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CAM as a Dumping Ground

I know a woman who is a survivor of colorectal cancer. At one point, doctors had given up hope and put her in hospice, but she failed to die as predicted and was eventually discharged. She continues to suffer intractable symptoms of pain with alternating diarrhea and constipation. I don’t have access to her medical records, but she tells me her doctors have talked about irritable bowel syndrome (IBS) and have also suggested that the heavy doses of radiation used to treat her cancer may have caused permanent damage to her colon. Whatever the cause, her symptoms have seriously interfered with her mobility and her quality of life. Her health care providers have recently recommended questionable treatments in what I think can be construed as using CAM  as a dumping ground for difficult patients.

The Surgeon

Colonoscopy hadn’t shown any obstruction, but one of her doctors had hypothesized that her symptoms might be due to impaired bowel motility in the irradiated area. She was desperate enough to consider surgery if there was a chance that bowel resection or colostomy might improve her symptoms. She belongs to a large, well-known HMO with a good reputation. She asked her primary HMO physician who thought the idea was plausible and referred her to a surgeon. The first surgeon said surgery was not indicated and referred her to another surgeon on staff. In addition to being board certified in general surgery, the second surgeon was allegedly board certified in something related to CAM (my friend can’t remember his exact words and has been unable to verify any such credentials online).

The surgeon recommended acupuncture, not once but twice. My friend’s husband (who teaches statistics at a nearby community college) told the surgeon that he was fascinated by the challenges of double-blinded studies of acupuncture and that he was aware of no benefits beyond the placebo level. The surgeon then retreated a little and suggested that the primary benefit of acupuncture in treating IBS was the “relaxation” effect.

They asked about referral to a dietitian and the surgeon made some very negative comments about dietitians, saying they were “too conventional” for his taste and were in thrall to the department of agriculture. In addition to her current treatment, he prescribed the probiotic Fortefy, digestive enzymes (Source Natural), and fiber: whole psyllium husk titrated to produce BM’s like ripe banana. There is some evidence to support probiotics and fiber for IBS, but it is far from conclusive. I couldn’t find any evidence that digestive enzymes taken orally are effective in IBS, and I don’t understand why he would recommend a diet supplement product over a prescription enzyme preparation designed to resist destruction by the digestive process. Moreover, if three new treatments are started at once and the patient improves, there is no way to tell which (if any) is responsible: if only one of the three was effective, the patient might end up unnecessarily continuing to use two ineffective treatments.

The Dietitian

The patient then made an appointment with a dietitian on her own initiative. The dietitian gave her a big spiel about an inflammation-free diet and gave her several handouts. One of the handouts offered this overly simplistic justification for the diet:

Inflammation and Anti-inflammation compounds are produced in our body from the food we eat. Pro-Inflammation is Omega-6 and Anti-Inflammation is Omega-3. The US diet contains way too much omega-6 (20/1 ratio which should be about 2/1). We eat too much grains (omega-6) and not enough veggies and legumes (omega-3). Even the cattle we eat are primarily grain fed as is farm fish. This all results in too much inflammation in our body. Heart disease is promoted by excess inflammation.

It recommended monitoring inflammation levels with a C-Reactive Protein (CRP) test, saying “It is now the standard test.” (Sez who? Standard for what? Validated by whom?)

Note: CRP is a marker of inflammation whose clinical usefulness is limited. It rises in many conditions including pregnancy, infections, burns, and rheumatoid arthritis. it has been associated with atherosclerosis but it is not independently useful for predicting heart attacks. Dietary and other interventions may lower CRP, but the “anti-inflammatory diet” has not been tested for this, and we don’t have any evidence that just lowering CRP alone would result in better health.

Another handout recommended monitoring inflammation with a complex “IF” rating that supposedly incorporates more than 20 pro- and anti-inflammatory factors. A separate, several-page handout listed the IF numbers for a long list of foods. The IF rating was apparently a solo invention of Monica Reinagel, a nutritionist who wrote The Inflammation Free Diet Plan. As far as I could determine, it has never been validated or shown to have any clinical usefulness.

