Respectful Insolence

ResearchBlogging.orgIf there is one aspect of “complementary and alternative” medicine (CAM) that can puzzle advocates of science-based medicine, it’s why, given how nonsensical much of it is given that some of it actually goes against the laws of physics (think homeopathy or distance healing), CAM is so popular. Obviously one reason is that there are conditions for which SBM does not have any “magic bullet” treatments. Diabetes, heart disease, other chronic illnesses, SBM can manage them quite well, but it can’t cure them. Then there are conditions that science doesn’t understand very well, conditions like, for example, fibromyalgia. It would be less than honest of me (or any other supporter of SBM) not to acknowledge that SBM sometimes has little to offer some patients. Of course, there’s no evidence that CAM has anything therapeutic or concrete to offer these patients either, although certainly CAMsters would like you and their other marks to believe that they do.

Actually, that may not be entirely accurate. There does appear to be something that CAMsters offer patients that we practitioners of SBM appear to have a problem providing. It’s unfortunate that this is true, but it does appear to be, and what it is should be fairly easy to guess. Basically, it’s time. Anecdotally, most of us who pay attention to the issue of CAM and the infiltration of pseudoscience into medicine have suspected this, but there hasn’t been a lot of data one way or the other to determine whether this is indeed the case and, if so, what the difference is. Last week, however, Dr. RW pointed me to a study that takes a stab at answering that very question. Published by a Dutch group, the study examined the practices of conventional physicians and CAM practitioners in terms of diagnoses seen and time spent with patients. The CAM practitioners included physicians practicing homeopathy, acupuncture, and naturopathy. A total of 5919 visits in 1839 patients were studied for diagnoses and time spent with each patient. These data were then compared with data from general practitioners (GPs) participating in the second Dutch national study in general practice (DNSGP-2). One result of this study was not surprising:

Comparisons of visit length in CM practices and mainstream GP revealed major differences. General practitioners usually invested between 1-15 minutes, whereas CM physicians used at least 30 minutes for repeat visits and even twice as much for intakes. One of patients’ reasons for consulting a CM physician is in line with these findings, i.e. the wish to get ample time to talk with the physician [42]. Other studies on visit length have indicated that in mainstream GPs shorter visits were related to discussions about only one or two health issues, whereas in CM more issues were discussed and a higher number of advices were given [28]. Visit length is also found to be positively related to patient satisfaction [24,26,27].

In other words, on average CAM practitioners spent at least twice as much time with patients as GPs, particularly for the first visit. Although the Dutch have universal health care, it would appear that the time pressures on GPs are the same there as they are here in the U.S., and, if this study is accurate, GPs there focus on key health concerns rather than a wide-ranging discussion. Here in the U.S., ever-declining reimbursement for primary care visits have led to increasing time pressure on doctors to see more patients in a day. This situation is not conducive to physicians spending a lot of time with each patient. Even as a specialist, in my own practice I can spend quite a bit of time with new patients, but that’s only because I am lucky enough to work in a large academic cancer center with a large support staff. That’s one reason why I like working in a large cancer center, aside from the opportunity for academic pursuits and lab research. If I were in private practice, I doubt I could afford to spend that much time with new patients.

One aspect of this study that Dr. RW didn’t mention is its other part, namely the comparison of diagnoses arrived at by the CAMsters versus the GPs. Table 3 in the paper tells the tale. Earlier studies have found that CAMsters tend to see more of specific types of problems, such as chronic disease, anxiety, depression and poor physical fitness. Findings of this study were described thusly:

The primary diagnoses indicate that CM patients visited CM practitioners for general complaints (as coded in the ICPC) more often than patients in general practice (Table 3), especially for fatigue. More specifically, in homeopathy practices 77% of these general complaints concerned fatigue, in acupuncture practices this percentage was 68%, and in naturopathy practices 45%. In homeopathy and acupuncture practices allergic reactions came as second most frequently diagnosed general complaint, in 12% and 11% of the general complaints, respectively. In naturopathy practices, infections were the second most frequently diagnosed general complaints (12%). Also, psychological problems were diagnosed more often in CM practices than in GP practices, in acupuncture and homeopathy practices about three times more often than in GP practices. The incidence of problems with the nervous system was also found to be higher in CM practices than in GP practices, whereas problems in the cardiovascular system were more often diagnosed in GP practices. Differences in diagnoses between three types of CM practices gave an idea of the specific expertise of each CM specialty. We found that the diagnoses of problems with the musculoskeletal system were highest in acupuncture practices and those of skin problems diagnoses were highest in homeopathic practices. Naturopathic physicians diagnosed more often gastrointestinal problems, compared to GPs as well as the other two CM specialties

