Respectful Insolence

Falsedichotomy

A lot of medical specialties have throwaway newspapers/magazines that are supported by advertising and somehow mysteriously managed to show up for free in the mailboxes of their practitioners. In my case, I’ve found myself on the subscription list for such papers about oncology, but, given that I trained as a general surgeon. I’m Board-certified as a general surgeon. When I have to recertify in about three years, it will be as a general surgeon, which was really fun to try to do last time after having specialized as a breast cancer surgeon and will likely be even more fun next time, when I will be 10 years further out from my general surgery and surgical oncology training. In any case, that must be why, no matter where I end up working, sooner or later I end up receiving General Surgery News (GSN).

As throwaway professional newspapers go, GSN is not bad. However, occasionally it publishes op-ed articles that make me scratch my head or even tick me off with their obtuseness. Lately, apparently, it’s started some blogs. The one in particular that is the center of attention for this post is by Victoria Stern and called The Scope and is billed as “exploring the lesser known sides of surgery.” Of course, it’s a bit odd that some of the first posts on this blog are about work hour restrictions and whether they leave new surgeons unprepared to practice surgery, the debate over breast screening, and what it takes to train expert surgeons, none of which are exactly “lesser known sides of surgery.” Work hour restrictions, in particular, have been discussed in surgery journals, at conferences, and among surgeons ad nauseam, particularly whether we are training a generation of surgeons unable to deal with the rigors of practicing surgery in the real world.

What caught my attention, though was a post from yesterday entitled The Myth of Alternative Care, Growth of Complex Care. Reading the title gave me a sinking feeling because whenever anyone mentions “complex care” in the context of alternative medicine, “complementary and alternative medicine” (CAM), “integrative medicine,” or whatever you want to call it, I know that a heapin’ helping of tropes and positive spin on pseudoscience is likely to be on its way. The reason, of course, is that CAM advocates love to argue that patient care is so complex that conventional medicine can’t adequately address it and needs some “help” from CAM. The article doesn’t “disappoint.”

Basically, Stern frames the post thusly. Alternative medicine is “bad.” No argument there. However, CAM is a different beast altogether. She starts with the standard CAM talking point that increasingly “patients are looking for answers outside of conventional medicine.” (Where have I heard that one before? Oh, yes. In pretty much every article and post spouting CAM apologia that I’ve ever read.) She then cites a 2006 study that I’ve blogged about before about the use of alternative medicine to treat breast cancer that pointed out the less than optimal (to put it kindly!) outcomes that result from such practices. She then quotes my good buddy Steve Novella, such that it becomes rapidly obvious that the post is set up to contrast “integrative medicine” with that nasty cancer quackery such that CAM/IM is a good thing:

“Alternative medicine is harmful,” said Steven Novella, MD, a neurologist and assistant professor at Yale University School of Medicine who is executive editor of the blog Science-Based Medicine. “If such alternatives were evidence-based at all, they would be considered medicine, not alternative medicine, and would be adopted into mainstream care.”

Complementary therapies, however, are a different ballgame altogether. Unlike alternative therapies, complementary interventions are not touted as cancer treatments. As the name implies, complementary modalities, such as vitamins and herbal supplements, massage, acupuncture, are meant to accompany mainstream care. The idea is to treat the entire patient, not just the disease.

And there’s the granddaddy of CAM/IM tropes right there, the claim, either direct or implied, that CAM/IM, contrary to “conventional” science- and evidence-based medicine treats the “whole patient” (in this case the “entire patient”) and “not just the disease. This argument is, as I like to say, a pile of fetid dingo’s kidneys, because the implication is that you can’t treat the “entire” patient without embracing quackery such as acupuncture. A good primary care doctor using science-based medicine is a wholistic doctor who treats the “entire patient.” The same is true of a good oncologist practicing science-based oncology or a good surgeon practicing science-based surgery. The false dichotomy is plain: Either embrace the quackery that is CAM, or you are not treating the “whole” patient. Yes, it irritates the crap out of me, because I see it so much, and so few physicians directly question the assumption at the heart of a passage like the one above.

Let’s just put it this way. Whenever a CAM apologist says that she doesn’t practice that awful, nasty alternative medicine (which is quackery) and doesn’t recommend using it instead of conventional therapy, I say, “That’s nice.” No one should be recommending foregoing effective science-based treatment in favor of magic and fairy dust. That is a bare minimum that we expect of physicians. However, when in the same paragraph (sometimes in the same sentence) I see advocates saying that it’s perfectly OK to add unproven therapies as an adjunct to conventional medicine (the “complementary” in CAM) or “integrating” them with science-based medicine, my teeth start to grind involuntarily. Bad reasoning has that effect on me. Think about it. A lot of the “respectable” CAM in integrative medicine derives from the very same pseudoscientific and prescientific ideas that are behind the quackery.

I like to use the idea of “energy healing” like reiki to illustrate the point. As I’ve written so many times before, reiki is finding its way more and more into academic medical centers as a “respectable” bit of integrative medicine. The key precept of reiki, as you will recall, is that reiki masters claim to be able to channel “healing energy” from what they call the “universal source.” Now, to drive the point home, let me suggest that you substitute the word “God” for “universal source.” See what I mean? Reiki is faith healing that substitutes Eastern mysticism for Christian beliefs. So, if faith healing is bad used alone, why is it suddenly “good” and “treating the whole patient” when used with standard treatment. The only reason I can think of is that at least the patient is getting standard treatment. That’s not enough. We shouldn’t be recommending the addition of ineffective treatments based on magical thinking to conventional treatment. Whether practitioners realize or admit it or not, acupuncture is based on similar prescientific ideas, given that qi (life energy) is supposed to be flowing through “meridians” (never mind that no anatomic structure has yet been discovered that corresponds to acupuncture meridians) and the needles are supposed to be “unblocking” or “redirecting” its flow for therapeutic effect. The same concept fits into chiropractic, as well, where removing subluxations is supposed to remove impediments to the action of “innate intelligence” healing the body. The list goes on and on and on of how vitalism is at the root of so many CAM treatments that are being “integrated” into medicine.

