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Between a Rock and a Hard Place: A Case Study Exploring the Battle Lines of Science Based Medicine

Editor’s Note: This is a guest post solicited by Dr. Hall, who describes Dr. Albietz thusly: He’s a skeptical young pediatrician who works in a PICU and recently had a chiropractor come into the PICU to consult on a child with intractable seizures. He was sort of coerced to allow this at the parents’ request and against his better judgment. His hospital had set a precedent of letting alternative practitioners have temporary privileges in cases like this. He was torn between his academic integrity and doing the most humane thing for the patient and family.

Primum non nocere.” First, do no harm. It is a guiding principle of medicine, and one which is next to impossible to achieve in practice. It is difficult for the general public to hear, but any intervention a physician makes, and indeed the decision to make no intervention, carries a risk of harm with it. Given enough time, every physician will make a decision which results in unintended harm to a patient, even death, and it haunts us every day of our careers. Faced with this horrible certainty, what is one to do? The only responsible, ethical position to take is to ensure that each patient receives the care most likely to generate a positive outcome, in other words, to stack the deck as steeply in favor of the patient as is possible. Diligent application of the scientific method to every therapy, novel and new, old and venerated, is the only way we as physicians can be certain we are doing the greatest good and the least harm to those who seek our help; it is the only way to assuage our conscience if things end badly.

Our professional organizations and academic institutions have been vital in formulating, propagating, and enforcing the practice of evidence based medicine (EBM). They have stood, to borrow the phrase from Carl Sagan, as “a candle in the dark,” promoting the best practices and protecting patients from those that are ineffective, fraudulent, harmful, or even simply sub-standard. It is a heartening environment in which to work.

With increasing distress, I and others have watched, and I fear have been complicit in, the assisted suicide of EBM at the very moment it is reaching maturity. While our academic centers have supported EBM, they have simultaneously allowed its antithesis to take root within their very halls under the misnomer of Complimentary and Alternative Medicine (CAM). As CAM is almost by definition non-evidence based, EBM and CAM are guaranteed to come into conflict in practice.

This conflict is one I was certain I would confront in due time, but not on my very first day as a newly minted faculty member. Few things are as stressful to a family as an acute, severe illness. The disruption of normal life, reminder of mortality, financial burden imposed, and in particular the loss of control are trying to everyone who finds themselves in the intensive care unit. These factors are magnified when the victim is a child. When faced with the critical illness of their child, parents will seek help from any source they feel may hold the slightest glimmer of hope. Frequently this will lead them to some form of pseudoscience. It is not uncommon, then, for me to be faced with questions about homeopathic treatment for a child with a severe infection, herbal supplementations for a metabolic disorder, or chiropractic after a car accident.
In most situations, such questions are a request for more detailed discussion about their child, for reassurance, or for insight into what I and the other physicians are actually thinking about. Sometimes a rational explanation of why any given pseudoscience is unhelpful and may put their child at risk is enough to explain why my preferred needle is an IV and not acupuncture. Even in the situation where families are staunch believers in a pseudoscience, most recognize that the intensive care unit is not the place for its application. Such was not the case on my first day.

Among the children in my care was a 6 month old child with a new onset of seizures. He had appeared to be previously healthy, but now was on a breathing machine, heavily sedated, and would seize again whenever his medicine was lightened. Frustrating to his family and his caregivers was the lack of a clear diagnosis, a reason for his aggressive seizures. My team and I took a great deal of time every day to explain what we knew and what the plan, both short and long term was for their child, and even went so far as to involve the family in our daily rounds. In spite of these efforts, their dissatisfaction grew, and their relationship with me and the care team became increasingly antagonistic.

While I worked with many sub-specialists and pursued causes both likely and less so, his family pursued its own investigation. The child’s uncle was a chiropractor, and told them of another chiropractor who claimed to specialize in neurological problems. The family asked on several occasions to have the neuro-chiropractor brought in to the hospital and officially consulted by my team.

Here then, is the crux, the conflict. EBM or CAM? Shall I refuse to involve the chiropractor, as there is no reason to suspect he has anything of value to add, and significant risk to the child can be incurred with manipulations? In refusing the family’s explicit request, I would almost certainly undermine their trust, making it more difficult to provide the care this child will continue to require. In protecting this child from the chiropractor and preserving my academic integrity, I would sacrifice any hope for a healthy collaborative relationship with the family. On the other hand, I could grant the family’s desire to have the chiropractor become a functioning member of the medical team, which would bolster their confidence while exposing the child to risk without benefit, and sacrificing both my and my institution’s academic integrity.