I was actually surprised that infections were so frequently diagnosed in naturopathy practices. On the other hand, given the number of dubious and outright bogus diagnoses in naturopathy, there’s no way of knowing what kind of infections were being diagnosed. For all we know, these naturopaths could be diagnosing one of the favorite alt-med catch-all diagnoses, chronic fungal infections. Be that as it may, the difference in diagnosis patterns is important. The preponderance of musculoskeletal complaints and, in particular, complaints of fatigue suggest that patients seek out CAM for complaints for which SBM doesn’t always have good responses. Alternatively, this could be yet another study implying that CAM patients seek out CAM for what we call the disease of living; i.e., the fatigue and little aches and pains that we all experience as we get older. Another favorite of the CAM practitioners are allergies. Unfortunately, it wasn’t clear from this paper if these “allergies” were mainly food allergies akin to the type of “allergies” diagnosed, for example, by DAN! practitioners in autistic children. After all, if there’s one thing I’ve learned from blogging about alt-med for over five years, it’s that, in alt-med, if it isn’t an “allergy,” it’s a “food allergy” or a “chronic fungal infection” or, of course, the dreaded “toxins.”

Unfortunately, the authors appear not to “get it.” Although they do mention that the Royal Dutch Medical Association (RDMA) emphasizes that it is the physician’s duty to emphasize the importance of mainstream, evidence-based treatments at all times and that it emphasizes that CAM exists “outside the world of mainstream medicine” (would that medical societies here in the U.S. would take such a strong position with respect to CAM!), they seem untroubled by the infiltration of woo into Dutch medical practice and appear to have done this study at the behest of the Netherlands association for homeopathic physicians (VHAN). Worse, they describe homeopathy, traditional chinese medicine, and naturopathy pretty much the way that woo-meisters describe them, complete with references to “energy” and “energy flows” being restored.

Overall, this study basically confirms what most of us have already suspected, namely that CAM practitioners spend a lot more time with their patients than science-based practitioners do, but they come up with a distinctly different set of diagnoses, mainly general diagnoses related to fatigue and musculoskeletal. Putting the two together, I fear that the cost of that extra time spent by CAM practitioners is a whole lot of dubious diagnoses. Sure, this study doesn’t show that; it can’t. But taking into account just what acupuncture, naturopathy, and homeopathy are, how could it be any different? The very basis of these specialties consists of prescientific conceptions of disease akin to miasmas or imbalances in the four humors or, in essence, vitalism, complete with references to “life forces” (qi or “energy”).

This study suggests another thing to me. People with chonic complaints want very much to know what’s wrong with them. Being told that a diagnosis can’t be easily derived from their symptoms and findings (or that there is no known diagnosis for them) is profoundly dissatisfying. Enter the homeopath, the acupunturist, or the naturopath. They are virtually always able to give a patient a diagnosis–or often several diagnoses–virtually all of them bogus, such as “imbalances in energy flow,” chronic allergies (unsupported by science-based diagnostic tests indicative of allergies), food allergies, or chronic fungal infections. At the same time, they spend a lot more time with patients. It’s a combination that’s hard to beat for a certain class of patient, and even hard-nosed skeptical patients can be taken in by someone willing to take a lot of time and provide answers that SBM has trouble giving. It doesn’t matter if those answers have no basis in science or are based on quackery; it can be very seductive, and many are seduced.

I often wonder what would happen if practitioners of SBM spent as much time with their patients as CAM practitioners do. I can’t help but wonder if it would take away one aspect of CAM that is, to the average patient, very appealing compared to SBM.

REFERENCE

Heiligers, P., de Groot, J., Koster, D., & van Dulmen, S. (2010). Diagnoses and visit length in complementary and mainstream medicine BMC Complementary and Alternative Medicine, 10 (1) DOI: 10.1186/1472-6882-10-3

Comments

  1. #1 JerryM
    February 9, 2010

    It’s precisely because we have universal healthcare that GP’s don’t have as much time as they would like – they’re being swamped by people with little to no real illnesses.

    Unfortunately more and more CAM practices are being covered by insurance – although most still need a supplemental healtcare package (+10-100€/m).

    It is rather telling that each particular CAM practice seems to diagnose a particular disease – how much of that is pre-selection by patients I can’t tell.