Unfortunately, Stern also incorporates another trope into her post:

In his surgical practice, Bruce Ramshaw, MD, FACS, chairman of the Halifax Health General Surgery Residency Program and co-director of the Advanced Hernia Solutions, Daytona Beach, Fla., takes a similar patient-centered approach to care. Dr. Ramshaw and his team, which includes a patient care manager, do not just treat hernias, they also try to understand their patients—what they really go through in their day-to-day lives as well as their fears and concerns about their health—offer potential solutions to diminish issues or anxieties, and involve family members in the process for added support.

In hernia repair and in medicine in general, there is no perfect way to treat each patient, said Dr. Ramshaw, but he hopes to come closer to an optimal treatment paradigm by applying this patient-focused approach to care. “Our goal is to form genuine relationships with patients,” Dr. Ramshaw said. [Read more about Dr. Ramshaw’s thoughts in his opinion piece, Love: Its Real Effect On Patient Care].

This kind of complex care that looks at the patient as a whole is becoming increasingly important not only for enhancing patients’ overall health, ensuring that they stay away from dangerous interventions and helping patients measure their expectations, but also as a way to create a true bond between physician and patient, an element of care that has been waning over the years. Although compassion and empathy won’t treat a person’s ailments, these traits can only help improve patient care and ultimately patient health.

Actually, there is little objectionable in Dr. Ramshaw’s article, other than its tendency towards a bit of “Patch Adams” sentimentality (although I note that he has written other things for GSN that I thought about blogging about before regarding “complexity theory” in medicine). So what is the problem? It’s not so much with Dr. Ramshaw as with what Stern does with his statements and articles. I think you can see it. Notice how CAM/IM is being conflated, without evidence, with measures that not only “treat the patient as a whole” but serve as a way to create a “true bond” between physician and patient. This is another massive false dichotomy. It is not necessary to embrace quackery to form a “true bond” between doctor and patient. Indeed, recommending treatments without good evidence behind them strikes me as potentially major impediment to forming such a “true bond,” at least if the patient ever finds out how thin the evidence base is for these treatments. In addition, what does it tell physicians practicing science-based medicine who can and do form “true bonds” with their patients without selling them fairy dust to tell them that such fairy dust is necessary to help them form such “bonds”?

Stern promises that her next blog will explore the “pros and cons of integrative medicine.” I can hardly wait.

Comments

  1. #1 Chris Hickie
    fortress of stolidtude
    August 15, 2014

    This ridiculous idea that somehow as physicians we only treat the disease and not the patient really bothers me, too. I have had, however, several (but definitely a small minority) nurses tell me that “you Dr.’s only treat the disease, but we nurses treat the whole patient.” Again, same thing–but coming from directly within allopathic medicine. Sometimes I think people confuse the fact that we may have a very busy clinical schedule and are trying to stay on time for the behalf of our patients, and instead think were somehow uncaring or ignoring the “whole patient”. In pediatrics it’s even more critical to get a lot of family and social history because the parents are the ones almost always responsible for carrying out the care plan for the child. And, I do wish I had more time in the exam room to simply talk with families. Once, however, I know you’ve got a basic ear infection and nothing more and I’ve determined that the parents will be good about giving the antibiotic–well, it’s time to go care for my next patient.

  2. #2 Tsu Dho Nimh
    West Enchilada, NM
    August 15, 2014

    The false dichotomy is plain: Either embrace the quackery that is CAM, or you are not treating the “whole” patient.

    I have NEVER made it out of a specialists office without them asking about the basic lifestyle issues .. smoking, drinking, and general diet and well-being. Because I don’t smoke, seldom drink, have a wide-based omnivore diet and am moderately active, the discussion ends there.

    If it needed to be addressed, I’m sure it would be.

    One doc recommended I get an occasional massage, from the spa of my choice, for relaxing my back muscles. This was after they had done real physical therapy to get it to the point where an occasional massage could prevent the muscles from getting to the spasm stage.

  3. #3 BKsea
    August 15, 2014

    Integrative medicine is a win-win: you fool the patients into thinking you are doing something for them and you steer them to more unnecessary services that make money for the hospital.

  4. #4 KayMarie
    August 15, 2014

    I wonder if some of that comes from the acute care situations where I really do want my doctor to just see the compound fracture of my leg, or just see the raging infection.

    But that they don’t see any of the medical history, standard preventative care, and psychosocial (do you feel safe in your own home required question at my PCP) etc. as “whole person” is bothersome. One would think some of the Patient-Centered Medical Home things would support at least some medical centers have a broader view that could be called holistic if that term wasn’t so loaded.

    That being said I do know there are some concerns that patients with serious chronic illnesses are not always getting the same standard of preventative care as healthy people with similar demographics based on some of the proposals going around here. It may just be again a matter of focus. Making sure they have one big thing under control may take up so much time that other things tend to slip through the cracks. It isn’t so much willfully ignored as people aren’t as good at multitasking as we want to think we are.

  5. #5 Renate
    August 15, 2014

    The part of the patient that is ‘helped’ by CAM/IM is the wallet. CAM/IM makes it lighter.

  6. #6 Eric Lund
    August 15, 2014

    Alternative medicine is “bad.” No argument there. However, CAM is a different beast altogether.

    At least when the government of Oceania decreed that we are now at war with Eurasia and allied with Eastasia, and have always been at war with Eurasia and allied with Eastasia, expecting me to forget that only yesterday we were at war with Eastasia and allied with Eurasia, they weren’t trying to get me to believe both of those things simultaneously. But more or less by definition, alternative medicine is a subset of CAM. So if the former is bad, why should I think the latter is good?

