Respectful Insolence

I’ve written a lot about alternative medicine, much of which I consider to be woo; i.e., treatments for which there is no medical efficacy and the belief in which often requires magical thinking. I’ve expressed my disappointment in medical physicians who fall prey to and become purveyors or woo, doctors such as Dr. Deepak Chopra, Dr. Joseph Mercola, those pushing to “integrate” woo into medical school curricula, and physicians who sell expensive “screening tests” such as breast MRI whose value has not been shown in valid, well-designed clinical trials. All of these activities represent, to me, a betrayal of what we should stand for as physicians and, yes, healers.

Unfortunately, thanks to declining reimbursements from insurance companies and the government, more and more physicians are being tempted to make up lost income by turning to woo, and the results are not pretty, as a recent article in TIME Magazine shows:

Removing hair from unmentionable parts of ladies in Westchester County is how my friend Jerry spends a good part of his week. Not that there’s anything wrong with that, except Jerry (not his real name) is a cardiologist, trained at one of the finest medical programs in the country. Trained to save lives. His expertise is the complex and delicate management of congestive heart failure, but he gets paid a lot more to do a laser Brazilian.

Another friend tells me about the “magnetized” water and testosterone ointment he sells to folks who have seen his antiaging ads in shopping circulars. He was a brilliant pathologist; I once entrusted my patients’ lives to his call on biopsy specimens. He began making a few extra bucks with naturopathics, then enough to quit real medicine altogether. I trust little about him since he started with the magnetic water because I know he knows better: he passed physics to get into med school. But now he can finally afford that Range Rover he’s had his eye on.

If I want to buy a stock or mutual fund, I can call up my old friend the ob-gyn. I know three anesthesiologists who became financial analysts with investment firms. Two radiologists run imaging businesses, and a good orthopedist friend dropped out to put up magnetic resonance imaging (MRI) facilities. Each trained hard for at least nine years to join his field of medicine. In no case could leaving have been an easy divorce.

So here is the cause of your doctor’s pain in 2007. Behind him or her is a 15-year trend of diminishing fees that shows no signs of abating. Graduating med students aren’t blind; they see established physicians with busy practices dropping out. Looking ahead they see more headaches–more controls and regulations, more scrutiny, more liability, less money. So what has the resourceful American doc done?

Welcome to the world of alternative medical income. Some docs leave medicine; six weeks of securities-trading classes and you can be a stockbroker. Most try to do something quasi-medical. Three top bailout categories of this sort have emerged: cosmetics, diagnostics and what I call “nothing-really-works-anyway therapies” (NRWATs).

I know, I know. A lot of you out there are thinking: Boo-frickin’-hoo! (Except that you’re probably using the real F-word.) And maybe you have a point. Even in these days of declining reimbursements and rising malpractice premiums, the vast majority of doctors nonetheless do better than around 90% of the wage earners in the population, the exceptions being, unfortunately, many pediatricians and primary care doctors in non-procedure-oriented specialties. Certainly, even in academics, I manage to make a comfortable income. To some extent, I sympathize. But I can also understand how some who don’t have a big a commitment to evidence-based medicine as I do and a straight salary that doesn’t depend (much) on my clinical productivity might find the prospect of a little (or a lot of) income on the side pushing woo or doing cosmetic semi-medical procedures like laser hair removal to be highly tempting, and they do:

Headaches, heartaches, backaches, aching feet, fatigue, anxiety and those vague, burning pains in your legs at night–these are the nemeses of real doctors. Many people have these symptoms, but the cruel truth is that there is no reliable cure for any of them. Clever doctors watching their incomes melt away have taken notice, establishing all sorts of lucrative NRWAT practices. They’ve become chiropractors, osteopathic manipulators, prolotherapists, postural therapists, acupuncturists, even Therapeutic Touch practitioners. Each of these therapies proclaims the existence of force fields, bodily reactions, energies or auras that simply cannot be measured or observed scientifically. The “patients” who pay these docs run the gamut from the hopelessly deceived to the downright self-indulgent. But lest we look down too haughtily on NRWAT providers from the moral high ground of real medicine, we must admit that their patients come back again and again, seemingly happy with the treatments. And they pay them with real money–which seems, alas, to have become the whole idea.