  2. #2 DLC
    February 9, 2010

    well, when you’re taking a wild guess at what’s ailing your patient, guessing “fatigue” or “chronic fungal infection” is usually a safe bet. After all, fatigue is just nebulous enough to cover almost anyone. who hasn’t felt fatigued or run down ? The “chronic fungal infection” is a bit more risky, because some anti-fungal meds can have nasty side effects — but then, homeopaths could prescribe homeopathic solution of cyanide and it wouldn’t matter. Although I would love to have some 30c plutonium . . . LOL

  3. #3 Whamo
    February 9, 2010

    Why is it that CAM doctors can ‘afford’ the extra time with patients? Are they getting paid that much more? Or is it due to the supplementation of their income by all the extras they might sell out in the lobby?

    I am not in the medical arena at all as any more than a patient, but I would have guessed that the average GP made about the same as a CAM doctor or more.

  4. #4 Pablo
    February 9, 2010

    Why is it that CAM doctors can ‘afford’ the extra time with patients?

    Because they don’t have as many patients, I suspect.

  5. #5 Anonymous
    February 9, 2010

    I once chose a GP who, due to his lack of patients (perhaps because of advancing age), could spend lots and lots of time with me. I drove almost an hour to see him. Though I suspected he was no longer up on the latest medicine, and some of his ideas seemed downright folksy, the comfort I got in being heard more than made up for it to me. Psychological foible? Perhaps.

    If healthcare dollars could be spent in SBM and not diverted to useless care, maybe the average time spent with a doctor could be improved.

  6. #6 Charlie
    February 9, 2010

    Not sure about Holland, but in UK GP’s are not paid “per patient seen” but “per session” (to put it very simplistically) so if you are a CAM practitioner you can adjust your charge to fit your “expertise” as well as selling …supplements.

  7. #7 History Punk
    February 9, 2010

    A thing that always amused me is how many people will reject nonsense from the “Western” quack tradition like the Blessing of the Throats on Saint Blaise Day or the annointing of the sick, but will indulge without fear in their allegedly “Eastern” equivalents like Reiki and Therapeutic Touch.

  8. #8 Anonymous
    February 9, 2010

    What about the CAM that does work, like meditation, which has proved over and over in scientific studies to alter the brain (for the better) thus easing depression, anxiety, stress and sleep related disorders,etc.? If scientists spent more time studying CAM techniques, the quackery from the truth might be discerned to the benefit of all. And yes, having time with your doctor would do a lot–besides piece of mind, the relationship between doctor and patient would reduce specious malpractice suits….

  9. #9 Orac
    February 9, 2010

    What about the CAM that does work, like meditation, which has proved over and over in scientific studies to alter the brain (for the better) thus easing depression, anxiety, stress and sleep related disorders,etc.?

    What do they call alternative medicine that works?

    Medicine.

    As I’ve said time and time again, I reject the very idea of “alternative” medicine or CAM, the latter of which is more a marketing term than anything else, as is “integrative” medicine. The same scientific standard should be applied to all therapies.

  10. #10 LC
    February 9, 2010

    Unfortunatly I suspect it is only to get worse.

    The various health systems are already overloaded by chronic hypocondriacs and time wasters. Your average GP works long stressful hours with large queues and cant afford to waste his limited time listening to someone whine about their cut finger or cold when real cases are waiting. And with the massive influx of baby boomers waiting in the wings….

    So enter ‘alternative medicine’ – 9-5 hours, hand out glasses of water as cures and can sit back and listen to someone ramble on for half an hour about their ‘problems’. No stress, no government/administrator whining about not meeting patient numbers, no worrying about if specialists are needed, no worrying about malpractice, etc. I wonder how nice, fluffy and understanding ‘CAM practioners’ would be if they were on call 24/7, were expected to produce impossible results, get screamed at, under threats of lawsuits, etc.

    It’s easy to have nice long talks and be understanding when no real pressure is applied.

  11. #11 Jud
    February 9, 2010

    I would guess that one reason CAM practitioners can spend more time with patients is that neither their educations nor running their practices is as expensive as for practitioners of SBM.

    Think of the cost of a med school education, of equipment, of highly educated/qualified staff…. These costs must be remitted by the most remunerative use of an SBM practitioner’s time, or he/she will soon be an ex-practitioner.

  12. #12 DrWonderful
    February 9, 2010

    “The same scientific standard should be applied to all therapies.”

    Orac, I could not agree more and again applaud you for appearing to be the most balanced and objective of the CAM hunters. However, it begs the question…what is the standard you would propose? At what point is the evidence to be determined “acceptable” and therfore a procedure deemed by the high priests of science to be allowable.

    I gather you are a cancer researcher but also treat patients? You must know as well as anyone the “art” that is involved with caring for patients. Sometimes docs need some flexibility and room to work with different types of cases and people. By creating a very high and strict cookbook standard, instead of simply an evidence influenced culture, would we not be too restrictive?

