM.”

    How about screaming loudly and demanding another health care provider?

  20. DLC says:

    A good article.
    And I also agree with Harriet Hall above.
    If your medical practitioner advises you to try scam, scram.
    Do not walk, Run to the nearest exit.

  21. pmoran says:

    Some over-simplification of complex matters, I fear.

    EBM provides excellent guidance as to what to do for patients having defined conditions that have clearly effective treatments (relative to cost and risk). No one here questions that and I wonder why we have to keep on saying that in different ways.

    And who would argue against advising patients in the strongest terms regarding obviously fraudulent or quack treatments that do nothing but cost the earth, such as the Burzinski treatment for cancer, or highly suspect stem cell therapy for anything at all.

    But when a migraine patient asks about acupuncture, it is probable that your treatments are either not working as well as the patient would like or they are having unwanted side effects from them, and they are probably simply hoping for your permission to pursue it. At this point, where the best possible conventional measures are not solving a problem, what is most important — the best interests of the patient, or the adherence to a rather narrow interpretation of what the science says about acupuncture and similar, predominantly placebo treatments?

    What the science says fairly clearly is that they might just help such a patient a little — or perhaps a lot, depending on many factors — we don’t know for sure, and we should not in a SBM blog be pretending that we do.

    I thought KA was similarly slightly off-target when defining the primary ethical obligations of the physician as being to science without even mentioning the patient. That would certainly apply in an ICU or in the operating theatre, and in most specialist neurological or oncological practice (hint!), but there may be quite sound reasons why many family doctors don’t yet want to completely abandon dubious but relatively safe methods in favour of the contents of their drug cabinet.

  22. Azinyk, your ideas could work on the Internet. If anyone were willing to post a site devoted to exposing quackery, I would be happy to make a modest financial contribution.

    Pmoran, I have to agree with you. In medicine there is what we know, what we don’t know and what we suspect. (All with varying degrees of certainty, of course, depending on available evidence.) With that information patients can make their own decisions.

    Regarding running away from an MD who advises sCAM and finding another doctor, easier sad than done. Getting an appointment with a doctor, is not very easy anymore in many places.

  23. delaneypa says:

    “Religious beliefs should be completely out of bounds. It is not the place of the physician to validate or refute personal religious beliefs.”

    I once had a patient tell me that they didn’t want the flu vaccine “because God will protect me from it.” I pointed out that God killed 36,000 American annually via flu…a comment which elicited only a blank stare.

  24. DBonez says:

    Like anything faith-based, especially science-based medicine vs. CAM, the first question should be IF it is real, not which to choose from. With such a profound lack of skepticism in modern cultures, virtually everything presented to us is taken at face value and assumed to be real and valid until proven otherwise.

  25. DBonez says:

    “You groused something like, “Imagine if they invaded your professional field.” No one picked up on that–at least in the edited version of the podcast–but I immediately thought of your good efforts on this blog.”

    You learn to cope, but continue in disgust trying to keep a clear line established where science ends and woo begins. In my hobby (high-end audio) we call the woo-addicted “audiophiles.”

  26. Zetetic says:

    Some comments…

    rjstan – There IS a web site that debunks quackery quite regularly, look up James Randi’s JREF site.

    Concerning EBM providers that actually recommend CAM, there are some health care organizations that actually refer to CAM as a sort of blow-off valve. The patient has already been evaluated and there’s nothing wrong with them and if they go to a CAM provider, they don’t keep returning with non-problems and wasting the EBM provider’s time. I’ve read that some organizations even employ CAM providers (at a lower wage) for this function.

  27. mjranum says:

    Religious beliefs should be completely out of bounds. It is not the place of the physician to validate or refute personal religious beliefs.

    Really? What if the beliefs are stupid and are going to kill the patient? I.e.: “I’ll just let prayer heal me.”

    It sounds like the medical profession has gotten a serious dose of Euro-style cultural relativism and lost track of the two facts that:
    a) you are there to help the patient
    b) you often (almost always?) know better than the patient

    There’s no difference between a religious belief in the healing power of prayer and a personal belief in the healing power of homeopathy. They are both delusional and stupid and – perhaps with a bit of tact – yes, patients should be told that.

    I read this blog, and Orac’s blog, with considerable interest. What I see are real doctors who are trying to understand medicine in a scientific context, agonising over the fact that woo woo and pseudoscience is gaining ground on all fronts. Yet, you conclude that “it is not the place of the physician to refute religious beliefs”? Well, if you’re going to roll over and play dead like that, then you can’t complain about the onslaught of woo, since religion/magical thinking are the ur-source of most of the woo in the world.

    mjr.

  28. Zetetic, “There IS a web site that debunks quackery quite regularly, look up James Randi’s JREF site.”

    The JREF site is a SKEPTIC site that debunks “WOO”. How many people know what the Skeptic definition of woo is? How many care?