Another handout gave a Rainbow Remedy Recipe for cooking a mixture of beans, nuts, and colorful vegetables. Another handout was an extensive list of foods containing phytochemicals that “might help decrease the risk of cancer.” For example, the allyl sulfides in garlic and onions “may block the action of cancer-causing chemicals.” (Yes, they “may,” but does that mean eating those foods will actually reduce your risk of cancer?)

I had to laugh at the handout entitled “Fred’s Diet Plan.” Who is Fred and why should we eat like him? (I’m guessing it was extracted from Reinagel’s book, since it ends “Recipes…see pages 90-137”).

One thing really set off the alarm bells.The HMO has a secure e-mail system that it normally uses for all communications between providers and patients. The dietitian asked for the patient’s personal e-mail and sent the information to it, saying she couldn’t send the information through the HMO’s e-mail system. She didn’t make the reason clear, but it sounded to the patient like she didn’t want others at the HMO to know what she was recommending.

Responding to Frustrations?

My friend got the impression that her doctors felt frustrated because they had nothing to offer her, so they found it convenient to foist her off on an acupuncturist and suggest questionable treatments just to get her out of their hair. Did they care whether she was being given science-based information or was being baffled with bullshit? Did they believe she would benefit from  some kind of placebo response? Did the HMO management know what was going on in their institution? Do they approve of the surgeon claiming expertise in CAM? Do they approve of their dietitian recommending the anti-inflammatory diet? Does she recommend it to every patient?

In a novel I read long ago, an intern said he had put an obnoxious patient’s bed in “the orthopedic position.” When asked what that meant, he said you put the bed as high as it will go and hope the patient will fall out and break something so you can transfer him to the orthopedic service and be rid of him. That was fiction, but the reality is that every doctor has difficult patients he dreads seeing on his appointment list, sometimes because they are obnoxious but often because their symptoms are stubbornly resistant to treatment and he knows he has nothing more to offer them. Referring them to an acupuncturist would be an easy way out, a way to reduce stress and to avoid guilt feelings for being unable to help those people. Surely that is a natural temptation.

“Integrative” medicine is another tempting way out. When science-based medicine has little or nothing to offer, the “integrative medicine” concept is seductive. It allows you to step outside the constraints of the scientific arena. In CAM there are no rules because there’s no solid evidence to base rules on; you can pretty much try anything that occurs to you, and just make things up as you go.

Self-Reinforcement

We have talked a lot about why patients use CAM. We have not talked as much about why some doctors are drawn to it. I suspect the “difficult patient” dilemma is one of the reasons. Once started, using questionable treatments is self-reinforcing:

  • If it doesn’t work, the patient may give up on you and never come back to bother you.
  • If the patient never comes back, you can assume your treatment worked and he didn’t need to come back.
  • If a patient doesn’t improve, you can rationalize:
    • You can remember the others who did improve and convince yourself that it works most of the time and that the current patient is an exception.
    • You can persuade yourself that it’s the patient’s fault for not following your instructions to the letter.
    • You can imagine that the treatment would have worked if only the patient had come to you in time, earlier in the course of the illness.
    • You can tell yourself you were right, but not quite right enough; and you can devote many more appointments to tweaking your recommendations.
  • Most patients will improve over time, just from the natural course of the disease or from other unrecognized confounding factors, and you can take the credit.
  • Patients who improve will give you the credit and tell you what a wonderful doctor you are.

Dumping Ground?

Are doctors using CAM and integrative medicine as handy dumping grounds for difficult patients? I’m guessing that’s one reason for their increasing popularity.