    Field docs slugging it out in the trenches are dealing with patient lifestyles and personalities plus the insanity of our current reimbursement structure. We have many more variables to deal with in the real world than the research often considers.

    It’s easy if you’re faculty or retired or not even a frontline health care provider to create a theoretical “standard” but having one that actually works in the real world is something completely different. I still think docs need more room to maneuver and higher tolerances than what you and your partners are suggesting.

  13. #13 RMM Barrie
    February 9, 2010

    Orac

    I often wonder what would happen if practitioners of SBM spent as much time with their patients as CAM practitioners do.

    Nothing, because of the predisposition of the CAM patient to want to believe the nonsense. This patient also does not want to accept the reality of SBM, that does not have ready answers for complex symptoms, or when SBM does have an answer; these patients prefer to deny reality. “No, the 2 pack a day habit did not cause my lung cancer, it is because I did not detox properly”. However, if this patient broke a bone, they would go mainstream because that is within their realm of understanding.

    I can’t help but wonder if it would take away one aspect of CAM that is, to the average patient, very appealing compared to SBM.

    Might help a little, but the CAM patient probably does not understand the nuance, is not oriented to listen, and holds other beliefs that would take an inordinate amount of time to convert the few. SBM has the balance about right for being productive, and if the practitioner remains alert, they can send this patient off to whatever counseling they may need.

    Is my view of reality, not jaded, just realistic.

  14. #14 Anonymouse
    February 9, 2010

    You’re forgetting another part of the equation, which is that pain and fatigue are conditions that respond very well to the placebo effect. Simply having a CAM practitioner spend time with a patient and listen to them can make the patient feel better, without the side effects of pain medications and other treatments.

    I know because I went through this when I experienced a bout of reflex sympathetic dystrophy. The pain medications I was given didn’t work very well and the side effects (severe diarrhea) were intolerable. I sought out acupuncture and the Feldenkrais method and eventually recovered. Did the therapies “cure” me? I doubt it, but I know that I experienced considerably less pain after my sessions. Probably placebo effect, but I didn’t care at the time. All I knew was that I got relief from the overwhelming pain.

    Of course, now I’m suffering from chronic migraines and I’m going the full-on drug route. Topamax for me and it’s working beautifully with minimal side effects. But I completely understand why patients go the CAM route and why they derive benefits from it, even if it’s only placebo.

  15. #15 Scott
    February 9, 2010

    @12:

    I think you’re missing the forest for the trees. The details of the standard are not terribly relevant. For acupuncture, homeopathy, reiki, colloidal silver, etc., essentially any evidentiary standard leads to their being rejected.

    Unless you propose to adopt a standard of “anything at all is allowed no matter the state of the evidence for it”, it frankly is quite irrelevant whether the standard is “more likely than not,” “a reasonable degree of certainty,” “beyond a reasonable doubt”, or anything else.

    So I’ll turn your question around. What standard do you propose that would NOT lead to the mentioned “treatments” being rejected?

  16. #16 Denice Walter
    February 9, 2010

    Purely speculation: I often wonder how much CAM serves as a surrogate support system or pseudo-psychotherapy. I suspect some the time is spent with the patient’s reiteration of problems, physical and otherwise,counseling by the provider, and above all,dispensing soothing reassurance with a relaxed attitude.Perhaps the spiritual flavor suggests this as well: making it attractive to those who might not seek traditional therapy/counseling,possibly because of stigma,cost,or misinformation.So much of woo addresses emotional issues, and unlike that cold-hearted science-y medicine(the real one),altmed provides instant answers and certainty.

  17. #17 cuco3
    February 9, 2010

    Time is money. Whoever pays for it there are finite resources. GPs have bills to pay.

    I’d be interested to know how much it costs to become a proper GP – training, equipment, insurance, certification – compared to a homeopath or other quack. I expect that real doctors have much higher overheads, so they either need to charge more per patient or see more patients.

  18. #18 Pablo
    February 9, 2010

    You’re forgetting another part of the equation, which is that pain and fatigue are conditions that respond very well to the placebo effect.

    This is actually most of it.

    How much time would a CAM doctor spend with a patient who came in with a broken wrist? It’s a trick question, of course, because no one would go to a CAM doctor for a broken wrist.

    So instead, the patient comes in with “fatigue,” and the doctor sits and listens while the patient complains about how none of those other doctors can do anything for them. Who doesn’t feel better after a good long vent on a sympathetic ear?