  7. #7 Dorit Reiss
    August 15, 2014

    If my primary care physician is not treating me as a whole, which part is she neglecting, besides, of course, my aura?

  8. #8 Dangerous Bacon
    August 15, 2014

    This business of using CAM to “treat the whole patient” gives me the impression that there must be an organ in the body with special woo receptors, which conventional medicine ignores while treating the rest of the body. Thanks, but I don’t see the point in catering to this fantasy body part.

    “you Dr.’s only treat the disease, but we nurses treat the whole patient.”

    Based on my observation of hospital nurses, I’d amend this to “you Dr.s only treat the disease, while we nurses spend lots of extra time drawing up our vacation schedules.” ;)

  9. #9 Mephistopheles O'Brien
    August 15, 2014

    To be fair to the nurses, among many other things they insert the IVs and catheters, they clean up the messes, they help the patient urinate, and they say encouraging things like “you’re lucky to get Dr. Hickie – he’s one of the best” or “I know you hurt but it’ll get better soon” or “there there”.

  10. #10 Mephistopheles O'Brien
    August 15, 2014

    If my primary care physician is not treating me as a whole person

    It sounds as if those who say this believe your PCP has mentally dissected you (in many different and overlapping cross sections) and considers you a digestive system, skin, circulatory system, nervous system, respiratory system, and miscellaneous other parts moving along in close formation.

  11. #11 Guy Chapman
    United Kingdom
    August 15, 2014

    I guess you spotted the piece about naturopaths looking to be primary care physicians in MO, supported by the argument that people like them, because they spend longer talking and also give diet and exercise advice.

    Name a doctor who would not like to give patients more time, and who would not offer them diet and exercise advice.

    The problem is not the diet and exercise advice, or the tea and sympathy, both of which are mainstream, but the “Venn diagram” issue: there is an overlap between what IM offers and what can be supported as valid in an evidence-based context, but it amounts to only a small percentage of what the quacks actually do.

    Me, I don’t want my diet and exercise advice to come form a “primary care physician” whose entire clinical training amounts to about one month of medical residency and who believes in homeopathy, acupuncture, herbal medicine and reiki even though they are mutually contradictory and largely based on thinking so wolly it would make a sheep jealous.

  12. #12 Chris Hickie
    August 15, 2014

    @MOB, #9–one of those nurses is my wife. She’s taught me a lot about not just plowing through to a diagnosis, overriding whatever a parent of patient still yet wanted to tell me. And, when we first me, I’m not sure she always thought families were “lucky to get Dr. Hickie”.

  13. #13 JustaTech
    August 15, 2014

    Now, forgive me for not having a clinician’s understanding, but I’m pretty sure that hernia care is a fantastic example of modern medicine saying “You have this condition, we can do this surgery and you will be cured.” Nice and wrapped up with a little bow. At least, that’s how it seemed to me when my husband had his hernia fixed.

    With more complicated diseases or disorders, I could the doctor needing to work with the patient on causes, fears, long-term impacts, etc.

    As for “treating the whole person”, if your doctor comes in an only talks to your tumor, or doesn’t talk to you at all, what you have there is a jerk. It doesn’t mean all docotors are jerks, it just means that this doctor is a jerk and you should find a new one. But that could be just as true of your hairdresser.

  14. #14 Leigh Jackson
    August 15, 2014

    “vitamins and herbal supplements, massage, acupuncture… ensuring that they stay away from dangerous interventions and helping patients measure their expectations, but also as a way to create a true bond between physician and patient” (Stern)

    Create a true bond? By colluding in magical thinking? Placebos are justified as complementary treatments if the intention is to treat “the whole person”? There is a true case for vitamins – in the case of deficiency. Otherwise they are a placebo. Suggestion is the mechanism; subjective are the benefits. Herbal supplements as treatment for side effects of chemo and radio therapies? Ditto. Placebo. Massage can help to relax a person physically and mentally for a short time. As long as it is employed explicitly for this purpose and not misleadingly suggested to be of any other benefit, I see no problem with it.

    Acupuncture is magic ritual, pure and simple. Voodoo stuff. It should not be endorsed by medical professionals. Any more than the ancient rite of bleeding. In truth, that is just what acupuncture is. Limited bleeding by puncturing the flesh rather copious bleeding by slicing it. Ancient mumbo-jumbo accompanies both these ancient practices.

    A true bond is not engendered by physicians colluding in woo-doo medicine. Treating the whole person should mean properly – fully – applying the principle of informed choice. Not pandering to ill-informed wishes for popular but nonsensical treatments. If patients are going to choose acupuncture they ought to know that they are choosing junk medicine. An elaborate placebo. They would be better off with a gentle massage. No mixed messages and no medical risks.

  15. #15 sadmar
    August 15, 2014

    Orac wrote:
    “It is not necessary to embrace quackery to form a ‘true bond’ between doctor and patient.”

    Bingo! The questions are:
    1) If SBM-docs were doing enough of that would anybody be turning to CAM to deal with ‘the whole patient’?
    2) Given that CAM is doing nothing to actually address the illness in question, what function does it serve “the whole patient.”
    3) What specific methods can SBM-docs employ to serve those functions without engaging in any CAM-validation?
    4) In situations where a non-CAM ‘holistic’ approach is impractical, is a limited tolerance of CAM (emphasis on LIMIT) a better choice than having patients get turned off from SBM altogether?

    Chris Hickie points us in an important direction by saying, “Sometimes I think people confuse the fact that we may have a very busy clinical schedule and are trying to stay on time for the behalf of our patients, and instead think were somehow uncaring or ignoring the ‘whole patient’.” ‘Sometimes I think people confuse’? How about ‘Most of the time people do interpret.’ And, please, Chris, keeping up with your busy schedule is only acting on behalf of your patients within the terms set by insurance companies and HMOs that have Taylorized primary care. Regardless of your actual compassion, the patient does NOT feel seen as a person at all, much less a whole person. You patient DOES feel uncared for and ignored, and too often IS ignored. THIS IS NOT YOUR FAULT! It’s a systemic problem with the American health care system, and there’s little if anything you as an individual physician can do about it.

