‘An Astrologer Casting a Horoscope’ from Robert Fludd’s Utriusque Cosmi Historia, Oppenheim, 1617 (via Wikipedia)
I have always been very accepting of patients’ attitudes to complimentary medical therapies, even homeopathy. But this week, as I listened to Bosworth MP David Tredinnick arguing that homeopathy was a valid therapeutic option, I wondered whether doctors can respect the views of the patients too much. The interview (audio here, Radio 4 Today programme, 0851), during which Robert Winston defended/apologised for his previous description of Tredinnick as a ‘lunatic’* caused me to reflect on my own hypocrisy.
In the clinic, with a patient, it goes like this:
Me: “…so that’s the plan for the next two weeks. I’ll arrange the endoscopy, and chase the results of the scan… then come bacl to see me in a month or so. Does that make sense?”
Patient: (meekly) “Yes doctor. I just wanted to ask though…”
Me: “Go ahead.”
Patient: “I’ve been seeing a ——ist. Is it OK if I carry on?”
Me: “I’m sure that will be OK. As you probably know, there isn’t any good evidence that helps this condition. But it shouldn’t do any harm, and some patients do feel benefit from it…”
This is a standard, respectful response. As long as the patient adheres to conventional advice, most doctors do not mind if alternative therapies are pursued in parallel. But the response outlined above is actually disingenuous, because I do not believe in alternative therapy. I believe that the patient believe, and I respect that belief. To paraphrase, what I am saying is – ‘Yes, yes, of course you might be interested in seeing the ——ist. It’s completely useless of course, but I haven’t got a problem with it as long as you do as I say and take the proper tablets too.’ To paraphrase even more harshly, ‘Yes of course, go and spend good money on quackery, do what you like… but make sure you come back to see the proper doctor.’ Perhaps it would be more honest to just say that. But there is no need to antagonise, because there is rarely a risk to the patient. Usually, he or she will pursue both forms of treatment in parallel. The ‘real’ treatment makes them better, the alternative treatment makes them feel better (and may, through the complex and insufficiently understood placebo mechanism, assist in their recovery). No need to be disrespectful…
Except… when it actually matters. I am reminded of other patients – who have been diagnosed with cancer and have done a ‘Steve Jobs’. He was diagnosed with a rare, sometimes quite indolent neuroendocrine tumour. However he avoided conventional therapy for 9 months, favouring alternatives. The Science Based Medicine blog reports, ‘He kept to a strict vegan diet that included large quantities of fresh carrot and fruit juices’ and quotes from his biography:
To that regimen, he added acupuncture, a variety of herbal remedies, and occasionally a few other treatments he found on the internet or by consulting people around the country, including a psychic. For a while, he was under the sway of a doctor who operated a natural healing clinic in southern California that stressed the use of organic herbs, juice fasts, frequent bowel cleanings, hydrotherapy, and the expression of all negative feelings.
This is not an isolated case. Less well known patients diagnosed with cancer do take themselves abroad and submit to entirely unproven methods of cure. It does not work, and when they return, more unwell, scans show how the malignancy had spread during the ensuing months. In cases of life threatening illness there may well be a duty to let the veneer of respect fall away, to reveal what we really think. “NO! DON’T! You are wrong.” In our training we are encouraged to incorporate the patient’s values and beliefs into our method, such that a therapeutic plan is developed in partnership. We give credence to beliefs, even if they seem absurd, because
i) we know that an individual’s internal psychological structures, and coping mechanisms, must be preserved as they are necessary to encourage recovery, and
ii) challenging them risks disruption of the patient-physician relationship. My argument necessitates a strong challenge when life is at risk.
Such challenges do not come naturally or easily to doctors who work in a non-paternalistic and collaborative way.
What I am describing here is a form of flexibility with respect to our response to patients’ beliefs. As the risk grows, our freedom to warn and challenge grows. Our highly developed method of ‘partnership’ crumbles to reveal paternalistic foundations – ”We know best, you are wrong.”
And what of Tredinnick’s beliefs? The trouble is, he sits on the house select committee for science and technology. The committee exists ‘to ensure that Government policy and decision-making are based on good scientific and engineering advice and evidence’! The strange thing about listening to Tredinnick on the radio was that… he came across in an entirely plausible way. He displayed a politician’s natural ability to connect with the beliefs of many of those he represents, and when challenged by Winston turned to the ‘patient experience’ rather than objective evidence. His respect for homeopathy seems to be based on the fact that, in general, people feel better when they use it. This is the placebo effect, and cannot be denied. It resists the powerful black hole that is the evidence free zone around homeopathy. And it applies to any therapeutic symbol that one chooses to invest ones faith in – a sugar pill, a magic stone, a new diet. It is not science, but it is relevant, for it taps into the core of our patients’ psychology. It cannot be ignored or dismissed without careful thought.
The challenges of persuasion and communication described above are in the power of individual clinicians to work through; we can modulate our approach according to the perceived risk. When a politician who is able to steer policy gives public backing to a useless therapy, we must be concerned. Such public statements, that homeopathy works, will be received by those suffering, or yet to suffer, both mild and severe illness.
* this epithet was felt to be justified because of the MP’s belief on astrology
Xmas is here! 3 collections of articles…