Posted in: Acupuncture, Herbs & Supplements, Nutrition

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28 thoughts on “CAM as a Dumping Ground

  1. Janet Camp says:

    Whatever the reason, the encroachment of CAM into medical practice is bad medicine and SBM has to get together in some formal/organized way and address this. Surely this type of “dumping” is unethical? If a doctor doesn’t want to see a patient, why not simply flat out suggest another doctor who might be more compatible with the patient? It does not seem that your friend is making up her symptoms and maybe someone else can help her? Maybe she’s stressed by being led down the path by her current medical team and the stress aggravates her symptoms? Is she even sure she saw a Registered Dietician? Many people have no idea of the difference between a “nutritionist” and an RD. I’m not saying an RD couldn’t be corrupted by CAM, but you’ll likely get noting but total nonsense from most “nutritionists”.

    I have posted here numerous times about personal run-ins with doctors who are “integrating” CAM (not to simply “tell my story”, but to cite the everyday encroachment of CAM). I have told each of them what I think in stark terms and not gone back, but in each case the waiting room was full of adoring (usually) women testifying to this doctor’s “wonderful and caring” approach. So it isn’t always an attempt to “dump”, but rather an effort to GAIN patients. One of the worst I recall is a Neurologist I saw (on referral from my regular and much-liked doctor) who enthusiastically recommended fish oil (even though I had no diagnosis and was only there for a test). I asked for some documentation and received a small clipping from a community newspaper written by a columnist that had absolutely no documentation and made outrageous claims–it read like an ad that one used to see only in the back of a pulpy magazine.

    It’s hard enough to try to talk about any of this to the religiously devout CAM users, but when MD’s start pushing this stuff, it becomes impossible–what do you say when someone tells you that her doctor sent her for acupuncture or gave her a completely whacky diet? This takes us back to your last post about choosing a doctor. I’ve thought more about that and I realize that I now approach any new doctor rather warily until I am sure (s)he is not going to veer from the SBM path. I now use a large teaching hospital (in Wisconsin) and have not been seeing the level of CAM “contamination” that I was seeing previously in small clinic settings (Washington State and Wisconsin). I guess that’s a good sign, but I have no idea if this is valid or just a happy and temporal coincidence.

  2. MerColOzcopy says:

    Loved the article, concise to the point. I think I am getting this SBM, it’s like a tool and is only as good as the one administering it. And CAM is like a pair pliers.

    I was diagnosed with IBS, (I had no Diarrhea or constipation), after my doctor could not find the cause of my pain in right side. Ironically “the orthopedic position” would have solved my problem. Changed beds all was good.

  3. mdstudent says:

    The reason why there are doctors who support cam boils down to the nature of basic sciences medical education. These are programs, however rigorous and demanding, where blind memorization and regurgitation of facts is often enough to at least make it through. I often meet “smart” students who, if they don’t enthusiastically support something like chiropractic and acupuncture, are at least open to the idea that they somehow work because they make people feel better or because “science doesn’t understand everything”. When I entreat them to think critically I’m labeled closed minded or a pharma pusher.

    Are doctors using CAM and integrative medicine as handy dumping for difficult patients? Maybe, or maybe they’re just not so bright.

  4. windriven says:

    Dr. Hall identified an issue that is perhaps central to the staying power of sCAMs: medicine sometimes has no answer and that is frustrating to both the physician and the patient. When the end of the medical road is reached, no next step is very attractive. Give up? Palliative care only? Woo?

    In cases where the prognosis is clear and terminal the palliative care option makes sense. But that apparently isn’t the situation with Dr. Hall’s acquaintance.

    Dr. Hall summed the problem thus:

    “When science-based medicine has little or nothing to offer, the “integrative medicine” concept is seductive. It allows you to step outside the constraints of the scientific arena.”

    What precisely is the alternative? One could even make the argument that the patient (or doctor) is behaving more or less scientifically by casting about for new therapies when existing therapies all fail. Nothing in the accepted armamentarium works therefore let’s come up with a conjecture and run some crude tests of that conjecture. Perhaps that will lead us to an hypothesis that can be tested rigorously…

    If we are going to fight unscientific nonsense we are going to have to offer an alternative when the limits of current medical practice are reached.

