A patient came to clinic with a sheaf of papers. In the four months since his last appointment he had researched the subject of allergies, found a private clinic and submitted himself to the most unconventional series of tests. The clinic sent him a long list of foods and substances to which he was supposedly intolerant, from ‘live oak’ to ‘cucumbers’ to ‘Penicillium, the fungus that produces Penicillin’. Based on these results he had scoured his diet for culprits and changed his lifestyle. But his symptoms persisted. He had evidently placed his faith and hope in this clinic. To me it was baloney. Yet here he was, seeking my opinion, and my validation of the answers he had found. It was a classic example of conventional medicine running up against a patient’s need to find solutions to unexplained symptoms somewhere, anywhere.
To incorporate these results into my management plan would have been dishonest, as I had no trust in them. However, to reject them out of hand felt insensitive, for they represented his laudable and sustained attempt to manage his condition (‘dangerous’ or ‘significant’ pathology having already been excluded by endoscopies and scans etc). What to do?
Negotiating a route between respect for a patient’s inclination to seek answers and the concrete wall of ‘evidence based medicine’ proved difficult. He asked how he should phase out various ingredients, when he should phase ‘cumin’ back in… I looked at the surreal report, at the list of intolerances, waffled a bit, looked up, and said,
“Mmmm… I’m not sure how much we can believe in this.”
His face fell.
“Oh. It had a good write up on-line.”
Then, to soften the impact, I said,
“Well, sometimes we aren’t quite as up to date as we could be, and I’m not saying there’s nothing in it, but I have never seen anything like this. I would be guessing if I gave you advice based on this.”
I put the papers down.
“It seemed really accurate,” he said. (Then why aren’t you better? I thought).
I wondered, quickly – what benefit is there in destroying a patient’s faith in something non-evidence based? His future health and quality of life was going to depend more on his sense of control over his symptoms than my ineffectual interventions. Yet, to support and encourage him on this journey into the world of unproven techniques and internet based analysis could be seen as collusion in nonsense.
He kept referring to the report. I studied it. The more I looked the less I believed. I chose to be definitive,
“To be honest, I can’t believe any of this.”
I lined the papers up and pushed them towards him. Then I gave some general advice, none of it likely to bring much comfort. He left.
I reflected. This man walked in with the rudiments of a plan. He walked out with a handful of (expensive) scrap paper. In denying the validity of his faith in those tests I had slammed the door on a route to wellbeing – an unproven route, but a way forward nevertheless.
This is the challenge. For every concrete interaction with ‘normal’ medicine, patients are likely to seek any number of alternative answers. As rationalists, trained to prize evidence above all, we instinctively reject such interference, but in doing so we risk rejecting our patients.
[some details altered to preserve confidentiality]
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