Help – My Doctor is a Crank!

I often receive e-mail from SBM readers (or SGU listeners) who have had the experience of their doctor, nurse, dentist, physical therapist, or other health care provider recommending to them a treatment option that seems dubious, if not outright pseudoscientific. They want advice on what to do.  There are common themes to the e-mails – the writer often feels very uncomfortable in the situation. They do not feel comfortable confronting their provider directly, yet they do not want to acquiesce to the advice either. They are also often asking my opinion about the advice – is it really as wacky as it seems. This uncertainty saps them of their resolve, leaving them feeling a bit helpless.

Here is one such e-mail:

Ten days ago, my wife and I welcomed our first child into the world. She was born a couple weeks early, which left her mouth a bit too small and week to breastfeed effectively. To prevent her from losing too much weight, we were referred to a lactation consultant (who works out of the pediatrics department at the hospital where our daughter was born). This consultant (who is also an RN) suggested a regimen of supplementing nursing with pumped breast milk.

This was working great until my wife’s milk production dropped the day before our follow-up appointment. When we asked what to do about this, the nurse recommended that my wife take fenugreek, an herbal supplement. I was a bit skeptical of this advice, so I asked what it was about fenugreek that helped with milk production. The lactation nurse’s answer was vague — she said things like, Herbs can be helpful for lots of health issues, and, a lot of women I see seem to think it helps (oh, the logical fallacies). When we pushed her on this a little more, she handed us a flyer, printed by the hospital about fenugreek. The flyer seemed to support the use of the supplement, but mentioned that there was no scientific research demonstrating that fenugreek increases milk supply. When we asked why it hadn’t been researched, the nurse responded that there wasn’t a lot of money in lactation and that scientists generally aren’t interested in the kind of things she does (basically, that she was doing the good work that cold-hearted scientists refused to do).

She also mentioned that there was a prescription drug that boosts milk supply, but it carries with it the risk of a pretty serious side effect (depression), so she prefers her patients to try the supplement first. I asked how we could be sure the supplement didn’t also carry the risk of negative side effects if it hadn’t been studied, she simply said that it worked out fine for the patients she’s seen.

My wife and I decided to let it go for the time being and decide later whether or not to go the supplement route (it’s hard to argue with a nurse when you’re under-slept, one of you is topless, and the baby is screaming for food). Fortunately, her milk supply picked up a bit on its own, so we didn’t have to resort to using an untested therapy (yet).

First, let’s address the recommendation – fenugreek to increase breast milk production. Substances that increase milk production are called galactogogues. There are a number of drugs that have been shown to increase milk production, although the levels of evidence varies. For many there are only case series. Oxytocin is supported by double-blind placebo controlled trials, and is both safe and effective. Other commonly used drugs, like metoclopramide, are supported by unblinded case series only.

Fenugreek is a common spice and medicinal herb used in India. Among its putative effects is increased lactation, however, there are no clinical trials to support its use. Recommendations are based upon anecdotes only. This 2010 review article reports:

The side effects most commonly reported are a maple-like smell of the urine, breast milk, and perspiration, diarrhea, as well as the worsening of symptoms in individuals with asthma or hypoglycemia. The potential for transfer to milk or side effects in the infant are unknown. As is the case for most herbal products, the dose necessary to obtain a galactogogic effect has not been defined. Only one study on the effect of fenugreek on lactation has been reported. Swafford asked 10 mothers to maintain a diary of the quantity of milk produced with a pump for a period of two weeks. In the first week, baseline milk production was evaluated; in the second week, mothers took fenugreek, 3 cups, three times daily. In the first week average quantities were 207 ml/day, whereas, milk production in the second week averaged 464 ml/day (p = 0.004). Unfortunately, the report excluded any information regarding the characteristics of the mothers enrolled in the study or the postpartum period during which the study was done. Nevertheless, the daily milk quantities reported during treatment do not seem to be particularly high (reference: Swafford S, Berens P. Effect of fenugreek on breast milk production. Abstract 5th International Meeting of the Academy of Breastfeeding Medicine September 11-13, 2000, Tucson, Ariz Academy of Breastfeeding Medicine News and Views 2000;6(3).)

So – there are side effects, even potentially serious side effects like exacerbating asthma and hypoglycemia. The dosing is unknown, and the one small efficacy study that was done was unimpressive.

There is nothing implausible about the claim that an herb can be an effective galactogogue – herbs can be drugs with pharmacological activity. What is disturbing about the nurse’s recommendation is the double standard. She seems to believe that herbs are inherently safer than drugs, which is a false dichotomy based on the naturalistic fallacy, but not logic or evidence. She essentially recommended an untested drug with uncertain dosing, side effect, or efficacy over drugs with better evidence for both safety and efficacy.

It should also be noted that the e-mailer’s mild production spontaneously increased after the consultation. If she had taken fenugreek, that would have been one more anecdotal report apparently supporting its efficacy.

But onto the real question of the e-mail – how to respond in this situation. My advice is to first not be intimidated. Feel free to express your concerns or uncertainty about the recommendations being made. I commend this e-mailer for asking for published evidence, but don’t take an evasive answer as adequate. Ask for published evidence or authoritative reviews. If they do not have any handy, they can certainly prepare this material for the next visit or simply e-mail it to you.

If you feel up to the task, you can research the question yourself and then ask your health care provider to comment on the material you find (but don’t overwhelm them with mounds of material).

Depending on how egregious the pseudoscientific advice was, you should also consider simply leaving that provider for someone with whom you feel more comfortable and confident. I do recommend, whether or not you stay with the provider, to give them feedback. Express your exact concerns about their advice. How they respond will also tell you a great deal about their approach and dedication to evidence-based practice.

In short, I think patients should feel empowered to push back against practitioners who stray from science and reason as a basis for health care recommendations and practice. Those pushing for anti-science in medicine are certainly vocal, and their agenda will advance if others simply do nothing. In fact – if a practitioner recommended an outright anti-scientific treatment (like homeopathy, say) I would go beyond giving them individual feedback. I would write to the head of their clinic, hospital, or department and express your concerns. You are a consumer as well as a patient, and administrators listen to their consumers.

The above situation is becoming distressingly common, and it is not easy to deal with. It is one more type of harm that is caused by the infiltration of anti-science into medicine. I had a similar experience myself. My wife and I were referred to a practitioner to address a problem with one of our children (I am being deliberately vague on details). At the first visit the practitioner made a comment (as an aside, not directly related to the visit) about vaccines and autism. I, of course, politely challenged her on that statement, and she backpeddled – I think just to end the confrontation. My wife thought that I was inappropriate to challenge her – she was concerned about my accepting the role as patient rather than physician.

At the next visit, however – the visit when the practitioner was giving us her actual recommendations, my wife had a change of heart. The practitioner’s recommendations were entirely limited to “natural” interventions like diet and herbs, and she shied away from any medications. Her recommendations were ideology-based, not evidence-based, and in the end the consultation was entirely useless. My concerns at the first visit – that perhaps this practitioner does not have a firm grasp on the concepts of science-based medicine, were entirely vindicated.

This is an important point – if a practitioner recommends something that is blatantly against the science and evidence, how can you have confidence in any of their recommendations? I am not talking about not being up on one bit of latest evidence – no one can know everything. A serious lapse, however, can reveal a systematic bias in a practitioner’s approach to evidence and practice.

Unfortunately, patients cannot take for granted that a licensed professional is necessarily science-based.

Posted in: Science and Medicine

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