That is true; many, if not most, patients who are into woo like therapeutic touch are often quite satisfied, leading reasonable people to ask: What’s the harm? A lot of this stuff, as the author of this article so perceptively calls this woo, “nothing really works anyway therapies.” And patients will pay, cash on the barrelhead, without all that nasty paperwork that insurance companies or Medicare demands in order for a physician to claim reimbursement. It’s very easy to see how using the authority of one’s M.D. to peddle a little seemingly harmless tonic might be very tempting indeed when income remains stagnant or declines in response to forces that a physician has no power over. And, besides, what isthe harm, anyway? Most of these treatments (but certainly not all) probably do no harm, although in the case of cancer and serious diseases they most definitely can delay the use of known effective treatments. But most physicians don’t treat cancer with woo; they treat backaches, headaches, anxiety, and other milder ailments. It’s not as though many of these physicians are recommending the Hoxsey therapy instead of chemotherapy for cancer, for example, fortunately. I reserve special contempt for physicians who use woo to treat cancer instead of evidence-based medicine. But how far towards woo is it acceptable to go?

As Dr. RW points out, this very question was studied in a survey published three months ago in Medical Economics entitled, What Would You Do? Alternative Medicine. Here was the scenario:

Frank, a 55-year-old teacher, has colon cancer that has metastasized to several lymph nodes and extends through the middle tissue layers of the colon wall. In addition to resection, he has undergone two rounds of chemotherapy. He says that he found the side effects of chemotherapy intolerable, and he wants to be treated instead at an alternative center that rejects what its founders call “toxic” treatments in favor of “natural” remedies, including chiropractic, whole-grain diets, and meditation. After acknowledging that his oncologist has expressed disapproval of the alternative treatments, Frank asks you, his primary care doctor, to serve as a collaborative physician with the alternative center.

If you were Frank’s doctor, what would you do?

And here were the responses:

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How do these results relate to doctors embracing woo? First, look at how few physicians would stick by their guns and try to guide the patient away from woo and back towards sound evidence-based medicine. A mere 21%. And look how many would collaborate with the altie center without any caveats. That number truly depressed me when I saw it, particularly when coupled with at least one of the comments in the article, who justified his collaborating with the center by saying, “He’s going to die anyway.” Contrary to what some doctors answering the survey said, the prognosis for this tumor described, although not fantastic, is by no means a death sentence. By the description given, this was probably a Stage IIIB or IIIC colon cancer (depending on whether four or more lymph nodes were involved), for which the expected five year survival is in the 30-40% range. True, that’s not that good, but it’s very incorrect to say the patient “is going to die anyway.” One third or even more of patients like “Frank” can be “cured.”

The second point is that nearly 80% would collaborate with woo simply because it’s what the patient wants, even when they know there’s no good evidence that it does anything therapeutic. My problem with this, of course, is that collaboration implies approval. But there’s another pernicious effect. From a willingness to collaborate with woo-meisters, it’s not all that huge a step for a physician to wonder if there’s anything so wrong with going beyond collaborating and becoming an active participant in giving the patients what they want, even though they know it’s not good medicine, particularly if it’s for diseases for which “conventional” has a paucity of effective treatments. Sometimes physicians don’t go quite this far and instead start incorporating woo like therapeutic touch or even homeopathy into their practices in addition to standard evidence-based medicine, fearing that their woo-steeped patients will leave them otherwise. Att least such patients are getting appropriate conventional care, reason such practitioners, but even this approach is an ethical minefield, because, again, the physician is putting the imprimatur of scientific medicine on woo. As Dr. RW points out, though, it’s possible to respect your patient’s world view even when it’s steeped in woo and still remain true to yourself:

A common justification by mainstreamers for their pseudoscience promotion is that doctors must respect patients’ beliefs and choices. Implicit in that argument is the tired canard that telling the truth about unproven methods and respecting patients’ choices are mutually exclusive. My own experience with patients is different. It is possible to tell the truth with respect and agree to disagree. If the patient is deeply steeped in woo I simply acknowledge our opposing world views and explain that in order to maintain a sense of professionalism I must remain true to the world view I believe in and was trained in and in which is western science. In this manner it is possible to respect patients’ beliefs without agreeing with them. It is not necessary to promote quackery, even implicitly, to treat patients with respect. I’ve found that even patients who are extremely into woo accept this approach.