  19. #19 F. Marie
    February 9, 2010

    Although my mother makes fun of people believing in things like homeopathy, she did try to see a naturopath about her back pain because she was desperate for anything that would help. The naturopath spent two hours with my mother, had her perform a wide variety of bizarre “exercises” and ended up giving her a lot of vague recommendations. None of it helped her in the slightest but immediately after the visit my mother did feel that she had gotten some benefit from it and I think it was because of the time the naturopath spent with her and the general concern the naturopath expressed. When the perceived benefit was gone a day later, my mother didn’t pursue that avenue again. She eventually had to have two vertebrae fused.
    The human connection that many people I have talked to feel with their CAM practitioner isn’t just part of the time spent, however. I know I have had long doctor’s visits for my chronic conditions and felt more like some mildly-interesting bacteria specimen being examined under the microscope than a person the doctor was concerned about. I have also had shorter visits with physicians who did truly care and I valued those a great deal more. I’m afraid that the money and prestige involved with being a doctor does attract a group of people who are more interested in those things than with the welfare of their patients. (I would count one of my cousins in this group.) Certainly this is not a universal trait among physicians, but it is not rare, either. In my experience, I have found it to be more common among specialists – the doctors people with unusual chronic conditions get referred to.

  20. #20 Scott
    February 9, 2010

    How much time would a CAM doctor spend with a patient who came in with a broken wrist? It’s a trick question, of course, because no one would go to a CAM doctor for a broken wrist.

    Very few, anyway. But I’m afraid there are some. And there are probably also a few CAM practitioners who wouldn’t tell them to go to the ER. (Again, not many at all, but I expect you could find one or two if you looked hard enough.)

    Never underestimate the ability of the “true believer” to convince themselves that their magic can handle any situation.

  21. #21 James Sweet
    February 9, 2010

    Our pediatrician/family doctor usually spends 45 minutes to an hour with us even for totally routine visits. I have no idea how he stays in business, but it’s awesome. (Disclaimer: He’s a DO, and I know some commenters on this blog have found a very likely tendency for DOs to engage in quackery — but my experience so far is that he has most certainly not drunk the Kool-Aid. In fact, he helped me talk my wife back into getting our son vaccinated. FWIW.)

    The increase in diagnoses is very interesting. It is indeed part of the human condition that we want answers, and it’s hard to accept when there aren’t any — so much so that it drives many people to just make up answers for the harder questions (*cough*religion*cough*). To paraphrase the bumper sticker, Inexplicable Shit Happens. That’s one of the toughest, but most important, lessons in life I think.

  22. #22 Pablo
    February 9, 2010

    Both my PCP and our son’s pediatrician spend as much time with us as we want. However, I don’t need much so with the PCP I am usually done in 10 minutes, at most, and with the pediatrician, we might go 15.

    Neither has dismissed a concern of any sort, but they also don’t waste time doing stuff that is unnecessary.

  23. #23 #1 Dinosaur
    February 9, 2010

    Pardon my language, but: DUH! People are willing to PAY (out of pocket; yanno, CASH money) for woosters to spend tons of time with them, basically to lie to them. Why the hell don’t they think they should have to pay someone (ie, me) who can actually do something for them?

    We know what the problem is; it’s money.

    (Re-posted from my comment on Dr. RW’s blog.)

  24. #24 Anthro
    February 9, 2010

    I have seen some evidence of doctors trying to deal with the time problem. The last two specialists I have seen are using Physician Assistants who come in first and spend a fair amount of time asking lots of questions and letting you answer them in detail. They take notes and show lots of interest. Then, he or she leaves and in a few minutes the PA and the doc come in together and the doc asks one or to questions, takes a look at what the PA has prescribed and passes it or makes a change. Basically it seems that the doc just does what he/she would have anyway and the PA is there to provide that time factor that patients want and need. In one case with the dermatologist, she overruled the PA and did a lot of tests including a nasty biopsy and it turned out that the PA was right all along. I think the doc was just being “better safe than sorry”.

    By the way, CAM people will freely admit that they think SBM is best for emergencies, but they would quickly add that they stink when it comes to “prevention”. Most of the people I hear this from are young enough not to yet be affected by the chronic diseases of aging, nor are most of them overweight. Time will tell.

    Some good news. When I get my allergy shots, there is almost always at least one child there who is allergic to eggs (or something) getting a special type of vaccination. It’s good to see that these parents haven’t drunk the kool-aid.

  25. #25 Shannon
    February 9, 2010

    I would guess that the “chronic fungal infection” checked off on the insurance form is actually communicated to the CAM patient as “candida”, that purportedly has a “cure” that is based on a restrictive diet that excludes all sugars and all wheat in order to “kill” the “yeast”.

    *rolls eyes*

  26. #26 Shannon
    February 9, 2010

    Also,
    as a user experience designer I am interested in the field of Health Care design which studies the poor experience many individuals have receiving care, and offers scientific, methodological solutions to the issue of poor patient experience. i hope this growing field will mitigate some of the problems that turn people away from SBM.