  5. WilliamLawrenceUtridge says:

    I see CAM as a form of emotion-based coping. It’s a way of helping yourself feel better when you can’t do anything real. It’s truly unfortunate (and probably inevitable) that it’s so strongly linked to and self-defined by opposition to mainstream medicine and magical thinking. Is it better than simply saying “I can’t think of anything else I can do to help you”? That’s a tough question.

    I think mainstream doctors providing acupuncture is actually somewhat of a good thing. They would have the anatomy knowledge to avoid damaging nerves or puncturing blood vessels and could use it as a way of keeping in touch with patients and showing caring when they have no other options available. But it’s a fine line and a complex issue.

  6. Scott says:

    @ windriven:

    For that subset of CAM which falls under the heading “not known to work,” it may be (to varying degrees depending on prior probability) reasonable to do such casting about. But much of the better-known CAM is under the heading “known not to work” so (aside from the psychological comfort of Doing Something) there’s no justification for it even in the most intractable cases.

    IMO, when a particular patient reaches a point where there is no known scientifically-based treatment to try, the next step should be to look into whether there are available and relevant clinical trials. If there are none, I would say that the proper reaction would be the truth – “unfortunately, we don’t have anything else we can try. All we can do is comfort/palliation.”

    To more precisely address your question, “What precisely is the alternative?”, in such cases the answer is probably “there is none.” Just because we WANT there to be something reasonable which can be done, doesn’t mean there is.

  7. Chris Repetsky says:

    I agree completely with MDStudent. I’m a medical student myself, and I often come across colleagues in class who are sympathetic or supportive of SCAM. Some of it boils down to the lack of training in critical thinking and more regurgitation of facts (as MDStudent said) and some of it is the student’s background. For example, the University I attend has a large Indian student base, and a good majority of them support Ayurvedic Medicine, despite it lacking an evidence base. I theorize this is largely due to upbringing and culture, which is certainly hard to shake.

    On a related note, we had a meeting with a representative from the National Board of Medical Examiners recently, and she previewed some changes coming up for the new Step 1/2/3 exams. The new Step 1 licensing exam will now include sections on interpreting medical studies and research, and drawing appropriate conclusions from the information presented. They are also going to be adding sections on interpreting Pharmaceutical company advertisements, and again drawing conclusions based on the data presented. If the NBME implements this correctly, I think it will be a giant step (no pun intended) in the right direction.

  8. Mhops says:

    I can see how it would be very tempting to “dump” frustrating patients off on a CAM practitioner. Afterall, I am not aware of any chronic diseases that they claim NOT to be able to treat. In contrast, I know that I have limits with science-based medicine. Sometimes I am forced to say that I have run out of plausible, evidence-based options. That’s a very difficult, humbing conversation to have with a patient who is suffering. It would be much easier — and unethical — to claim that magic is the answer. And anyway, if that were the case, why wouldn’t I have done that at the start?

  9. DKlein says:

    Am I too naive? Maybe another reason they turn to CAM is they just want to help and be helped when nothing else “works”. When my neurologist suggested acupuncture last year for migraines, it was because he wanted to try one more thing to help me with. My migraines were coming more frequently than the number of ($40 each) abortive pills my insurance was allowing. There was some “research” out there about acupuncture for migraines but it may very well be he only read the headlines, which really isn’t the best way to make treatment recommendations. I don’t believe he is on the CAM bandwagon. The practice makes no mention of CAM on their webpage.

    Doctors are patients too and sometimes just get as frustrated with inadequate therapies as their patients do and just want relief. Way back in the mid 80s, I worked for oncologists who were on staff at a big NY cancer hospital. The wife of one of the oncologists told me that her husband was trying Saw Palmetto for BPH because he was so frustrated with existing treatments. He had tried “everything” and was still having problems. He never recommended herbs to his patients then and I don’t think he does now but the hospital he is affiliated with now has a big holistic spa and integrative program. A doctor I work for occasionally has a very sick wife and I overheard a conversation he had with a nurse about going to an alternative doctor because they’re so desperate for something that will help her.

