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The Truth?

Facepalm
Summertime and the living is easy. I am in Sunriver, Oregon for the week and I though, hilariously, that I would have plenty of time to write a post. Between the hiking, the biking, the golf, the food and the beer, there has been little time to sit in from of a keyboard. There may be no better place to spend a week if you like the outdoors, but they do not have internet on the hike around Paulia Lake. So while a caramel banana cake bakes for a dinner tonight, I have an hour or so churn out a post. Do not expect much.

One person’s ethics is another’s belly laugh, but in medicine ethics are formalized. The basic principles in the US are

  • Respect for autonomy – the patient has the right to refuse or choose their treatment (Voluntas aegroti suprema lex)
  • Beneficence – a practitioner should act in the best interest of the patient (salus aegroti suprema lex)
  • Non-maleficence – “first, do no harm” (primum non nocere)
  • Justice – concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality).

These are guidelines, not mandated, but if you get an ethics consult in my institutions the above concepts are the framework within which the consult will be completed.

Patients can only be autonomous if they are given accurate, truthful information with which to make a decision about their treatments. You can’t lie to patients, but we all know how you phrase an idea can subtly alter the response. Do you say an 80% success rate or a 20% failure rate? I tend to say both. And not everyone can handle the unvarnished, blunt truth. Part of the art of medicine is trying to tell each patient the truth, the whole truth and nothing but the truth in a manner palatable for the individual patient. It is not easy and I am certain I do not always do a good job.

What troubles me is how much what is written about SCAM’s is to my way of thinking, not truthful, or shaded in a way as to be, at best, disingenuous. I am not referring to the Natural News or Dr. Oz. I long-ago realized those are not sources for a reality-based understanding medicine. I am referring to major medical centers that offer what I would consider misinformation. As an example, take the Mayo Clinic. Please.

I did my residency in Minneapolis at the county hospital. Occasionally a patient would go to the Mayo Clinic in Rochester for a second opinion, get all their tests repeated and more, and come back with the same diagnosis and treatment plan. We would say if you want a Rochester Sandwich, hold the Mayo.

That started my skepticism about big name clinics and famous hospitals. There are good and bad doctors everywhere. Judging from the metastasis of pseudo-medicine into many of the prominent medical institutions in the US, I suspect that these institutions are more interested in income than science-based medicine.

Which brings us to “Complementary and alternative medicine” from the Mayo Clinic, with the subtitle:

You’ve heard the hype about complementary and alternative medicine. Now get the facts.

Given that they have an Integrative Medicine Department, I was wondering how they would spin ‘the facts.’ As always in a CAM article, they start with the disingenuous.

Nearly 40 percent of adults report using complementary and alternative medicine

It’s actually 38.3 %.When I was in grade school I would have been told to round to 38. I am surprised they did not round it up to “nearly 50%”. And you only get to that number by including interventions that are not alternative, like diet and exercise.

The use the National Center for Complementary and Alternative Medicine (NCCAM) classification:

  • Whole medical systems
  • Mind-body medicine
  • Biologically-based practices
  • Manipulative and body-based practices
  • Energy medicine

What all of these have in common, with the exception of “biologically based” which includes herbs, is a complete disconnect from reality as it is understood by the sciences. You would not know that from the Mayo.

Homeopathy is described as using

minute doses of a substance that causes symptoms to stimulate the body’s self-healing response.

Most homeopathic nostrums have zero active substance in them and the ideas behind homeopathy are totally nonsensical.

Energy medicine is an

Invisible energy force flows through your body, and when this energy flow is blocked or unbalanced you can become sick. Different traditions call this energy by different names, such as chi, prana and life force. The goal of these therapies is to unblock or re-balance your energy force.

No such energy has ever been measured and none of these interventions have been shown to have efficacy beyond bias. Credulity is the order of the day at the Mayo.

They continue:

Many conventional doctors practicing today didn’t receive training in CAM therapies, so they may not feel comfortable making recommendations or addressing questions in this area.

Could it be that conventional doctors, based in realty and science, know it would be unethical and fraudulent to recommend therapies that are fanciful delusions with no efficacy?

However, as the evidence for certain therapies increases, doctors are increasingly open to complementary and alternative medicine…While scientific evidence exists for some CAM therapies, for many there are key questions that are yet to be answered

What these ‘certain therapies’ are goes unmentioned, since the NCCAM has yet to support a study that demonstrates any benefit from the pseudo-medicines mentioned in the article. And there is the old saying, what do you call alternative medicine that has been proven to work? Medicine. BTW, I am not a conventional doctor, I am a doctor. I do not need the adjective.

They continue with the question

Why is there so little evidence about complementary and alternative medicine?

One reason for the lack of research in complementary and alternative treatments is that large, carefully controlled medical studies are costly. Trials for conventional therapies are often funded by big companies that develop and sell drugs. Fewer resources are available to support trials of complementary and alternative medicine. That’s why NCCAM was established — to foster research into complementary and alternative medicine and make the findings available to the public.

Perhaps there is a paucity of funding for these modalities because prior plausibility would suggest that since they are based on fantasy, not reality, it would be unethical and a waste of resources to study them? Not that the numerous well-done studies that show a lack of efficacy prevent the expansion of integrative medicine programs.

That’s in-depth consumer health at the Mayo. I can’t see that they have done much to improve since I was a resident. I would still hold the Mayo on my Rochester sandwich.

That is not unusual. How can you offer, as does the Osher Center for Integrative Medicine at Harvard Medical School and Brigham and Women’s Hospital, moxibustion, laser acupuncture, and craniosacral therapy without lying to the patient or by being so disingenuous about these therapies disconnect from realty that it amounts to the same thing?

Or, as at UCSF, can you ethically say

While Ayurveda places greatest emphasis on preventing disease before it occurs, scientific research suggests Ayurvedic treatments have positive effects on a range of conditions and disease. Ayurveda is believed to have positive results in the treatment of diabetes, asthma, attention deficit disorder, osteoarthritis, Parkinson’s disease, management of hyperlipidemia and schizophrenia, as well as prevention of certain types of cancer.

While I would not be surprised when any intervention has an effect of diabetes or hyperlipidemia (for many patients any change away from the standard US diet is probably beneficial), schizophrenia and cancer? Really? I can’t find any clinical trials on PubMed to support that contention.

Oh wait. Believe. Believed to have positive results. That is the kind of disingenuous statement that, to my mind, is the moral equivalent of a lie.

Pick an academic Integrative Medicine program, any academic Integrative Medicine program. Are they fully compliant with truth and reality? If so, I cannot find one.

My hospital system, and the hospital systems in Portland in general, are surprisingly SCAM-free. I had long thought that Portland was a mecca of pseudo-medicine, instead we are a bastion of reality-based medicine.

So I lack the opportunity, but it would be interesting for someone to ask for an ethics consult concerning the appropriateness of the information and services offered by their Integrative Medicine. Perhaps the year you plan on retiring.


Posted in: Medical Ethics, Science and Medicine

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