    (I shall offer but one personal anecdote: I was seeing a GP who I had no doubt was a good guy. But the kept his appointment train on schedule and didn’t have TIME to listen to me. I got tired of that, especially since I was getting no help for a chronic throat irritiation that was messing up my work: I couldn’t get through class without a coughing fit. So I got on the waiting list for GP who had a rep for taking time with patients and really caring. When I finally got transfered to her she was great. I got referals for my throat problem, and eventually discovered that the previous GP had missed a potentially life-threatening problem by being in such a rush. My new GP was beloved by all her patients, despite the fact she was always behind schedule, and if you got in by 3PM for a 2PM appt., you were doing well. So, of course, the medical group she was working for canned her.)

    Ok, so the answer to question 1 is ‘maybe a few, but not so many.’ The answer to question 2 is that CAM augments real medicine by dealing with the psychological needs of the patient. The acupuncturist, chiropractor, and the faith healer are spending a lot more time with the patient, and no doubt have mastered ‘bedside manner’ since they’re business depends on the placebo effect and bad attitude would surely mess that up.

    I’m not knowledgeable enough to say much in answer to question 3, but I can offer one example from my own medical history. In 2010 I had a Rouen-Y performed by Dr. Jonathan Aranow at Middlesex Hospital in Middletown, CT. When Dr. Aranow entered the field of bariatric surgery he made a study of outcomes, and found a high correlation of failure (i.e. returned obesity) to cut-and-done surgical practice. So he created a program that requires patients to agree to a non-woo ‘holistic’ program before and after he operates. Specifically, the patients have to have regular meetings with a dietitian, a psych evaluation, and most importantly attend a regular schedule of support group meetings before and after surgery. He also has a ward at Middlesex devoted mainly to his patients, in which all the nurses have received specific training in dealing with issues folks experience during their post-surgical hospitalization and prepping them for their aftercare.

    I posed question 4 largely because my experience with Dr. Aranow left me with the impression that his practice is the exception for surgery-in-general, not the rule, because there are things specific to bariatric surgery that allow him to do what he does that do not apply across-the-board, and even then may have required an extraordinary effort on his part to institute. Instituting non-woo methods to ‘treat the whole patient’ may be much easier said than done within the realities of our medical system.

    So I return to the proposition I advanced in the discussion of Dr. Cowan’s headache practice. If the SBM-based Doc can’t offer a more legit means of addressing the psychological needs of patients, a certain tolerance of CAM WITHIN STRICT BOUNDARIES has it’s advantages, chief among them the credibility it provides by recognizing the importance of those needs, which helps keeps the patient connected to Real Medicine.

    Of course, the best course is to advocate for systemic reform that would accomodate non-woo ‘whole patient’ approaches, but that would seem to depend on a complete reversal of how our society (and insurance companies) treat mental health issues, and I’m not holding my breath.

  16. #16 sadmar
    August 15, 2014

    OT:
    On 8/13, Orac wrote a sentence including the following statement I have isolated by editing:

    “I’ve seen so many of the same old lies that I’ve deconstructed that I ignore the vast majority of them.”

    The thought that Orac is down with Derrida made my day!

    :-) :-) :-)

    (Worry not, skeptics. Orac is desconstructing, but not at all in the Derridean sense. Not that that would be a bad thing. I’m not a fan of ‘deconstruction’ in general, m’self, but it can be interesting sometimes. To the point, that kind of ‘deconstruction’ of Mary Tocco, Mlive, Mike Adams, et. al. could be pretty devastating, though IMHO an even more effective critique could probably be mounted from other branches of ‘Critical Theory’.)

  17. #17 Krebiozen
    August 15, 2014

    I had functional endoscopic sinus surgery a couple of weeks ago, which gives me a convenient opportunity to consider how much I felt I was treated as a “whole person”. From beginning to end, I can’t think of any way I could have been treated more ‘holistically’. They thoroughly checked my history, did appropriate diagnostic tests, including an ECG and swabs for MRSA, asked what medication I had taken that day, and double-checked my identity, when I last eaten and drunk and the nature of the surgery I was having.

    They explained exactly what they were going to do, what I could expect, what possible adverse events might occur and the odds of those happening. I even enjoyed a chat to the anesthetist who explained that she wasn’t using the usual short-acting barbiturate because the US has depleted the worlds supplies through using it for executions, until I lost consciousness.

    All that’s about as holistic as it gets, isn’t it? With the best will in the world I can’t think of any CAM interventions that might have helped. A foot massage in the recovery room? Handwaving while I was on the table? Post-op MRSA inoculation? Acupuncture? No thanks.

    All I was interested in was surviving the operation with as little discomfort as possible, and the success of the operation itself. Maybe some kind of placebo would help with pre-op anxiety and post-op discomfort, but I have coped just fine with nothing but good old-fashioned pharmaceuticals. In fact when I woke up, after a moderate dose of Fentanyl I felt great*. The last thing I needed was some New Agey flimflammery.

    * That might also have something to do with the 4% cocaine they still use as a local anesthetic in ENT surgery. The anesthetist was surprised I knew – “we don’t tell people that,” she said.

  18. #18 Chris
    August 16, 2014

    “With the best will in the world I can’t think of any CAM interventions that might have helped. ”

    Did they give you the pre-warmed blanket? At my last colonoscopy I was covered by a heated blanket. Ooh, that helped lots as the sleepy time drugs took effect (along with the anti-nausea meds, since I am among the one in ten who gets queasy with narcotics). Every thing is better with a warm comfy blankey.