    Whether or not a physician recommends CAM is another area of research when it comes to finding a doctor. This is both amusing and deflating because when I was going to naturopaths, the question to ask them was if they were into things like Landmark (est) training which teaches that illness is just a racket to get out of being responsible for your life.

  10. annappaa says:

    Yep. Someone in my family is dealing with chronic pain issues after an accident, and is also a member of a major HMO. Last I heard, the HMO issued a referral to an acupuncturist, and although the insurance plan picked up some of the tab my family member still spent hundreds of dollars on several sessions, which ultimately didn’t seem to be beneficial whatsoever. I’m discouraged to learn that this may well be some kind of phenomenon. I wonder if we’re talking about the same HMOs.

  11. AndersB says:

    It’s by far the easy way out, it’s as simple as that. From my experience, the vast majority of medical students (at least here in Norway) do not, when pressed about the matter, believe in the alleged physical properties of various CAM treatments (perhaps with the exception of acupuncture for certain chronic pain conditions).

    We had an absolutely rubbish lecture in my first year, by a MD who headed some sort of IM project. He was suprisingly honest about what the evidence showed, and presented graphs and data from the major meta-studies on the subject. It was a sort of surreal experience, listening to him exalt the wonders of acupuncture, while offering dataset after dataset and graph after graph showing it had no benefits over placebo.

    This “new” sort of doctors are perfectly able to examine the evidence, and I’m pretty sure they themselves would never use CAM, but there is so much positive reinforcement from patients and society when they embrace CAM, that the facts and evidence no longer matters. The alternative-crowds great and general suspicion towards doctors is only rivaled by their idolization of doctors “who dare speak the truth”, and these doctors are seen as open, modern and brave. Not only by those drawn towards new-age mysticism, but by the media and the general public aswell.

    There are several methods these MDs can employ to justify their actions. Most notable is the argument that if people go to a MD first, instead of going directly to CAM-practitioners (without proper medical training), the MD can catch and treat real medical conditions, should the patient have them. It’s quite like the argument for legalizing recreational drugs, “People are using X, and are going to keep using X no matter what we do, so we should instead ensure that the use of X is done under the least harmfull circumstances possible”.

    A different tactic, which going back to the lecture I mentioned previously, was employed by my lecturer. I raised my hand and pointed out that the very data he presented to us, directly contradicted his talking-points. His answer was that many procedures and even surgical operations had no scientific backing, and some of them probably didn’t have any effect over placebo.

    In retrospect, I’m quite pleased by my (at the time, sincere) reaction. I was simply aghast and asked him if he truly meant that people were being cut open, exposed to all the possible complications of an invasive procedure, without any real benefits. He somewhat reluctantly had to nod, so I pressed on, asking him why he wasted his time trying to add on more ineffective treatments instead of helping to weed out the things that needed weeding out, and if he didn’t agree his time would be better spent working towards a scientificly sound and evidence-based medicine.

    He never quite replied, other than some mutterings about “that’s one way to look at it” and some hilariously insincere comments about how he welcomed critical questions. Also, the lecture ended ten minutes before planned, and there was absolutely no room for questions, he was half way out the door by the time he finished speaking.

  12. cervantes says:

    This just landed in my in-box. Unfortunately there’s no way to dope slap these people over the Internet:

    “FOR IMMEDIATE RELEASE
    March 27, 2012

    Contact Shannon Rose, Megale Public Relations (347)92-STARS or (347) 927-8277, Email: info@mediaproductions.tv

    TheraBiogen, Inc. Donates to India for H1N1 Outbreak

    (New York, NY) – TheraBiogen, Inc. creator of the homeopathic remedy “TheraMax™ Cold and Flu” has generously offered their product to India’s Minister of Health and Family Welfare to help in their H1N1 Flu outbreak.

    India has stated it is suffering from an outbreak of H1N1, specifically known as the “Swine Flu”. To date, the strand of flu has claimed 12 lives.