As though this situation were not already difficult, there is precedent within my hospital to allow temporary privileges for chiropractors to see children while they are inpatient when families have requested it. Furthermore, the university we are affiliated with is one of dozens of major institutions which now teach elements of CAM in medical school and who have a section of CAM within the university. Put bluntly, this means that if I as the attending physician were to make a stand at this child’s bedside against the involvement of chiropractic within my ICU, I would not have been supported by my own administration.

In this child’s case, I opted for a compromise between the two polar alternatives I described. I allowed the chiropractor a one time visit to see the child, under the stipulation that his visit be supervised by me while he examined the child, and that no manipulations of any kind would be done before consultation with both myself and the involved neurologist. I would gladly speak to him and the parents together regarding our thoughts on the case, and take his recommendations under advisement, but would be under no obligation to act upon them.

The chiropractor’s recommendations were a bit surprising. He had no interest in spinal manipulations of any kind. The philosophy under which he labored was that he needed to encourage “normal neuronal pathways.” This amounted to gentle tactile stimulation, passive range of motion exercises, having the parents talk to the child, and playing music he claimed was specially designed to stimulate different parts of the brain. He also made dietary and nutritional recommendations, which included continuing to use breast milk (he was stunned and impressed I would “allow” such a thing to happen), and supplementing his mother’s diet with fish oil. Further herbal recommendations were made directly for the child; these I flatly refused to entertain without knowing the exact contents and pharmacologic interactions. In the end, the family was pleased by the visit, we enhanced our relationship with them, and prevented the child from coming to harm.

In this episode, I don’t feel that it was in the child’s best interest to fight the battle between EBM and CAM at his bedside (though I acknowledge that such a fight may be required under different circumstances). In hindsight, though, I feel it could have been handled slightly differently. We frequently have priests, imams, prayer sessions, rabbis, etc visit children within the PICU and make no special arrangements. We will speak to these people about their thoughts on the patient and the family’s condition, if they so desire. We do not, however, seek to give them privileges within the hospital. I think that I should have allowed the family to have the chiropractor visit as they would any other family friend, and if they wanted me to speak with him, I would agree to do so. This would have allowed the family to be heard and to have their needs sated without giving the mistaken impression of treating a chiropractor as an equal.

What are we to make, however, of the situation within our academic institutions? As long as CAM is supported, EBM will remain difficult to practice. The public will become more confused as to what constitutes safe and effective medicine, funds will be wasted on futile projects, and medical progress will be retarded. Most concerning, the next generation of physicians, immersed in the mutually exclusive principles of CAM and EBM will be poorly prepared to provide the best possible care to their patients.

The current political, commercial, and academic powers have been ineffective at preventing the corrosion of the principles of EBM. We have a professional and ethical obligation to strengthen and reform the intellectual infrastructure of medicine. If, however, it is no longer sufficient for physicians to align themselves with existing organizations in order to stand clearly in support of EBM, it may be time to develop a way for physicians and health care professionals who practice science based, evidence based medicine to publicly stand up and be counted.

Primum non nocere. An unattainable goal it may be, but a relentless commitment to EBM is the only way for us to honor our duty to our patients and our profession. To compromise for anything less is unacceptable.

Posted in: Chiropractic, Medical Ethics

Leave a Comment (26) ↓

26 thoughts on “Between a Rock and a Hard Place: A Case Study Exploring the Battle Lines of Science Based Medicine

  1. The Blind Watchmaker says:

    I share your feelings on this subject. The physician does not want to alienate the patient or the patient’s family by shunning their wishes for non-rational treatments. But at the same time, the physician does not wish to pander to the same non-rational beliefs and give the appearance that such beliefs are legitimate “alternatives”.

    I am afraid that my own hospital is doing some market driven pandering of its own. To quote from a recent disturbing memo, we now we have a new “Integrative Medicine Department” that is “pleased to offer your patients more options to enhance their medical care. In addition to medical acupuncture, massage therapy, and guided imagery, Integrative Medicine now offers two Naturopaths and two Traditional Chinese Medicine (TCM) practitioners.”