  19. #19 Peter Dugdale
    August 16, 2014

    There you have it you doctors, you’re lacking the patient-centered approach. We had an educational “reformer” in England many years ago who insisted that her ideas were a “child-centered” approach. Unfortunately, nobody called this out at the time as feel-good contentless baloney, and education has never recovered.

    As for bonding with my doctor – I want him to fix me quick, and hope never to see him again. Something even suggests to me that an appropriate distance to one’s patient may improve the objectivity of the diagnosis and treatment.

  20. #20 sadmar
    August 16, 2014

    @Chris
    Everything IS better with a warm comfy bankey. I remember cold hard metal tables, and really thin bankies that didn’t cover my feet much less keep my legs warm and comfy. Maybe I’m a fool, but i have the feeling that if patients could choose between the feeling of a warm comfy bankey and some mystical-BS hand-waving they’d take the bankey every time. Could hospitals offering Reiki correlate to warm cozy bankey shortages? (Did I mention that my notion of tolerating a bit o’ CAM within strict boundaries would never, ever include f-ing Reiki?)

    @Kreblozen
    I fixed your comment:
    “With the best will in the world I can’t think of any CAM interventions that might have helped me.”
    You may be shocked to learn that some surgical patients are not actually you.

    @Peter Dugdale
    “I want him to fix me quick.”
    Uh, what part of the contradiction between ‘fix me’ and ‘quick’ do you not understand? Or, for that matter, the non-equivalence of “quick” “distance” and “objectivity”?

    Folks! Pull your heads out of the sand, for cryin out loud. If John Doe Patient and Jane Doe Patient felt they were being treated as ‘whole people’ the numbers of folks running off to CAM would be way lower than it is. And for anybody near my age (60), the point of reference from which MDs look like un-caring a-hats isn’t any new-agey feel-good snake oil, just the way the ol’ family doctor treated us up to, say, 1985.

    You’re basically responding to the claim “doctors should listen to their patients” by saying “well, I don’t need my doctor to listen to ME, so what’s the problem?” (Anecdotal much?) Try some, I dunno, empirical inquiry, like ask a representative sample of surgical patients whether they feel their doctors listen to them, or treat them like a person instead of a piece of meat, or how their view of medicine might be affected by active disdain or benign neglect?

    Hell, I’m not asking doctors to make patients ‘feel GOOD’, with baloney or any other luncheon meat. I’m suggesting that there’s good evidence that certain aspects of medical practice make sick people feel worse, and maybe, just maybe, that’s a problem.

    Did you ever think every time a quick-fix distanced doc leaves a patient full of WTF! and hoping never to see him or her again, that might be another dollar in Mike Adams pocket? Cha-ching! Mike thanks you very much for your insensitivity. Maybe if you keep doing such a great job for him. he’ll give you a little kick-back ;-)

  21. #21 Narad
    August 16, 2014

    Did they give you the pre-warmed blanket? At my last colonoscopy I was covered by a heated blanket.

    Sheesh, I’ve had two in two months, and it was more like an oversized bath towel. I complained a little about the IV being too literally chambré on the second one. Then again, I think they must have let the fellow run the snake for that one, since it’s all really hazy after I uttered the words “this seems a lot more uncomfortable than last time” (during which I was wide awake and only grimaced at the turn into the transverse colon).

  22. #22 Krebiozen
    August 16, 2014

    Chris,

    Did they give you the pre-warmed blanket?

    This was sinus surgery, not a colonoscopy*, so perhaps that’s why I didn’t get a pre-warmed blanket. I was pleasantly warm anyway in the two gowns (to protect my dignity a posteriori), disposable underwear, surgical stockings and slippers they provided – thank you NHS.

    This was the first GA I’ve ever had, and I was very pleasantly surprised (we all hear horror stories, I’m sure). The anesthetist warned me I might feel a warm tingling and a metallic taste as the drug went in, which I did. A few seconds later (it seemed) I was awake again to find 4 hours had passed. No nausea, no sore throat (they don’t intubate, they use a laryngeal mask, and don’t use an inhalation anesthetic, just IV drugs). I had some bleeding and pain at the surgery site, but a nurse was there immediately to give enough Fentanyl to relieve the pain entirely, and the next thing I knew I was in recovery eating a sandwich and sipping a drink. Marvelous.

    * I had a sigmoidoscopy some years ago without anesthetic, with an audience of medical students all watching my face, which I figured afterwards was to allow them to see just how patients react to “a little discomfort”.

  23. #23 Leigh Jackson
    August 16, 2014

    With you Peter. Bugger bonding. Just give me a doctor who knows what they are doing. Heaven on earth there isn’t and never will be. Next please.

  24. #24 Chris Hickie
    August 16, 2014

    Chris Hickie points us in an important direction by saying, “Sometimes I think people confuse the fact that we may have a very busy clinical schedule and are trying to stay on time for the behalf of our patients, and instead think were somehow uncaring or ignoring the ‘whole patient’.” ‘Sometimes I think people confuse’? How about ‘Most of the time people do interpret.’ And, please, Chris, keeping up with your busy schedule is only acting on behalf of your patients within the terms set by insurance companies and HMOs that have Taylorized primary care. Regardless of your actual compassion, the patient does NOT feel seen as a person at all, much less a whole person. You patient DOES feel uncared for and ignored, and too often IS ignored. THIS IS NOT YOUR FAULT! It’s a systemic problem with the American health care system, and there’s little if anything you as an individual physician can do about it.

    I will have to disagree here. It’s not the insurance companies that dictate my schedule. It is how many families have given me the privilege of caring for their children. The conundrum–once word of mouth from families who like your care as a physician gets out–of being thought of as a good physician is that you quickly start filling all your appointment slots and start having to book new patients out longer than you wish. Then you face a dilemma. Do you not take new patients so that you can give existing patients the same time you’ve given them. Do you take new patients and book shorter appointment slots? Do you work longer hours? Do you hire another physician, remembering that if you are popular, people may still be calling wanting only to see you? So, if I schedule more patients into the same 8 clinic hours a day, it can be my fault if I’m not spending enough time to make sure the patient/family get as full an exam/history/plan as needed.