    TheraMax™ Cold and Flu has been tested in vitro on various strains of influenza and in vitro specifically on H1N1 strain by an internationally recognized researcher in this country. In those animal studies, a number of conclusions were reached regarding TheraMax® effects on H1N1.

    TheraMax™ Cold and Flu is delivered into the body through a nasal spray. It’s non-addictive all natural decongestant formula aids in speedy relief of sneezing, runny nose, itch-watery eyes, nasal congestion and sinus pressure from the flu and colds. It has the potential to be a preventative if used at the first signs of a cold or flu.

    This product is completely homeopathic and doesn’t contain zinc like their competitors, reducing the risk of side effects caused from Zinc remedies.

    In a gesture of compassion, TheraBiogen, Inc.’s CEO Kelly Hickel has informed the Indian Minister of Health that he has a modest supply on hand which he will gladly send over immediately, and should more product be necessary they will gladly donate their net profit as a humanitarian effort to aid in their fight against the H1N1 Flu strain.

    The H1N1 Flu is a vicious strain of flu that often causes casualties every year. It’s important to protect yourself during cold and flu season to prevent yourself from contracting this strain of flu.”

  13. ConspicuousCarl says:

    BILL: “I am so totally broke, but I met this guy yesterday who offered to trade me two 5s for a 10. And he only charges a nickel for the transaction, which is way cheaper than a stock broker!”
    ED: “That doesn’t actually turn any profit, and in fact you are wasting a nickel.”
    BILL: “But I am flat broke and TOTALLY DESPERATE and this doesn’t cost much.”
    ED: “It’s basically just a scam, even if it is a cheap one.”
    BILL: “He’s just trying to help when nothing else is working for me! Besides, a guy at the bank referred me to him.”

    DKlein on 27 Mar 2012 at 12:06 pm

    Am I too naive?

  14. jpmd says:

    And for really obnoxious patients, don’t forget the even higher “neurosurgical level” bed height.

  15. windriven says:

    @Scott

    “To more precisely address your question, “What precisely is the alternative?”, in such cases the answer is probably “there is none.”

    I totally agree. But that is not going to satisfy some people. In fact if I had, say, a daughter suffering from some unknown creeping fung, it probably wouldn’t satisfy me. My next step wouldn’t be acupuncture delivered with sharpened acai berry twigs but it is easy enough to understand why that might appeal to a non-scientific individual.

    My point was that if we are to successfully wave people off the path to woo, we have to be able to offer an alternative. “Grin and bear it” won’t strike most people as a viable alternative.

  16. Harriet Hall says:

    Instead of grin and bear it, what if the doctor explained that there was no effective treatment for the patient’s symptoms, but offered to work with the patient to find ways of coping and enjoying as worthwhile a life as possible despite the symptoms? Continuing support and comfort instead of abandonment.

  17. pmoran says:

    I’m a bit with Windriven, as some might predict.

    This is like some CAM testimonials. We lack critical information and can slant the story to support certain points of view.

    The very worst thing that the doctors did with this patient is to tell her she had terminal cancer.

    Also, if radiation enteritis is the likely diagnosis, this woman is in for a terrible, progressively worsening time, and she will need ongoing highly sophisticated and carefully titrated pain and bowel management. Surgery, even ileostomy or colostomy, might very well also come to be needed at some stage, despite being considerably more risky after radiation.

    So while her surgeons might display, as they will in the real world, varying degrees of permissiveness towards the patient also trying out CAM and dietary ploys, there should have been no question of using CAM as a final resting place for her. That would be grievous error number two, but not because of the failure to stick to FDA approved treatments no matter what.

    Now, the irritable bowel syndrome is a diagnosis of exclusion — other pathology must be excluded, and even then part of the mind should be kept open.

    The only circumstances under which I would seriously consider it as a diagnosis in such a patient might be if she had a history of symptoms suggesting that diagnosis before those leading to the diagnosis of bowel cancer, and if thorough bowel investigation including enteroscopy and possibly laparoscopy revealed no trace of radiation damage or stricture (which is very unlikely) or other pathology, also if thorough general assessment led to no suggestion of anything other than blooming good health.