And so have I. In reality, most of the time, when a woo-steeped patient comes in for a consultation, my approach is to explain my viewpoint and try at least to get her to accede at least to surgery, because most significant number of women with operable breast cancer are cured with surgery alone and the consequences of not at least removing the primary tumor can be horrific.This can be accomplished in a nonconfrontational manner while respecting the patient’s beliefs. However, like Dr. RW, I will not collaborate in a treatment that science tells me to be either ineffective, unproven, or so scientifically implausible as to be not worth investigating if it is being chosen instead of what I know to be effective care. If the patient is doing it on the side, I will not object as long as I know it doesn’t interfere with treatment (drug interactions with herbal remedies, for example), but neither will I facilitate access to such remedies. I will simply ask to be informed and remain nonjudgmental.

Still, I’m in the proverbial “ivory tower,” in an academic medical center. Such woo-steeped patients are actually surprisingly few compared to what I had expected when I started here, and that’s probably because most patients seeking woo probably don’t come to academic cancer centers when diagnosed with cancer. Sometimes I ask myself if I could maintain my purity of devotion towards EBM if I were in the trenches in a private practice. After all, here I’m paid a straight salary; although I make less than I could potentially make in private practice, I don’t do too badly. I’m at the moment largely buffered from the financial effects of declining reimbursements, and the university is self-insured, meaning that I don’t have to worry about how much malpractice insurance costs despite practicing in a state that’s a malpractice free-for-all that obstetricians are leaving in droves. If I had to face what my colleagues in private practice face, I have to wonder whether I could resist the urge to make a little on the side with woo.

Heck, being in academics, I sometimes wonder if the only reason that I’ve resisted other ethically dubious incursions into unproven or dubious therapies that are mainstream, not alternative, medicine, such as this or this, is because my laboratory investigations are a bit on the esoteric side and my clinical responsibilities are intentionally kept light.

I like to think that none of that would matter, but, then, I could never really know that unless I tried to survive in private practice for a while.

Comments

  1. #1 Blake Stacey
    February 6, 2007

    If all these woo remedies “work” on chronic problems for which we don’t have pills — fatigue, aching feet and so forth — wouldn’t it be just as good to prescribe meditation, classical music, and/or soaking in a bubble bath? One could be upfront with the patient: “The rationales which people give for Therapeutic Touch are without a doubt nonsense. It’s like waving your hands over your car to fix its muffler. What you’re really seeing is the body’s ability to take care of itself.”

    Since the state of mind is the key to making the placebo effect work, perhaps there’s an honest way to bring about a beneficial state of mind. You could still turn a profit, too, by selling Mozart CDs and bottles of bubble bath.

  2. #2 Robin Peters
    February 6, 2007

    You know, it’s funny you should bring up the topic of making money off woo. I’ve noticed – with what little experience I’ve had with woo – that that stuff is just as expensive as what you conventional practitioners charge for your services. It’s just that we patients are shielded from the cost of conventional health-care services by our insurers. We have to pay out-of-pocket for the woo, however.

    True Believers don’t mind the costs, though. You hear them gripe about Big Pharma, pharma shills, and the cost of conventional medicine in all its forms, but you don’t hear them gripe about going to some exotic location (with all the associated costs involved in travel), paying an exorbitant fee to Dr. Woo, and then dying anyway. And you don’t hear them complain about the costs involved in the homegrown woo, either – just about the costs of conventional medicine, and how all the conventional health-care practitioners are in the back pocket of Big Pharma and are serving as pharma shills.

  3. #3 qetzal
    February 6, 2007

    My question: what does it mean to for a PCP to say they would “work with” the alternative center.

    I would understand and support a PCP who says “I disagree with your decision to pursue this. I won’t assist in this “treatment” because I think it’s unethical, but I will agree to continue monitoring your health while you do so.”

    That seems very appropriate, if the patient agrees. At least then, the PCP can provide independent oversight in case the woo is actively harmful, and s/he has a chance to change the patient’s mind if things don’t go well.

    Might some of the 71% have answered with this in mind?