    I’m not anywhere neat the best pediatrician there is. I’m just trying to do my best by my patients. I am bothered that parents will compliment me because I spent more than 5 minutes in the room or that I actually took their infant out of the car seat to examine them. Bothered because that’s unacceptable health care and probably a big part of the reason those in the woo areas can pull in new patients so easily.

  25. #25 Krebiozen
    August 16, 2014

    sadmar,

    @Kreblozen
    I fixed your comment:
    “With the best will in the world I can’t think of any CAM interventions that might have helped me.”
    You may be shocked to learn that some surgical patients are not actually you.

    Really? I thought I made it clear that I understood that when I wrote:

    I had functional endoscopic sinus surgery a couple of weeks ago, which gives me a convenient opportunity to consider how much I felt I was treated as a “whole person”.

    Also:

    Folks! Pull your heads out of the sand, for cryin out loud. If John Doe Patient and Jane Doe Patient felt they were being treated as ‘whole people’ the numbers of folks running off to CAM would be way lower than it is.

    What evidence do you have that patients don’t feel they are being treated as whole people by conventional doctors? It looks as if fewer patients are “running off to CAM” in the US, since spending on CAM plateaued a few years ago. I know that CAM use in the UK, where I am, is in decline.

    And for anybody near my age (60), the point of reference from which MDs look like un-caring a-hats isn’t any new-agey feel-good snake oil, just the way the ol’ family doctor treated us up to, say, 1985.

    I’m just a few years younger than you, but I find doctors far friendlier, more communicative and much less paternalistic than they were 30 years ago.

    You’re basically responding to the claim “doctors should listen to their patients” by saying “well, I don’t need my doctor to listen to ME, so what’s the problem?” (Anecdotal much?)

    I’m responding by saying that in my experience my doctor does listen to me, and that I don’t know how my recent experience of surgery could have been improved, certainly not by someone trying to convince me that imaginary healing energy is real, or that they can heal me by waving their hands about, or by sticking needles in me.

    What do you have, apart from anecdata?

  26. #26 Krebiozen
    August 16, 2014

    Also @sadmar,

    Try some, I dunno, empirical inquiry, like ask a representative sample of surgical patients whether they feel their doctors listen to them, or treat them like a person instead of a piece of meat, or how their view of medicine might be affected by active disdain or benign neglect?

    Something like this, looking at patient satisfaction after joint replacement, you mean? The main findings:

    Three factors broadly determine the patient’s overall satisfaction following lower limb joint arthroplasty; meeting preoperative expectations, achieving satisfactory pain relief, and a satisfactory hospital experience.

    That broadly agrees with what I and others have written about our experiences with conventional medicine. Does some addition to a 5 minute chat to the surgeon and the anesthetist really improve patient satisfaction that much? I doubt it. Most of the research I have seen that finds greater patient satisfaction after CAM than conventional medicine is in primary care. IIRC, over 90% of the problems seen in primary care get better on their own, and a fair proportion are stress-related. These are areas where placebo effects are substantial, and where a good ear and sympathetic reassurance are most valuable, not in surgery so much.

    I can’t resist mentioning this study looking at patient satisfaction after sinus surgery (FESS versus FEDS). They devised a questionnaire they called the Sino-Nasal Outcome Test (SNOT-20) to assess this. Personally, knowing that the surgical team treating me had a sense of humor like that would be more important than any level of Reiki attunement.

    Incidentally, one of the least communicative health care therapists I ever had was an osteopath (or possibly a chiropractor, I don’t recall) and acupuncturist I was recommended by a friend after I was in a car accident. The man mumbled something incomprehensible, cracked my back (which scared me half to death – I assume the mumbles were some kind of warning), mumbled something else and stuck a load of needles in me, then disappeared for 20 minutes, came back, removed the needles in silence and his receptionist took my money.

    His poor bedside manner was rivaled only by another acupuncturist I saw for sinusitis a few years later; this one was an old Chinese man (beard, mustache, silk robes, the works) who spoke no English, and barked questions at me through a young woman translator. The needling and ephedra he prescribed didn’t help at all either.

  27. #27 eliot
    August 16, 2014

    Sadmar, comment 15 – agree wholeheartedly with your narrative there.

    Given the potential power of engaging with a patient’s psychological needs, and the consistent haste of GPs (ie limited capacity or capability to do this), it seems a bit huffy to categorically dismiss the role of complementary providers.

    I think in particular of the lifestyle factors – taking the time and range of strategies (including tapping into a people’s disposition for woo beliefs) necessary to change habits… Whether dietary or exercise. It may be that the faith around energy for or whatever in something like tai chi or yoga may be the ingredient that gets a person moving and aware of their physical health, as well as the benefits of meditation (with or without mysticism). And if this is packaged or embraced (ie a person commits to the particular lifestyle) with other complementary practices that aren’t doing harm but are benefitting psychological health and attention to physical habits, surely this isn’t a bad outcome?

    Or perhaps the question is, what can the SBM health model as it stands offer instead, that will get people feeling cared for and engaged in their health, recognising human irrationality or need to identify with particular practices or philosophies? More of the same doesn’t seem to work.

  28. #28 Dorothy
    Oz--the other one
    August 16, 2014

    sadmar makes a point and gets told off because told off feels misunderstood. CAM may be in decline, but using it in major medical facilities is on the increase, which is what this post is about. ORAC goes on about GOOD doctors and sadmar tries to talk about ahat doctors, for which he gets dissed. I don’t care much for his/her style, but have tried to make a similar point here before under another nym and received similar abuse.

  29. #29 Mephistopheles O'Brien
    August 16, 2014

    @Dorothy – could you please point out to me who told off sadmar? Thanks.