    Over-commitment to the diagnosis of IBS might thus be grievous error number three.

    Note, however, that once having decided that the diagnosis was IBS and if every mainstream option was now being rejected by the patient as not helping, it can be argued that acupuncture and other CAM measures are worthy of a trial in patients amenable to it. This condition is very placebo-responsive and such methods may help tide her over bad patches while hoping the condition will eventually burn itself out, or better treatments emerge.

    Also, like the patients in Janet Camp’s doctors’ waiting room, sometimes what patients mainly want from us is the feeling that they are being cared for. It is not easy to sustain that once the medicine cupboard is bare which is why there is also some foundation to Harriet’s complaint concerning CAM being sometimes a reflection of a doctor’s feeling of impotence. She must feel this herself on occasions.

    That may be the least culpable aspect to this apparently very difficult case.

  18. Janet Camp says:

    Windriven said:

    If we are going to fight unscientific nonsense we are going to have to offer an alternative when the limits of current medical practice are reached.

    I agree, but just not an “alternative” alternative. I don’t think that’s what Windriven meant, and I think Dr. Hall is onto something with “ongoing support and comfort”. But a lot is going to have to change to permit that, even for those doctors capable of that kind of nurturing. These days I get about six minutes with my doctor–even less sometimes with the specialists. They are trying to cope with this by sending in surrogates (PA’s, nurses, techs) who sit and let you vent for a while, but really offer nothing else. It helps, but I might not think so if I was dealing with something terminal or chronic pain.

    I’m having my breast biopsy tomorrow and I’m told that a “specially trained” and “caring” nurse will be calling me with results unless I prefer them from my Primary Care doctor. The “special” nurse talks to me like I’m three years old, so I think I’ll just “take it like a man” from the doctor. The shot nurse gave me a big hug before I left the allergy clinic and that was really nice. My doctor hugs me too, but only when I knit darling sweaters for her babies!

  19. windriven says:

    @Dr. Hall

    “what if the doctor explained that there was no effective treatment for the patient’s symptoms, but offered to work with the patient to find ways of coping”

    I think that is a terrific approach. But under current payment structures the physician is going to have to be one hell of a good Samaritan.

  20. DW says:

    I can’t see the huge issue here. As long as the doctor is fully honest with the patient and explains clearly that he/she has run out of evidence-based options, i.e., “We’ve tried all the things that we know work,” it’s only common sense then to suggest the patient try some things that are NOT known to work. As long as these are not suspected to be harmful, or plainly idiotic and thus wasting money or raising false hopes, the patient has nothing to lose. I don’t see why doctors should twist themselves into pretzels to be sure NEVER to recommend trying something untested. There’s a time and a place, and it’s when the tested options have failed.

  21. DW says:

    That said, as I mentioned on another thread, I think it is a problem when doctors recommend CAM (or refer to naturopaths etc.) for patients who they suspect are somatizing or have psychological problems. Hypochondriacs and somatizers and patients with psychiatric problems manifesting as physical symptoms represent an enormous wide-open field for CAM hucksters. It is literally predatory. I think that some mainstream docs figure there’s no harm done, if the complaint is basically imaginary why not send the patient to some quack who’s going to prescribe a lot of vitamins or massage or biofeedback or something, if it keeps them happy for a little while? They are so wrong; it can start a terrible spiral of taking bizarre combinations of some useless remedies, some dangerous remedies, all of them expensive and not covered by insurance.

    This is a real problem that I would love to see addressed here. It is expensive and wasteful of resources and tragic for the patients, and (last but not least) it helps to spread acceptance of CAM.

  22. windriven says:

    @ Janet Camp

    I hope you will take the next opportunity you have to ask the nurse who speaks to you like a three year old if she knows what she’s talking about; that you have a hard time taking someone seriously who has a 300 word vocabulary. It can be uncomfortable getting in someone’s face – and you don’t have to be belligerent about it, more like concerned or confused. I promise it will get the message across. Most people want to do a good job. She may think it is cute. Or she may be trying to convince you (or herself) that she’s all that and a bag of chips. Anyway, if the dope slap doesn’t work, mention it to the doctor. Physicians are also supervisors and often small businesspeople. They generally want to know if their surrogates are behaving like asses.