    Quackwatch is an excellent site that exposes quackery. It does so by presenting well researched, factual articles. My site exposes quackery, but there is a need for more sites, many more sites, that expose quackery, sites that use methods other than just the written word, like visuals and maybe audios, to educate the public, sites that offer the type presentations described by azinyk, sites which, like QW and mine, target the general public rather than elitest intellectuals who become as upset about things like dowsing and psychics as they do about the wholesale ripoff of the general public by a billion dollar industry built on fraud and things like ephedra which killed and seriously injured many human beings exactly like pharmacologists had predicted they would.

    Not everything irrational is dangerous. Not everything irrational is criminal. Irrational beliefs have always been around and always will be. Everyone is entitled to his beliefs irrational or otherwise. However, when you start making claims you can’t substantiate to sell goods and services, you are committing fraud. Most people are disturbed by fraud. Most ignore or laugh at irrational beliefs, other than their own, of course.

  29. mjranum – You misread me. I did not say roll over and play dead – I said it is not the place of a physicians to confront the religious beliefs of their patients, and that is true. But you still can challenge their decision not to receive treatment, and you can advise them to seek counsel that may change their mind. You should also let them know, in no uncertain terms, what the consequences of their actions are likely to be. You just shouldn’t tell them – your faith is wrong and stupid.

  30. pmoran,

    I disagree. There is great potential harm in supporting dubious treatments, even if there are no EBM options. These treatments are no given in a vacuum – patients will often seek out such alternative therapies for symptomatic relief, but then may rely upon them when they have a serious illness. They may get a placebo effect for their migraine, then think that “acupuncture works” and then go to a medical acupuncturist for their cancer.

    It is OK sometimes to do nothing, if there is no intervention that is more likely to help than to harm.

    Also – we never have perfect knowledge in medicine. That doesn’t mean we can’t make decisions. I can scientifically assess the plausibility and evidence for acupuncture and say it is not worth it – I don’t recommend it. Patients can still make up their own minds. If I tell them to try it – simply because we don’t know (which in this case is not even true) they will take that as an endorsement. Again – this makes patients vulnerable to bad medical decision-making down the road.

    You presented a false dichotomy – the best interests of the patient or narrow science. I think the best interests of the patient are served by an uncompromising adherence to science-based medicine. And there is nothing narrow about SBM – it acknowledges that medicine is an applied science, that we make decisions in the absence of solid data. But there are treatments that fall below the bar – and we should not endorse them, even tacitly by not rejecting them.

  31. Harriet Hall says:

    pmoran and steven novella,

    Isn’t there a middle ground? I think you’re both right. We can have uncompromising standards about scientific grounds, but we can also have compassion for patients who might get a placebo response or a psychosocial benefit from an irrational treatment.

    Do either of you object to the approach I have proposed in the past? Not suggesting acupuncture. Waiting for the patient to ask “What about acupuncture?” Explaining that you do not recommend it and why. Leaving the door open for the patient to try it anyway. Asking the patient to come back to you for followup. When the patient says he feels better, tell him you are glad, although you doubt that it was due to the acupuncture. If this is done right, you and the patient can agree to disagree and can maintain an attitude of mutual respect, and you can continue to monitor his overall medical care and make sure he isn’t trying anything dangerous.

  32. Harriet,

    This is not different than what I am saying. I never said I would refuse to see the patient back if they tried acupuncture – they may go ahead and try it anyway, etc.

    Explain to them why you do not recommend it – but in a way that is not judgmental of them. I have had plenty of patients who ignored my advice and used unscientific treatments. I do not judge them or condemn them in the context of our doctor-patient relationship. I simply explain to them how I interpret their experience (positive or negative) scientifically and what I recommend going forward and why.

  33. David Gorski says:

    I was actually asked this very question in an interview the other day. (Stay tuned; if the article ever makes print, I’ll post a quick blurb to this blog.)

    My take on the matter was that I would give my opinion about such remedies if asked, but I don’t generally tell patients not to use them as long as (1) they are undergoing effective anticancer therapy and (2) according to my best medical knowledge the remedy they are using does not interfere with science-based treatment.

    The reason is that, ethically as a physician, my first obligation is to the patient and seeing that the patient is treated as effectively as she can be (sorry, Kimball, my first obligation when treating a patient is not to science or reason). Telling a patient too stridently that her dubious therapy is, well, a dubious therapy risks doing one of two things: (1) driving her away from effective science-based therapy or (2) making her reluctant to tell me everything she is taking. Neither of these are good. #1, of course, means that the patient takes the risk of dying of cancer or not getting adequate palliative treatment by choosing woo over medicine. #2 risks interactions with the treatments the patient is undergoing that I can’t know about because I don’t know that the patient is even taking the therapy because the patient no longer trusts me enough to tell me. This is a particular problem with herbal medicines, some of which can affect clotting, and except when anticoagulation is needed for a specific purpose during the operation, surgeons hate operating on patients whose clotting system is not intact.

    I suspect it’s because of my specialty and the horrible consequences of a patient not getting effective treatment (which is why I tend to echo Dr. Moran), but my attitude has become: As long as they tell me about it and it doesn’t interfere with scientific-based treatment, patients can do whatever they like. If they ask my my opinion, I will tell them, as non-judgmentally as possible, but I’m not going to push too hard.

