Tuesday, February 3, 2009

Complementary Medicine

A conversation with a colleague today got me thinking about how mainstream U.S. medicine ("western medicine," "allopathic medicine," "evidence-based medicine") relates to the wide range of complementary approaches.

Here's my reconstruction of what my colleague said:
"I had bad gastric reflux symptoms for a year. I tried changing my diet but that didn't do the job. My primary care doctor suggested Prilosec, but it didn't help. Then he suggested Prevacid. It cost me $50/month [this was the copayment at the pharmacy - when I checked on line today the lowest price for 30 30 mgm tablets was $189!] and I just didn't feel right on it. My joints hurt and I felt funny. He referred me to a GI specialist. She did an endoscopy. It showed some little growths in the stomach apparently caused by Prevacid. She suggested that I continue taking the medicine anyway.

But I'd had it with Prevacid, so I stopped it. I decided to look into alternative ("natural") approaches. Someone suggested that I try Probiotics. [Here's what the National Center for Complementary and Alternative Medicine says about Probiotics: "Probiotics are live microorganisms (in most cases, bacteria) that are similar to beneficial microorganisms found in the human gut. They are also called "friendly bacteria" or "good bacteria." Probiotics are available to consumers mainly in the form of dietary supplements and foods."]

An Indian man at Whole Foods suggested what to try. It worked well. My reflux symptoms went away and the side effects of Prevacid were gone. I felt well.

I went back to the GI doctor for a follow up appointment. First I saw the nurse. I told her what I'd done. She said 'Lots of patients tell me that approach works for them.' But then the doctor came in and she stopped talking, as if she was saying something she wasn't supposed to say.

When I told the GI doctor about the Probiotics she said 'I've heard that it has helped some people, but we can only recommend what we know works.'"
I don't think this is an unusual vignette. Most physicians I know are not comfortable considering "alternative" approaches. I have no expertise in that area, but here's what I would have had the GI specialist say:
"I've heard the same thing from some other patients. From a scientific perspective we don't know whether this approach really works. But if you definitely feel you are doing better, I suggest that you continue what you're doing and monitor how you are. I also suggest that you go onto the web and see what is being said about Probiotics. Keep in mind that you can't believe everything you read. If the symptoms come back I'm happy to see you again. And if you're doing well - and I hope that's what will be happening - please give some follow up to your primary care doctor, just to make sure he knows how you are and what you've done for the symptoms."
"Evidence-based medicine" is a noble concept, but it's too much of a buzz word now - almost like a point of religious faith. Sometimes our evidence about what works is powerful, but often it's so-so at best. We should try to guide ourselves in accord with established facts, but we need to be more humble about the limits of our knowledge and more practical than my colleague's GI consultant was.

Since my first reading of Plato I've admired Socrates for his insistence that wisdom resides in acknowledging the depth of our ignorance. From my brief literature search today it looks as if evidence about the effectiveness of Probiotics for gastric reflux is somewhere between skimpy and nil. But my colleague's many months of experience with Prilosec and then Prevacid had produced no benefit, no matter what the "evidence" about statistical effectiveness might be.

A clinician schooled by Socrates would be able to acknowledge (a) the evidence we have favors medications like Prilosec and Prevacid, but (b) "evidence" isn't divine truth, and (c) thus far my colleague seemed to be doing decidedly better following a non-evidence-based approach so that (d) wisdom suggests continuing that approach and monitoring clinical status. The key evidence is how the individual human being is actually doing.


eric said...

We use a lot of glucosamine, fish oil, melatonin, and acupuncture in our practice. One person's spells are treated with aromatherapy. So long as I know that the condition isn't life-threatening, and that the risk-benefit ratio of "allopathic" treatments is little better than even, I'm all for "complementary" therapies. My impression is that this is a "cost-effective" approach for our HMO. A lot of us are using the "probiotics" saccharomyces and lactobacillus for prevention and treatment of clostridium difficile antibiotic-associated diarrhea. These aren't cheap for the retail consumer, and the evidence base is still pretty thin.
It's important to keep alternative therapies alternative. For the patient who seeks a treatment for every symptom, I can recommend alternative therapies, but that keeps us in the same box. For healing, I want to help people out of the dyad of symptom and treatment, to view their entire being in another way. It's important for patients to take their journey of self discovery on their own, with my encouragement along the way. When they find what works for them on their own, it works so much better than anything I could have prescribed.

Jim Sabin said...

Hi Eric -

Thanks for this beautiful note. You've described in an eloquent way what I see as an ideal orientation towards "complementary" medicine. The patients in your practice are lucky!