  30. #30 Denice Walter
    August 16, 2014

    Let me just do a quick outline but I shall return-

    Sadmar is correct in that people seek out alt med because they feel that SBM lacks something that they require HOWEVER often people are looking for services that go beyond the physical: they want emotional support, validation, advice on non-medical life issues and even esteem-building acceptance. Some may have psychological problems as well- which may present as physical symptoms- that are more in the realm of psychological services.

    I view woo as as set of ‘therapies’ that aim at making patients feel *feel* better but which do not necessarily improve their condition- it can be divided into ‘spa medicine’ and ‘grandmother medicine’- the former is quite obviously massage, skin care and pampering whilst the latter involves tea and sympathy as well as folk medicine with calm acceptance and wise advice.

    As children become adolescents they learn to develop ways to manage their own emotional states and inner thought through self-talk, physical activity ( and repose) as well as self- medication- both good and ill. In other words, they learn to provide for themselves what their parents and grandparents offered at an earlier stage.

    I call the more obvious excursions ‘sex, drugs and roll
    and roll’- adolescents use both internal and external means to control their own internal physical and emotional states- you can rev yourself up or mellow yourself down. And yes, I do mean REAL sex, drugs and rock and roll as well as their more abstract symbolically equivalent substitutes.Confiding in a friend who shares your worldview and supports you is often a feature of adolescent development.

    A physican is stuck with the problem of sorting what he or she observes- sometimes psychological symptoms ( depression and anxiety) can foreshadow physical concerns or be expressions of SMI which require additional care, sometimes a patient may be looking for something which cannot easily be acquired from SBM.

  31. #31 Denice Walter
    August 16, 2014

    That would be ROCK and roll

  32. #32 Krebiozen
    August 16, 2014

    Dorothy,

    sadmar tries to talk about ahat doctors, for which he gets dissed […] I don’t care much for his/her style, but have tried to make a similar point here before under another nym and received similar abuse.

    Dissed? Abuse? Where? Nothing I have written was intended as such. If someone accuses me of thinking every surgical patient is me, or of having my head in the sand, I’ll defend myself, that’s all.

    The argument here seems to be that people pay for CAM therefore conventional medicine is doing something wrong. I’m not sure that follows.

    Would anyone argue that people pay Burzynski for quack cancer treatments therefore conventional oncologists are doing something wrong? Could it not be that CAMsters are (knowingly or not) simply taking advantage of ignorance, fear and cognitive biases to sell their wares? That the apple pie of conventional medicine really is made worse, not better, by the addition of CAM cow pie?

  33. #33 Krebiozen
    August 16, 2014

    Put another way, I have had a number of unsatisfactory experiences with doctors. They would have been improved by giving me an accurate diagnosis and effective treatment. I don’t believe teaching me meditation, or giving me sugar pills, acupuncture or a foot massage would have helped much.

  34. #34 lilady
    August 16, 2014

    Every time Orac posts about CAM/Alt “Medicine” invading medical centers, I check out my County’s medical centers and their affiliated community hospitals, for the infiltration of any alternative practitioners. To date, there is no hospital which offers chiropractic, acupuncture, Reiki, etc., etc. services.

    There is a very well-known DAN! doctor who claims to have an affiliation with a medical center in my County; he lies.

    Sadmar describes the before care and after care (s)he received for bariatric surgery, as being superb. I know a few individuals who have undergone bariatric surgeries and they were required to undergo counseling and attend informational meetings, before undergoing those bariatric procedures. It was strongly recommended that they attend bariatric surgery support groups, following their procedures.

    http://www.pennmedicine.org/bariatric-weight-loss-surgery/patient/locations/hospital-university-pennsylvania.html

  35. #35 palindrom
    August 16, 2014

    “Holistic hernia surgery” sounds like a parody to me — hernia surgery has to be about the most mechanical process in medicine. Open up patient, fix hernia, close patient — presto! Problem solved!

  36. #36 Peebs
    In a dark and dingy alehouse
    August 16, 2014

    I think a lot is down to communication and, like most things in medicine, the basics of talking to a patient taught, then you go out into the big wide world and learn how to do it properly.

    Much the same as passing your driving test really. In the UK most learn and spend their lives driving a manual car.

    My Father put it perfectly;

    “You’ve passed your test, now you have to learn to drive”.

    Not sure how that comparison works on your side of the pond, but it works for me.

  37. #37 Denice Walter
    August 16, 2014

    ( continued form above)

    Woo seeks out paying customers in search of services- pseudo-health care, misplaced self-care, grandmother medicine, spa services, sage advice, spiritual guidance, surrogate friendship, guru-ship, quasi-parental guidance, ‘educational’ services, ( poor) psychological counselling, being a conduit for emotional transference, continual re-assurance that ‘all will be well’ and whatever else can be imagined.

    Freud wrote that religion served as a universal explanatory system, moral code and parental substitute which will hopefully eventually be replaced by scientfiic knowledge, democratically agreed-upon governmental- legal systems and adult independence and freedom of action.

    Woo-meisters would fulfill any of those roles as well- giving simple responses to qualm complex, existential fears- there is always an easy cure and emotionally rewarding answers for difficult physical and emotional questions.

    I have observed in the wake of the financial crisis, how alt media empires have added political and economic grandstanding to complement their alternatve health prevarication: they speak to frustration, anger and fear derived from other uncertainties as well as those of illness, pain and death.

    They voice their calming words after having provoked or exacerbated fears of social unrest, poverty, fascism or whatever other nightmares they can dredge up as if suffering and death weren’t enough. They capitalise on human fear and worry. Then they tell you that ‘stress kills’.

  38. #38 Denice Walter
    August 16, 2014

    @ Peebs:

    Ha ha!.
    I remember driving around town and doing really well when my father, who was instructing me, took me to the country to a relation’s weekend place and parked the car ( a manual, of course) on a steep hill and had me start it up and drive off.

    Which I did accomplish after a few tries and rolling backwards with my heart on my throat.