  27. #27 Vicki
    February 9, 2010

    #1 Dinosaur:

    It’s not, or not just, that patients wouldn’t pay a regular doctor (or nurse or PA) to spend more time with them. It’s that most medical practices aren’t set up to make that feasible. Sometimes I may walk into my doctor’s office with a list of four things, in order of priority, and hope she’ll get to all of them. Hope but not expect. When I call for an appointment, her staff may ask how urgent it is, but they don’t ask how many issues I need to deal with, or how long I think it will take. I would love a medical practice that would let me book, and use, two consecutive appointments, and pay two co-pays for them. But I suspect the insurance company would flag that as fraud.

  28. #28 Pablo
    February 9, 2010

    I am interested in the field of Health Care design which studies the poor experience many individuals have receiving care, and offers scientific, methodological solutions to the issue of poor patient experience i hope this growing field will mitigate some of the problems that turn people away from SBM.

    Shannon – one problem that you will not be able to fix is that where, unlike CAM whackos, SBM practitioners won’t lie to patients.

    I highlighed this problem in the discussions about Suzanne Sommers. I noted her interview where she lamented that doctors who use traditional treatment won’t say they can cure you. However, the doctors in her book, apparently, will say that. IOW, whereas traditional doctors are realistic, and will tell you the truth about what is going on (they don’t like the word cure because it’s not clear what it really means), CAM doctors have no problems lying straight out.

    How are you going to fix that? Tell doctors to start lying to patients?

  29. #29 Sastra
    February 9, 2010

    Also, psychological problems were diagnosed more often in CM practices than in GP practices, in acupuncture and homeopathy practices about three times more often than in GP practices.

    This is interesting; I wonder what’s behind it? Usually, CAM advocates brag that alt-med practitioners won’t tell you that your symptoms are “all in your head” the way ‘Western doctors’ insultingly do. And yet they’re diagnosing 3 times the psychological problems.

    Are acupuncturists and homeopaths blaming a lot on stress? My altie friends do seem to automatically assume that any physical problem is directly related to some problem with the person’s attitude, or due to anger or resentment which is ‘coming out’ in the form of a rash, or a back ache, or cancer. This might be one reason CAM takes longer: they need to have you go in to what and who has been bothering you, so they can get to the ‘underlying cause.’

    Or, could be that more people with psych problems go to acupuncturists and homeopaths in the first place. Might even be a clue…

  30. #30 antipodean
    February 9, 2010

    What I don’t get is this paradox:

    If I , as a scientist with enough expertise in a certain common disease that clinicians and medicical journals will sometimes ask my opinion on clinical decisions, hung out a shingle and started diagnosing a treating patients with only this specific condition I would rightly be charged and convicted of practicing medicine without a license.

    But these arseholes, who have no worthwhile training in anything whatsoever, hang out a shingle and start diagnosing and treating everything under the sun (and some diseases that don’t actually exist) get away with it. It’s all completely out in the open. Practising medicine without a license is fine as long as you give it a CAM spin.

  31. #31 TGAP Dad
    February 9, 2010

    Dawkins mentioned the time and attention issue in his excellent miniseries The Enemies of Reason, and I think it is certainly significant. In Trick or Treatment, Sing and Ernst cover the placebo effect in some detail, but the trend generally seemed to be the more “significant” the placebo (bigger pills, injection instead of pill, administered by doctor rather than nurse, etc.), the stronger the effect. So it doesn’t seem to big a stretch to my nonscientific brain to wager that the more attention paid to the patient, the stronger the placebo effect in these cases as well.

    I know that in the U.S., medical professionals have been commoditized to a certain extent, and the pressure is on increased production. It is the patient, and ultimately his or her care that suffers the effect of this.

    FWIW I caught an episode of The Story which involved a couple vacationing in rural France, in a family’s home, and needing a doctor’s care. Within thirty minutes of their call, a doctor, who spoke fluent English, was dispatched on a house call. He administered a thorough and lengthy exam, treated her and prescribed medicine for about $25 – which would have been waived if they’d been French residents.

    The micro-exams seem to be uniquely American.

