Dec 07 2008
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.
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