    I have no problem with promoting relaxation techniques and massage to ease the stress of hospitalization, but when we start presenting acupuncture as a legitimate medical therapy to our patients and their families, it gives a very conflicting signal. Hopefully, patients will not start refusing legitimate treatment in favor of such practices, and get such treatments under the very roof of my hospital.

  2. Militant Agnostic says:

    Isn’t medical acupuncture an oxymoron?

    How does it differ from traditional accupucture (other than propably being more expensive).

  3. Harriet Hall says:

    Perhaps the distinction is not betweeen “traditional” and “medical” but between “medical” and “cosmetic” acupuncture.

  4. Joe says:

    Harriet, I don’t understand your comment. “Medical” acupuncture (AAMA) looks as loopy as any other form one might name http://www.medicalacupuncture.org/acu_info/articles/helmsarticle.html

    Joseph, perhaps the chiro explained to you that they have recently begun issuing “diplomas” in various specialties. I forget most of them, but I suspect the one you met listed DABCAN as a credential (most, if not all, begin with DABC).

    Yours is a fascinating, and depressing, account. It is sad, and dangerous, that families can insist (with the hospital’s backing) that a quack be allowed in. You explained, convincingly, why you acceded to the request. I think you did the best thing.

    I hope the baby is okay.

  5. ReedE says:

    Great article Joe. A question that popped into my mind:

    If the child had died would the family have blamed you for not giving the CAM practitioners a free(r) hand?

    I fear the day when a jury finds that a physician as yourself has committed malpractice because you resisted consulting CAM practitioners.

  6. bcorden says:

    Good luck in your career. I used to practice pediatric oncology in the Southwest. Not infrequently the Navajos would request to do a “sing” over a seriously ill child. I don’t remember them ever getting privileges, though.

  7. MBoaz says:

    “Primum non nocere,” and yet the broader medical community seems to have no interest in protecting their patients by battling back against the quackery that is infiltrating their profession. Do no harm to whom? To patients, or to ones own self/practice/institution by enduring the PR nightmare that would be a full-fledged war against “CAM.” Ironically, it seems as though the quacks criticisms of the heartless medical establishment are lent some credence by the medical community’s unwillingness to stand up for science based medicine, and stand against these charlatans for the good of public health.
    Excellent article, and I absolutely understand your decision. You have to pick your battles, and you stood to gain nothing by objecting in this case. But man, it’s getting scary out there.
    Reed, I want to believe that such a scenario is too ludicrous to imagine, but at this rate. . . . .

  8. overshoot says:

    I fear the day when a jury finds that a physician as yourself has committed malpractice because you resisted consulting CAM practitioners.

    It’d make a Hell of a dramatic show, though, wouldn’t it? (I’m imagining something deliberately along the lines of Inherit the Wind.)

  9. weing says:

    This is really getting too much. It is enough when patients go by themselves to a quack. But when they demand your validation for their seeing a quack, that does make you legally accountable if you acquiesce to their demands. Looks like you’re stuck between Iraq and Iran.

  10. David Gorski says:

    It’d make a Hell of a dramatic show, though, wouldn’t it? (I’m imagining something deliberately along the lines of Inherit the Wind.)

    Sounds like a plot for Law and Order. ;-)

  11. LOL, I was thinking Law & Order, too. :D

    Thanks for writing up this account, Dr. Albietz. This is very interesting and very disturbing. You’re right, the erosion of EBM and SciBM is already well underway when hospitals permit CAM practitioners privileges. FWIW, I think you did the right thing in the situation. The hospital, however, is sacrificing patient care in hopes of bringing in more customers from the credulous demographic. What do you medical professionals see as the best solution to this problem of hospital administrators being too CAM-friendly?

  12. Zetetic says:

    How about intiating a hospital policy where EBM providers write up a strongly worded informed consent wavier policy for CAM?

  13. nitpicking says:

    As a nonmedical reader, my immediate thought was “What happened to the child? What caused the seizures in reality?”

  14. hatch_xanadu says:

    Yes, I’m curious to know what happened to the little fella as well — and whether or not the family attributed the outcomes to the chiropractor’s “healing” and/or blamed you for not allowing him in sooner. I realize there are privacy issues involved, but you can’t leave us hanging like that!

  15. LRosa says:

    I don’t think Harriet Hall got her wording right when she implied that allowing the chiropractor into this case was, as an option, “the most humane thing for the patient and family.”

