I think before we accept that a patient is simply not willing to take medication, we should try to counsel/educate them regarding the proven benefits of these medications. Further, we should emphasize that OTC supplements/herbals/vitamins are not regulated by anyone for the most part, many of them do not actually contain what they claim to, and most (if not all...) are not proven to have any clinical benefit. I take different stance with patients like the one mentioned above. If a patient is at first not willing to take "real" medication, then it is my job to educate them and counsel them so they will understand the benefits of evidence-based practice. It is also important to emphasize the consequences of not managing these disease states, which often times motivates patients to adhere to medication plans.

 Consider the proven benefit of such an established  drug as atenolol RX'd into I believe the fourth most given drug as recently as 2004 with little real evidence that it prevents events : or vioxx or the diabetes drug recently pulled...'.... I think before we accept that a patient is simply not willing to take medication, we should try to counsel/educate them regarding the proven benefits of these medications..."  It seems that proven benefit should be obvious .....when physicians question the benefit of statins like both Dr. Redberg and Dr.Topol recently have prehaps that evidence is in some way lacking?

While I acknowledge that some Rx meds have questionable benefits in certain circumstances, at least they contain what they say they do, and it is undisputable that some medications are absolutely beneficial. Contrast that with OTC herbals/supplements/vitamins, where there is variation in the products, no real regulatory control, and NO proven clinically relevant benefit for most products. All our patients know about medications is the garbage that is in the media, and what Dr. Oz told them. They don't understand that these home remedies are unproven at best, and in some instances, no safer than Rx meds. That is where the "education/counseling" comes in.

Charles Darwin wrote a treatise about this.  If you prefer "alternative medicine" (no such thing - it is not medicine) fine.  I don't have to "work with you" and frankly you shouldn't be paying me for doing what you think is best for you as I am adding no value to your decision making.  For those of us practicing evidence based medicine it may sound coarse but I don't see any reason to compromise treatment recommedations because a patient professses a desire to do otherwise. They go elsewhere at my direction.

But what happens to those of us for whom conventional medicine offers no help? I have a connective tissue disorder with multiple "minor" sequelae (including a heart murmur, mild asthma, digestive issues, and unstable joints). Over the past year I decided to stop seeing the chiropractor who quietly realigned my joints as needed (he can fix hips, knees, ankles, wrists, no Xrays, same day appt) for $40 a session, and see what conventional medicine could do for me.

It was an unmitigated and very expensive disaster. I learned that rheumatologists and physical medicine and rehab specilaists don't DO "manipulative therapy". Only the PTs do, and you have to get several hundred dollars (at least) of useless scans, and wait weeks while the joint deteriorates, in order to get to them. An asthma exacerbation sent me to a pulmonologist, who insisted I needed a thoracic CT with contrast- for a dislocated rib and workplace chemical exposure.

I went back to the chiropractor. He put the rib back in place. I stopped the offending experiments. My lung function improved. I eat a very high fruit-and-vegetable diet that has erased the digestive issues except for stress-induced gastritis (hiatal hernia), and stress reduction helps with that. Disciplined exercise (and an occasional realignment) with frequent work breaks and a few ADA modifications keeps me working. Except for the physical therapists (who are not MDs), NOBODY in conventional medicine offered me these benefits. I try desperately not to be a "hater", but please realize that some of us have life experiences that have driven us to doubt you. Take that into account, and try to be sympathetic and educational. We will listen if you actually help us. If you try to act like God, when we have seen too many medical gods fail us, we will be skeptical.

Glad to see another pharmacist posting on here!  I concur that education/counseling is key.

As for CoQ-10 and blood pressure, a meta-analysis of 96 patients showed the aforementioned reduction of 11mmHg.  Would THAT have been enough to approve a prescription medication for hypertension?  Of course, that's assuming each pill really did contain 120mg of CoQ-10...