  32. #32 Nesytanebetashru
    February 9, 2010

    @LC,
    All of this talk of hypochondriacs taking up the time of GPs seems to me to be blaming the victim here. If someone is convinced that they’re ill at the very least there’s something psychologically wrong. I’ve only met a few genuine hypochondriacs, so unless they’re all mobbing YOUR clinic all the time, I would say some of your patients are probably getting shortchanged because of your dismissiveness.
    You’ll notice that these are all diagnoses of diseases with rather fuzzy and general symptoms. Symptoms where there aren’t really any testable factors and the only thing the doctor has to go on is the patient’s vague description.
    I can imagine that a lot of these people have gone to normal doctors with their problems and either not been taken seriously or met with a shrug.
    Since CAM doctors tend to rely more heavily on descriptions of personal experiences in their “diagnostics”, it’s an attractive place for people who have only personal accounts to go.
    I think this might be where a lot of the conflict between CAM and SBM arise. CAM takes descriptions of symptoms as interpreted by the person experiencing them very seriously. This is very attractive to most people who see it as more one-on-one and caring than SBM. However, personal accounts are very unreliable–they’re an interpretation. SBM seems (and rightly so) to value them the same or less than actual data when making a diagnosis. So, SBM, while being quantitative, and, well, REAL, comes off as uncaring in comparison. It is especially frustrating for people whose symptoms aren’t easily measured and people with psychological disorders.
    My experience with CAM is this: I had a panic attack a few years ago, and it scared the crap out of me. I went to a psychiatrist who put me on Xanax. At the time I was keenly aware of everything that I was feeling, and any nuance in my mood. Being on Xanax freaked me out. You worry about things, but don’t actually feel worried. There’s a disconnect between thoughts and emotions and physical feelings when you’re on it. The doctor actually encouraged me to take one several times a day. I thought a small-pet-sized dosage was too potent.
    I was not disillusioned with SBM so much as I was with the doctor. He spent fifteen minutes with me max per appointment (which, of course cost > $200). Most of this time was spent filling out multiple choice with questions like “on a scale of 1 to 5, how much do you want to kill yourself”, so he could “grade” them and then tell me I needed more or less drugs.
    I decided to go to a nutritionist who specialized in handing out lots of mood-modifying (or so they claimed) suppliments.
    It seemed that GABA did help to calm me down a bit, and 5-LHTP did noticeably take the edge off of the depression. I later learned that 5HTP can cause serotonin syndrome and has just as many if not more severe side effects than normal antidepressants, and it made me vommit.
    I wish I’d known about this, or been warned about the puking. I don’t think that the CAM practitioners, were up on the research enough to know the effects of the drugs they were handing out. I think for them, a lot of it was just “lore”.
    In the end, they recommended an actual psychologist who has helped me a lot more than the suppliments ever did.
    And I went back on the normal drugs.
    I don’t regret the experience. They gave me someone to talk to about how I was feeling, which is what I really needed at the time. The CAM practitioners also kind of helped me explore the supplements out there, and my conclusion was that the supplements that worked, scientifically were even more a blunt and inprecise instrument than the parmaceuticals.
    You can draw your own conclusions from my experience, but in an ideal world, I would get the same concern and guidance (as opposed to being treated like an experiment or a piggy-bank) that I got from the CAM practitioners at the office of a real practitioner.

  33. #33 Natalie
    February 9, 2010

    Vicki @ 27 – I’m not sure if this will work for you, but it works for me. When booking my appointment, I tell the appointment setter “I need to schedule my physical and discuss x, y, and z with my doctor”. They appear to be setting a longer appointment for me because I’ve asked for talking time, basically. As far as I can tell, my insurance company doesn’t care.

    If you don’t want to tell the appointment setter all of your business, you could always be somewhat vague – “I need to discuss my prescription” or similar.

  34. #34 Ravenred
    February 9, 2010

    There was an interesting take on this by Dr Elliot Fisher (Dartmouth) about how piecework remuneration encourages poor healthcare practices and patient ownership (apologies if this link doesn’t work: http://www.abc.net.au/rn/healthreport/stories/2009/2740753.htm)

    CAM is tailor made to deal with (or pander to, depending on your viewpoint) people’s anxieties, realistic or not. If people don’t feel their feelings about their health are dealt with, then “merely” dealing with the physiological symptoms won’t necessarily make them feel better.

    My wife at one stage (after a nasty miscarriage) went onto the Chinese Traditional Medicine treadmill. When I gently challenged her, she said something to the effect of “Well this is something I can actually DO about my health”.

    The health economics of increasing practitioner time for individual patients are daunting, but the temptation of CAM can be fuelled by patient’s perceptions that they are merely a body on a slab as far as their GP is concerned. A greater role for Nurse Practitioners may be part of the solution.

  35. #35 Uncle Glenny
    February 9, 2010

    I saw a chiropractor (“low force”) over the course of a few years nearly 20 years ago. (The result of being hit by a car after having lived with a double-major scoliosis that I’d adapted to by basically giving up most flexibility in my torso.) I did get real PT for a while (less than 3 months), culminating in my first gym membership.