    Joseph, you were lucky this chiropractor stood by his agreement and was surprisingly conservative in his recommendations. I think it was Steve Barrett or maybe Bill Jarvis who got a free coupon for a chiropractic exam and asked the chiropractor just for his assessment — no adjustments. This chiropractor proceeded to give a our quackbuster friend a rapid neck adjustment without even a warning.

    Not that the success rate is great — and it takes more time than we usually have — but I think health professional have the responsibility to explain to patients and their family why a particular CAM practice is worthless/risky. How else will they get fully informed? One problem is that not all that many health professionals appear to be knowledgeable about CAM practices.

    Joseph’s story is an important cautionary tale of why we need to deal with daft CAM policies at hospitals and medical/nursing schools before situations involving patients arise. Once a hospital allows CAMsters in the door or staff to provide CAM, the game changes dramatically.

    My question: Is there a hospital anywhere today that is free of CAM?

    – Linda Rosa, RN

  16. Danio says:

    Sounds like a plot for Law and Order.

    Funny, I was thinking of ‘Eli Stone’, in which the jury sticks it to the formerly smug Big Medicine fat cats and awards millions to the CAM-lovin’ plaintiffs. It’s disturbingly easy to imagine, actually.

  17. Harriet Hall says:

    Linda,

    I’ll defend my wording. Joe was forced into choosing the lesser of two evils. The circumstances were unfortunate, and I’d like to see them dealt with before more cases arise, but at that moment, when the family was suffering, Joe’s approach was a humane compromise. I thiink he did the right thing.

  18. LRosa says:

    Dear Harriet,

    The “most humane” thing still strikes me as an odd way to describe “the lesser of two evils.” I did not mean to second guess Joe’s decision in this case. I certainly think that considering this situation, he was the best person to be involved.

  19. CAMbeliever says:

    I am a disabled RN who is a firm believer in CAM and especially chiropractic. A friend directed me to this site and out of curiousity, chiropractic was the first I visited. I herniated 4 disks lifting a patient. After unsuccessful back surgery left me in a wheelchair, I was rudely dismissed by the neurosurgeon: “Get used to the wheelchair, take your morphine and just deal with it” Well, prayer directed me to chiropractic and within 6 months, I wasn’t even using a cane, wheelchair stuck in a closet and I got off over 20 medications. I got my life back. Your attitudes are DANGEROUS to your patients. The neurosurgeon told me chiropractic would paralyze me…well guess what, I’m walking! The only reason there are few “evidence-based” studies proving efficacy is that big pharma, big medicine and big government aren’t willing to fund the studies because it would hurt their pocketbooks. A chiropractor, acupuncturist, herbalist etc are a lot less likely to HARM the patient than an allopathic physician who knows nothing more than how to prescribe poisonous drugs. CAM is proof the 2 can live side by side and they should. There is a place for both and sometimes even at the same time. Listen to your patients, read and learn. You are NOT GOD and you don’t know it all.

  20. Joe says:

    CAMbeliever on 04 Jan 2009 at 2:22 pm wrote “… Well, prayer directed me to chiropractic and within 6 months, I wasn’t even using a cane, …”

    Anecdotes are never persuasive. You may have had the same result from aromatherapy, or poetry therapy etc. In other words, it just took time.

    The reason that there is no definitive, scientific support for chiropractic claims is not lack of funding. They conduct and publish many studies. However, those studies are mostly low-quality, and the better studies do not support their claims. So, they proceed “as if” their notions are correct and simply need the right research to confirm that.

    In the particular case of government funding, Congress set up the National Center for Complementary and Alternative Medicine specifically to fund the most ridiculous notions. If chiropractors cannot compete with faith healers for that funding, that is quite pathetic.

    CAMbeliever on 04 Jan 2009 at 2:22 pm wrote “The neurosurgeon told me chiropractic would paralyze me…”

    So, you took your chances and got away with it. I am pleased to read that. I don’t know how long you practiced as an RN; you should know that prognoses can be reliably based, yet wildly inaccurate. Consider the fact that most people with ALS die within a couple years of diagnosis, physicist Stephen Hawkins has had it more than 40 years.

    The fact that you got better does not prove it was due to the chiro, and the fact that the chiro did not (has not yet) caused further harm does not prove that is not possible.