  39. #39 sadmar
    August 16, 2014

    Hey, Kreblozen and Dorothy and all. No worries. I don’t feel ‘dissed’ or ‘abused.’ We’re just having a vigorous discussion. I’m an Arts guy first, a Humanities guy second, with a little avocational interest in science, and I can’t help but express myself with certain, uh, literary flourishes that can make my intent difficult to discern. FWIW, irony and hyperbole (and especially ironic hyperbole) are my ‘natural’ tropes, and while I do mean to provoke, my spirit in doing so is actually good-natured, though I have no illusion that comes across in written text. I guess I’ll ask you all to take me at my word on that, and take the more-grating-seeming parts of my posts with a grain of salt.

    I have a lot more to say on the topic-at-hand, but it’s too long to post here, as i don’t want to clog the blog, and I already feel the length of some of my posts are stretching Orac’s hospitality. So, I’m going to find someplace else to put it up, and put a link here on RI.

    In the meantime I’ll just note that Denice Walter @ #37 articulates exactly why I’m here: pseudo-science as the nauseating exploitation of the weak for the sake of greed, our larger social pathology writ small, both reflecting and contributing to the cancers of fear, hate, and false messiahs that offer more fear and hate as salvation for the fear and hate already about. I’m just trying to think through ways to subvert these scum that are ‘outside the box’ of the usual skeptic takes.

    Sincere best wishes to you all. s.

  40. #40 sadmar
    August 16, 2014

    @ Chris Hinckie

    You sound like a great doctor. But I’m honestly not sure what you meant by the quote following. Can you explain?

    “I am bothered that parents will compliment me because I spent more than 5 minutes in the room or that I actually took their infant out of the car seat to examine them. Bothered because that’s unacceptable health care and probably a big part of the reason those in the woo areas can pull in new patients so easily.”

  41. #41 Lawrence
    August 16, 2014

    @sadmar – not to speak for the Doctor, but I believe he means that it shouldn’t be a situation where it is unique enough to warrant a compliment, but instead considered standard practice by a pediatrician.

  42. #42 Narad
    August 16, 2014

    Put another way, I have had a number of unsatisfactory experiences with doctors. They would have been improved by giving me an accurate diagnosis and effective treatment.

    I think I’ve mentioned this already, but conscientious editors have characteristic elbows. Maybe eight years ago, I lost most of the function in my dominant hand thanks to abuse of the ulnar nerve. So, EMG and off to the orthopods.

    The resident (fellow?) does his thing and returns with the attending. At some point, somebody must have questioned whether surgery was necessary, at which point the attending lifted my arm into the air and proclaimed, “I can pluck this nerve like a violin string!” (Or some instrument.)

    The resident was sent off to do his thing, and I repeated the question to the attending, who replied along the lines of, “Eh, I had something similar in med school. I fastened a throw pillow to the crook of my elbow at night, and it cleared up.”

    As did mine with the conservative approach. It was a weird two-hats routine, but I suppose I’d call it satisfactory.

  43. #43 Chris Hickie
    melting like a sidewalk crayon in AZ
    August 17, 2014

    @ Sadmar #40–Lawrence (#41) summed up what would have been my answer very concisely.

  44. #44 Craig Thomas
    August 17, 2014

    Dorit says:
    “If my primary care physician is not treating me as a whole, which part is she neglecting, besides, of course, my aura?”

    And that’s why you can never win the argument. “The whole person”, to advocates of CAM, includes stuff that medicine would never be attempting to address. You can’t fix this.

    ” If John Doe Patient and Jane Doe Patient felt they were being treated as ‘whole people’ the numbers of folks running off to CAM would be way lower than it is.”

    And this is the issue. “I went to my chiropractor” is such a common statement to hear. It’s a mixture of lack of education and a failure of legislation. People think they need it. And you can’t legislate these con merchants out of business without looking like science-nazis. So it’s down to education. Let’s have more of that.

  45. #45 Anj
    totally off topic
    August 17, 2014

    This is autism woo bingo. It might be a royal flush of autism. It’s definitely a prime example of looking for answers in all the wrong places.

    http://healingfamiliesnetwork.com/2014/06/15/nothing-is-impossible-autism-recovery-included/

  46. #46 Narad
    August 18, 2014

    It’s definitely a prime example of looking for answers in all the wrong places.

    As well as issues with reading comprehension, not that it really matters in this case.

    “Olivia’s ATEC in 2011 before any interventions was 143. Anything above 10 is considered Autism.”

  47. #47 sadmar
    August 18, 2014

    As Craig Thomas says, you can never win an argument with a die-hard advocate of CAM. But they’re not the target audience. The point of argumentation in pretty much any practical situation is to engage the ‘undecided’. My point is that the John/Jane Doe Patients who are feeling treated as less-than-a-person are mostly NOT feeling their medical treatment isn’t addressing their aura.

    Put another way: 1) The _typical_ patient’s desire for ‘whole person’ treatment is in no way inconsistent with real medicine, and was typically met in the past by Marcus-Welby-ish family physicians, and remains met today by pediatricians like Dr. Hinckie. 2) Insurance company profit mandates and other economic pressures have done much to squeeze ‘the human touch’ out of primary care. 3) This leads to discontents among the J. Doe Patients that can be exploited to swing them towards CAM. 4) The most effective method of combating this is not more education, but re-instituting and expanding the non-CAM little things that make patients feel good about their doctors. 5) For patients who are convinced that certain CAM practices (e.g. acupuncture and chiropractic) are effective in managing their pain, a strategy of limited tolerance and containment will be more effective than a full-on rejection of all-CAM-for-anything. Which is to say a) ‘tolerance’ is not ‘endorsement’, b) both the CAM practice in question and the claims of the individual practitioner must be seen in the not-a-scientist eyes of the PATIENT as being Complementary With NOT Alternative To real science based medicine.

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