    In the case of a cancer patient who chooses woo over science and won’t take effective therapy at all, then Harriet’s strategy strikes me as about right. A physician should never shut the door to the patient coming back and never, ever gloat if a patient comes back because the woo they chose didn’t work. However, there is one risk with this approach, and it is, sadly, a medical-legal issue. Continuing to follow a patient this way risks implying approval of the course of action and risks the family suing after the patient deteriorates or dies. That’s why rigorous and accurate documentation that the patient was informed of your medical opinion and of the rationale for following the patient this way is essential.

  34. pmoran says:

    pmoran,

    SN> I disagree. There is great potential harm in supporting dubious treatments, even if there are no EBM options. These treatments are no given in a vacuum – patients will often seek out such alternative therapies for symptomatic relief, but then may rely upon them when they have a serious illness. They may get a placebo effect for their migraine, then think that “acupuncture works” and then go to a medical acupuncturist for their cancer.

    PM I am glad you agree that acupuncture “may” help the migraine patient. What else really needs to be said? Are you not rationalising a position that is based primarily upon an (entirely understandable) emotional reaction to the pseudoscientific theories behind acupuncture? I suggest that the patient will be MORE inclined to trust and listen to you in the future if they sense that you value their welfare over all else and are willing to tolerate alternative use “just in case” it might help. Your position is paternal, and underestimates the discrimination that the public generally actually displays in the use of alternatives.

    SN It is OK sometimes to do nothing, if there is no intervention that is more likely to help than to harm.

    PM Agreed. My very thesis is that we are dealing with an ordinary cost/risk/benefit situation that should be assessed dispassionately along the usual evidence-based lines, not emotionally driven opinion.

    SN Also – we never have perfect knowledge in medicine. That doesn’t mean we can’t make decisions. I can scientifically assess the plausibility and evidence for acupuncture and say it is not worth it – I don’t recommend it. Patients can still make up their own minds. If I tell them to try it – simply because we don’t know (which in this case is not even true) they will take that as an endorsement. Again – this makes patients vulnerable to bad medical decision-making down the road.

    PM Yes, it is tricky what to tell the patient. If you truly wish them well and hope that they have a placebo response, then you will not wish to wholly dampen any expectations they may have of acupuncture. Harriet has a sensible approach. One of the advantages of family practice is the bond that builds up over time such that a good doctor knows instinctively what to say to any given patient.

    You presented a false dichotomy – the best interests of the patient or narrow science. I think the best interests of the patient are served by an uncompromising adherence to science-based medicine. And there is nothing narrow about SBM – it acknowledges that medicine is an applied science, that we make decisions in the absence of solid data. But there are treatments that fall below the bar – and we should not endorse them, even tacitly by not rejecting them.

    PM No, I said a “narrow interpretation” of the science . The science is wholly compatible with the existence of significant benefits from placebo treatments.

  35. mckenzievmd says:

    I was very interested in this article as I am frequently confronted with the very problem it addresses, and I found many of the suggestions sensible and helpful. I do have to add my disagreement though with the blanket statement that confronting a patient’s religious beliefs or value system is inappropriate. One’s worldview is not easily separable into non-overlapping magisteria, with philosophical beliefs about the universe in one box and beliefs about medical interventions in another. CAM is appealing to people whose worldview is sympathetic to faith as a justification for persisting in a belief or practice despite the evidence against it. We cannot effectively combat the irrationality of CAM without promoting reason and evidence as the best strategy for decision-making, and this effort is hamstrung by privileging religious belief and refusing to challenge it. We only do so, I believe, because the dominance of religious belief in our culture makes it difficult and threatening to challenge, not because it has any intrinsic claim to an exemption from rational critique.

    As Dr. Novella points out, quite correctly, insulting, demeaning, or browbeating one’s patients is of course inapprorpiate, and likley to be ineffective. But pointing out the irrationality of a particular justification for a medical decision and the evidence against it, even if it is a religious justification, is entirely within bounds. When I have a client who refuses to euthanise a pet in horrible pain because their religious beliefs do not permit euthanasia, I am obliged ethically to offer them, as compassionately as possible, my professional and personal opinion that they are prolonging the unecessary suffering of a loved one. People do not like to be told this, but I have abdicated my responsibility to my patient if I refuse to tell my client something they don’t wish, but need, to hear.

    Stephen J. Gould advanced the NOMA concept, that science and religion need not come into conflict, and there are some arguments of political expediency along this line that have some merit. But ultimately, if we intend to promote reason, science, and logic in medicine, we defeat our own efforts by refusing to critique the most potent form of philosophical opposition to reason and science, the notion of faith as superior to reason and evidence in determining truth.

  36. marilynmann says:

    I wish there were more physicians like you. Just in the last few weeks, I have had one physician tell me I should try acupuncture for neck and shoulder pain, and another send me to a physical therapist who told me I would not recover without acupuncture, which she of course provides. In the latter case, I do not know whether the doctor who recommended the PT was aware of her acupuncture sales pitch (I ended up going elsewhere).

Comments are closed.