  21. W.L. Reinholt says:

    What are we to make, however, of the situation within our academic institutions? As long as CAM is supported, EBM will remain difficult to practice. The public will become more confused as to what constitutes safe and effective medicine, funds will be wasted on futile projects, and medical progress will be retarded. Most concerning, the next generation of physicians, immersed in the mutually exclusive principles of CAM and EBM will be poorly prepared to provide the best possible care to their patients.

    When bottom line is of higher priority than “being right” where law plays second role to profit…you are bound to lose as you stand for clarity of purpose of practice.

  22. W.L. Reinholt says:

    To CAMbeliever…whatever was done that enabled you to experience the benefit you present here…as happy as I am for you…the sad reality is that there is no scientific basis to substantiate that which they did…no scientific evidence that what they said was wrong…leading them to do what they inferred they were going to do…and thus…other than that which you experienced…that is all that can be shown to have happenned. That being said…what is the medical practitiuoner to do? Recommend an unscientific procedure?
    What happens to him/her if they do that because you may want his/her support to lok elsewhere…and out of what they see as the way for them to go at this time…they too want to avoid that…so they support your desire to look out side the medical community…and it fails? Where does that leave them?
    Scientists are not God but something that is not scientifically approved…should both not be accpeted as the thing to do…nor should it be presented as science based.
    That is precisely the lot of CAM. Unproven claims.
    I can see why you are a CAM believer…and I will give you the benefit of the doubt…your belief came on the heels of the results…and that is why you are a believer…if I am correct their then it rules out “belief” in what they did that got you well…but as to what was done that provided the benefit you describe…as long as that procedure continues to fail the test or burden of proof…it is just one of those situations that verifies the reality that there is more to uncover.
    Medical science is based on proven methods and I hope it stays there.

  23. NuccaDoc says:

    “Medical science is based on proven methods and I hope it stays there.”

    Ahh, the repetitive cry of the “EBM” anti-CAM crowd.

    The only problem with that statement is that it is based almost purely in faith rather than in evidence – quite funny really when you consider the source!

    Point me to one single GOOD study that shows that back surgery (laminectomies, discectomies – take your pick!) is worth the risks associated with it from an EBM standpoint. Roughly 50% of back surgeries provide no help at all or make the patient worse following the treatment, and the number of “successful” cases drops to about 10% or less by the 5-year mark. But of course – that “scientifically-based”!

    Less than 25% of the medical procedures performed actually have literature to back them up. It’s not that you cannot practice CAM and be “EBM” … it’s that you cannot practice ANY level of healthcare and be truly EBM.

    Another one of my personal irritations with EBM anti-CAM sycophants is that “science” is not purely deductive in nature … no matter how much you holler that it should be! Science would not exist without inductive reasoning and innovation, and guess what … your “medical progress” would be non-existent without people working outside of purist EBM. We live in an expanding world of knowledge and the constant cry from the anti-CAM wing is that they don’t want other avenues of thought explored – heaven forbid something good might come of it that they didn’t think of first!

    The primary failing of nearly every EBM-crazed practitioner I have met is that they fail the defining characteristic of a knowledgeable person …. that being the ability to realize how little they/we actually know! I’m in no way against EBM, but the simple realization MUST be made that the current understanding of a human being is far too inadequate to allow you to follow a rote set of steps from a couple of very limited studies. Inductive reasoning, educated opinion, and synthesis of all available information must take place on a case-by-case basis for quality care and favorable outcomes to occur.

    As a side note, I too am very interested to see if all Dr. Albietz’s EBMitude managed to determine the cause of the girls seizures and if she has successfully recovered.

  24. Dr Benway says:

    Tu quoque.

    If many or even all “EBM” doctors fail to live up to the standards of EBM, that would mean those practitioners might be hypocrites or failures. However, it would not mean that “alternative” treatments are somehow more valid.

    “Roughly 50% of back surgeries provide no help at all or make the patient worse following the treatment…”

    Assuming this is true, it demonstrates the self-corrective nature of science. Medical practice can change as the evidence dictates.

    Why do we not see much change in practice thanks to evidence on the alt med side?

  25. daedalus2u says:

    Wow, if 50% of back surgeries provide no help or make it worse, that means that the other 50% provide improvement.

    50% of back surgeries provide improvement? Seems pretty good odds to me.

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