  4. #4 Sid Schwab
    February 6, 2007

    Like you, I’ve particularly encountered the problem of woo-meshing with breast cancer. My aim is to get them to follow mainstream treatment, and to consider the woo as in some way adjunctive. It didn’t always work, sadly. I approached my discussions on the subject, evidently, in much the same way as you did. When asked, on a couple of occasions, to do some thing or other actually to facilitate their choices away from acceptable treatment (one time, for example, I was asked to insert a broviak catheter for access to infusion of some sort of witches brew) I told them I was sorry, but that I couldn’t do.

    As for docs switching to pitching, the best one could say is that “the system” has beaten them down to the extent that they just gave up. But I’d say that gives them too much credit.

  5. #5 Calli Arcale
    February 6, 2007

    It’s a tough situation. One problem is that a lot of patients will insist on some kind of treatment even when there is nothing that will work; I could see a doctor thinking that harmless woo might help satisfy the patient. (Of course, there’s the unstated caveat that nothing is really harmless.)

    My grandfather, when he was practicing, used to give placebos to patients who wanted more treatment even when treatment wasn’t really indicated. I’m not sure how to feel about that, but I can see why he did it. I could see the same logic behind collaborating on woo. Again, I have mixed feelings about it, because to some extent it involves not being entirely honest with your patient.

  6. #6 anonimouse
    February 6, 2007

    This is really just a variant on the whole question of why “health professionals become quacks”.

    http://www.quackwatch.org/01QuackeryRelatedTopics/quackpro.html

  7. #7 Ahistoricality
    February 6, 2007

    The “collaborate with reservations” question really should have been broken down into two separate questions:

    1. Would you work with the alternative health center because you know the patient will do it anyway and want to make sure it does no harm?

    2. Would you work with the alternative health center because you think it could do the patient some psychological benefit and, who knows, maybe the science is wrong about this stuff?

  8. #8 Marcia
    February 6, 2007

    “Such woo-steeped patients are actually surprisingly few compared to what I had expected when I started here..”

    It’s my belief that woo-steeped patients are surprisingly few outside of the academic center, too. I encounter many patients daily who are preparing for all kinds of surgery and I ask them to tell me about any “complementary” or “alternative” medicine they are using. It’s rare that I find someone using something other than say garlic tablets or glucosamine.

    I also think you’ve got to believe that paying $50 to some “doctor” who advises “wearing a scarf” (as one does at the end of the linked article) when it’s cold outside, isn’t going to sit well for too long with someone who has to reach inside a wallet for something greater than a copay. Follow up appointment? I don’t think so.
    http://media.www.dailyvanguard.com/media/storage/paper941/news/2007/02/02/News/Beyond.Western.Medicine-2693806.shtml?sourcedomain=www.dailyvanguard.com&MIIHost=media.collegepublisher.com

  9. #9 anonimouse
    February 6, 2007

    Marcia – even if it’s one or two percent of the population, that’s still enough to keep the intrepid woo-shiller in business and add extra income to their “legitimate” practice or start their own altie practice altogether.

  10. #10 plunge
    February 6, 2007

    Yeah, thanks for sticking in the shiv about how family practice doctors and pediatricians don’t make SQUAT anymore. Thinking about that happy thought will sure keep our family real warm when we can barely afford to heat our house through our residency. :)

  11. #11 James
    February 6, 2007

    “I know, I know. A lot of you out there are thinking: Boo-frickin’-hoo! (Except that you’re probably using the real F-word.)”

    Anyone taking that approach is very short-sighted. If the returns are low enough to drive doctors out of the market then that indicates returns are too low. For anyone who doesn’t think there is a glut of doctors in the US, this is not good.

    The trick is not to assume that everyone should be paid the same.

  12. #12 Christian
    February 6, 2007

    OK, make fun of me, but being outside of the medical profession, would it be possible for insurance companies, etc to somehow gauge the effect of placebo medicine, and then somehow pay on it? Granted, we would be talking about reformation of the tort system to some degree, but hell, telling someone with terminal cancer that Vitamin C in some spiritually enhanced form has got to be more culpable than telling someone “Our treatment options have run out, if you wish to run to ‘XYZ Treatment’, feel free, just keep me informed of your treatment, and let me monitor your progression and make recommendations on what we know to have worked or not worked in the past”.

    I don’t want placebo to be the panacea, but it seems that sometimes letting the patient perform their own tilting against windmills will make them happy, we just need to inform them of the reality that they know?