    I didn’t tell the PT about the chiro, and politely shook my head if she suggested anything more wooful than releasing muscles in my back (she was quite wooful).

    The point though is, my insurance covered the chiro, but only 50%. But she was dirt cheap, under $50 I think (before insurance reimbursement) for a half-hour visit.

    A visit to my GP about 8-10 years ago, who is affiliated with a large urban teaching hospital, I discovered due to an insurance screwup, was well over $300. Just the 15 minute office visit.

    I don’t know how typical this sort of price disparity is; I expect it’s far more extreme than is typical nowadays. (The chiro also worked out of a small clinic shared with other woomeisters.) But I’m a bit concerned that with the health care debacle in the US and concerns about “discrimination” and “parity” and the like that the woomeisters are seeing green and are going to be pushing for undeserved, comparable compensation.

  36. #36 Tracy W
    February 10, 2010

    Dr Wonderful, I’m going to ask you some questions about what minimum of evidence do you think should be sufficient before overworked medics in the trenches should be using a new therapy.

    Take for example what people call “energy medicine”. In my experience they have mostly never even proved that what they think they are dealing with is in fact a form of energy (if it’s energy, you can use it to do work in the sense of physically moving things). I say this because when I ask them how they know that what they are dealing with is energy I never get an answer. Nor have they apparently done any sort of safety checks on what they think is a new form of energy, despite the nasty historical experience with the discovery of radiation, including famously Marie Curie dying of cancer. What sort of evidence do you think should be needed before trying a treatment that its proponents call “energy medicine”?

    Or consider that betwen 1935-1965 lobotomies (as part of conventional medicine), were performed to treat a wide variety of pschiatric conditions. What sort of evidence do you think should have been considered before wide-spread introduction of the lobotomy for psychiatric disorders?

    And, in turn, from these particular cases, can you derive a general rule going forward for other potential forms of treatment?

    I’m asking you these questions, rather than just answering yours, because your comment about the “high priests of science” makes me think that it’s necessary to go back to basics.

  37. #37 Jeff
    February 10, 2010

    Lets be thankful SBM practitioners DONT spend more time with the patients. I am sure they would find a need for even more prescriptions if given enough symptoms!!

  38. #38 Rev. BigDumbChimp
    February 10, 2010

    Lets be thankful SBM practitioners DONT spend more time with the patients. I am sure they would find a need for even more prescriptions if given enough symptoms!!

    Yes, I would never want my doctor to actually do anything for me.

  39. #39 Vicki
    February 10, 2010

    The last time I saw my GP, the only “prescription” she gave me was the piece of paper with the name of a specialist she was referring me to. I did get medication: a DPT booster, by my request, in her office on the spot (because it had been 9.5 years since my last tetanus booster, and I’d rather not have to chase down an urgent care clinic on a national holiday again, as with the last one).

    Jeff, you’re sounding perilously close to what a friend of mine calls the “just say no to insulin” approach.

  40. #40 Cat
    February 13, 2010

    Orac said: “I was actually surprised that infections were so frequently diagnosed in naturopathy practices. On the other hand, given the number of dubious and outright bogus diagnoses in naturopathy, there’s no way of knowing what kind of infections were being diagnosed. For all we know, these naturopaths could be diagnosing one of the favorite alt-med catch-all diagnoses, chronic fungal infections.”

    I’d put my money on “Chronic Lyme”. They see a lot of people complaining about fatigue and aches and pains, which (having had The Real Thing before) I can attest are symptoms of Lyme.

    My mother-in-law had some pain in the joints of her hands and saw a GP, who said “you have arthritis” and “take these pills” after only a few minutes of examination and discussion. She ran straight into the arms of a naturopath, who put her on a “detox” regimen of herbal supplements, tested her for “food sensitivity” because she had some intestinal discomfort, and postulated much about parasites and “chronic Lyme” possibly affecting the joints in her hand. She also went crazy trying to determine if she had mold in her house.

    She never seems to be much better, though she claims all these bogus treatments have improved her situation. I don’t know why some people are so offended by the idea that they might have to take an anti-inflammatory for the rest of their lives, but don’t mind wolfing down whatever herbal supplements they can find every day.

  41. I often wonder what would happen if practitioners of SBM spent as much time with their patients as CAM practitioners do.

  42. #42 doctor house calls
    February 21, 2011

    Time is money. Whoever pays for it there are finite resources. GPs have bills to pay. I’d be interested to know how much it costs to become a proper GP – training, equipment, insurance, certification – compared to a homeopath or other quack. I expect that real doctors have much higher overheads, so they either need to charge more per patient or see more patients.