  23. Harriet Hall says:

    @DW,
    “it’s only common sense then to suggest the patient try some things that are NOT known to work.”

    Sure, within reason. But there has to be some judgment about which things are reasonable to try, and there has to be some restraint: not bankrupting the patient with an endless search for every possible thing to try. And there has to be a balance between hoping the next new thing will work and dedicating one’s energies to acceptance and coping. And it’s not common sense to suggest the patient try some things that are known not to work.

  24. DW says:

    That makes good sense to me … if the doctor can go on serving as the patient’s advocate, helping him/her understand which “alternative” ideas are untested and could conceivably work, though there’s no evidence for it; which ones have been tested and shown NOT to work, even though unscrupulous or ignorant people go on promoting them; and which ones are possibly dangerous or outright scams. And help them see that, as you say, time and energy might be better focused on coping strategies.

  25. William B'Livion says:

    @ cervantes:
    > This just landed in my in-box. Unfortunately there’s no way to
    > dope slap these people over the Internet:

    Actually there is. But it’s a felony. And to do it well means several felonies.

  26. William B'Livion says:

    I suspect a big problem is what Sarno calls TMS (as mentioned in one paragraph once before on this blog) plus the placebo effect.

    Basically the doctors decide it’s “in your head” and want to get you to someone who gives you the warm fuzzies so you believe, and the belief manifests the cure.

    Because ultimately if they can’t *find* a cause, and someone can make the pain go away, it’s mostly fixed.

    Right?

  27. annappaa says:

    >TheraMax™ Cold and Flu has been tested in vitro on various strains of influenza and in vitro
    >specifically on H1N1 strain by an internationally recognized researcher in this country. In those
    >animal studies, a number of conclusions were reached regarding TheraMax® effects on H1N1.

    Uh. There were studies conducted and they reached “a number of conclusions”? Seriously? Are people so lacking in critical-thinking skills that a company can actually release this as a press release and not have to face the obvious follow-up question, “And those conclusions were …?”

  28. cloudskimmer says:

    Please don’t be offended by an idea from someone who isn’t a medical professional, but this case reminded me of an NPR Science Friday discussion a few months ago about fecal transplants. Repopulating the intestinal tract with microorganisms seems like a good idea, but evidently there are regulatory problems. Was this option ever discussed with your friend, Dr. Hall? Here’s a link to a Scientific American article from last December: http://www.scientificamerican.com/article.cfm?id=swapping-germs

    I really like your idea of offering support, but especially with the elderly and their problems getting to medical appointments, most patients will eventually stop going to see Doctors who cannot help them.

    Yes, I’ve seen several Doctors give up on my mother’s chronic pain problems, sometimes brusquely, sometimes compassionately, and they have, on occasion, recommended quack remedies, such as acupuncture. The one visit caused extreme pain, and afterwards there was nausea and vomiting, so she was never tempted to try it again. It made me wonder, if qi can be balanced and help with pain and nausea, can it cause the same problem if improperly applied? I phoned the acupuncturist later, and of course she denied any responsibility for those symptoms, but would probably have been happy to claim the credit had chance resulted in a favorable outcome. (I knew at the time it was unlikely to actually work, but hoped the placebo effect would giver her some illusory relief.) I made a point of writing a detailed letter to her primary care physician expressing my unhappiness with the acupuncturist and lack of supporting evidence of efficacy, hoping that he will not make such a recommendation again. This was his third, and he said the other two patients were happy with the procedure. It’s tough to have an insoluble problem in any profession, and I can sympathize with the Doctors who are in this position. It’s worse for the patients, with the burden of an illness with no prospect of recovery or improvement; for the elderly, this situation is inevitable.

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