    Orac, please feel free to shoot me down here, since this is definitely a gray area. We don’t want to encourage crap, but can we let them make choices based on the best information that we have, and then, after signing off on the fact that their choice may be crap, let them go with monitoring and input based on what we do know?

    Shades of Libertarianism, your choice may be stupid, but it is YOURS, don’t whine too much after you have made it with the best possible input?

  13. #13 HCN
    February 7, 2007

    Christian said “Shades of Libertarianism, your choice may be stupid, but it is YOURS, don’t whine too much after you have made it with the best possible input?”

    But the insurance company does not necessarily have to pay for it. In a pure libertarian world (insurance companies are subject to state law in the United States) the insurance companies would have TOTAL control over what politician pushed through a law that required insurance companies to pay for alt-med… the insurance companies fought that dictate — then a few years later that man died at a fairly young age, but the reason was suppressed by his family. It was speculated that he used alt-med instead of real-med for a condition until it was too late.

    In short: In a truly libertarian scenario an insurance company would only pay for medical treatment that has been shown to work. They would not have to waste their money on stuff that was not PROVEN to work. They would only pay for “Evidence Based Medicine”!

  14. #14 Francis
    February 7, 2007

    In short: In a truly libertarian scenario an insurance company would only pay for medical treatment that has been shown to work. They would not have to waste their money on stuff that was not PROVEN to work. They would only pay for “Evidence Based Medicine”!

    Nonsense. In a truly Libertarian scenario, the insurance company would pay for whatever medical treatment it agreed with the client that it would pay for. So you would indeed get insurance companies that paid for evidence based medicine only – but you would also get homeopathic medical insurance companies, medical insurance companies that paid for anything, and medical insurance companies that wrote in the small print that they would only pay out if the treatment involved one gram of unobtanium.

  15. #15 HCN
    February 7, 2007

    I find that hard to believe, considering how hard insurance companies fight to pay for anything that is the least bit “experimental”. They are businesses and would be resistent to anything that involved monetary OUTflow. So if there is any tiny reason to deny a claim, they would use it!

  16. #16 Sid Schwab
    February 7, 2007

    In the State of Washington, medical insurers must, BY LAW, cover such woo as aromatherapy, naturopathy, homeopathy, chiropractic.

  17. #17 Antiquated Tory
    February 7, 2007

    HCN,
    Unless of course market forces dictated that insurance companies offer coverage that specifically included various bits of woo. Someone would offer it if the financial guys found a way to make a profit on it.
    This is not the same as burying as many conditions as possible into the fine print of the policy so as to deny claims. After all, the ideal for any insurance company would be to take in premiums and never pay any claims for anything, but nobody would give them money in this case.
    In the end I don’t think this is much of a private/public issue: medical woo ends up being covered because there is a strong enough public demand that it be covered. Even more annoying is the public money, taken out of the (quite limited) common kitty, flushed down the toilet on alternative care. And with that floppy eared fool Prince Charles pushing it. At least British physicians are fighting back. And in Germany, where homeopathy and in fact all manner of woo is very popular, there are private health insurance schemes that pay for it, though the state insurance does not.

  18. #18 HCN
    February 7, 2007

    Sid Shwab said “In the State of Washington, medical insurers must, BY LAW, cover such woo as aromatherapy, naturopathy, homeopathy, chiropractic.”

    I know. It was pushed by a very conservative, albeit libertarian politician by the name of Kent Pullen. I thought it was amusing that this guy who was big on market forces and personal rights (especially with gun ownership) had to force the insurance companies to pay for alternative meds. I had enough problems getting insurance companies to pay for neurodevelmental therapy for my son (which is also legislated by law, but they now get around it by limiting it to something like $2000/year).

    By the way, he died at age 60 after an un-named illness:
    http://seattlepi.nwsource.com/local/117612_pullen15.html

    I always thought it was interesting that they kept his illness a secret. I keep thinking he shortened his own life by persuing “alternative” instead of real medicine.

    Though, he did have a longer life than one of the founders of Bastyr Univ (possibly due to something genetic):
    http://seattlepi.nwsource.com/local/6420ap_wa_obit_mitchell.html

  19. #19 Coin
    February 7, 2007

    In the State of Washington, medical insurers must, BY LAW, cover such woo as aromatherapy, naturopathy, homeopathy, chiropractic.

    Huh.

    What about contraception? Do they have to cover that?

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