In the common, traditional but more narrow meaning of "medicine" that would be any substance a person ingests, injects, inhales or applies to the body for the purpose of modifying a feeling or symptom or an identied disease process. So, "medicine" in the term "alternative medicine" is not erroneous. I suggest that the word "alternative" is the confounder since it is non-specific. It's common use refers to non-FDA approved, non-comercially manufactured substances for the abovce stated uses & methods. Language is cumbersome especially if one wants to clearly convey concepts & to be understood. Witness the constant creation of acronyms. I'm surpised people still talk about alternative medicne and not "AM". I would suggest that the title "School of Medicine" or "Dept. of Medicine" are inaccurate labels. We only assume we know what someone means when they use the word medicine. Chiropractic is a therapy, not medicine so how can it be labeled "alternative medicine"? Physical therapy is also not medicine but it is not considered "alternative". 

I do agree with the point Dr. Warber makes, which I see as:  If you want to be of assistance and benefit to a person seeking your counsel then you need to be prepared to to accept that persons beliefs and offer your studied advice honestly as best you can. I share the frustration of Sara MD in her "coarse" attitude. In cases such as this I see most clinicians as being inadequately prepared to function effectively and it is not necessarily their fault. Meganalysis of research of "non-FDA approved, non-commercially manufactured and non-chemical therapeutic modalities" by trustworthy sources is not made available at near the frequency of pharmaceutical company propaganda or results of individual or limited studies. 

 I say to her & others who feel the same way, take a deep breath and honestly state that either you are not knowledgeable in that area to be able to offer advice or that you are critically opposed to those approaches. Of course you can suggest they find a different provider. (I don't say "refer" as I believe it is unethical to direct a patient to someone whose practice philosphy you do not agree with.) But don't discard the notion that you can't be of service. There may be other facets of that patient's conditions which my allow for a mutually agreed upon intervention.

 

David,

I represent as effective only that which I can prove and document and anything else I plainly discuss the uncertainty with the patient (consumer).  It is called truth in advertising.  When various other practitioners rise to that level I will take them seriously.  Patients respond quite well to that blunt approach because it incorporates the fact that they can google anything I tell them and investigate the accurracy themselves - something I encourage and welcome.  Futility and uncertainty are part of medicine - fairytales are not.  If your doctor respects you enough to speak in those plain terms it should be pretty hard to be skeptical of the advise your receive.

Sara, I believe we are essentially in agreement. If a patient presents seeking validation of, or complicity in a treatment based on (to the best of my knowledge) anecdotal information, I could not cooperate. If I have knowledge of evidence of the effectiveness of any given therapy I would be obligated to inform the patient as to how convincing that evidence is. No one would disagree that there is little that is 100% I think. (Uncertainty) If I don't have sufficient knowledge then I would have them do a search, if they haven't already. If they have,  I guess they are more knowledgeable than me and they can go on about their business (with my admonition) and return when they have a concern for which they haven't already obtained an answer. However, I would attempt to communicate in such a way as to engage them in rational/logical thinking and try to explain all of the options of which I am aware or would consider. (Truth in advertising)

Looking at the article again I see the term "integrative medicine" which may be understood as "alternative medicine" but shouldn't be. Medicine in general should be "integrative"(except perhaps for surgery). That is, taking into account many factors in a given persons life in assisting them to be healthy. However, I would take issue with the definition that includes "spirit, heart, mind & body". "Spirit" is the mind and "heart" is body, not a source of emotions. That again is the brain, which I think is the most dificult part of humans to get to function well, including my own.

Since many people (more frequently immigrants, I have observed) will present with attitudes & beliefs inconsistent with western style medicine, often based on anectdotal history or tradition, clinicians trained in U.S. schools have an extra challenge in providing service to that population. I think one needs to be willing to be patient but no need to feel guilt if that isn't for a long time.

Like Mitzi, I've experienced major misdiagnoses and abject medical failures:

I received Dx of irritable bowel syndrome when it was actually endometriosis, and I was finally correctly diagnosed by a co-worker (a Vietnam era ex-medic) and then cured via hysterectomy that found both raging endometriosis and adenomyosis (confirmed by biopsy).

My sister had a craniopharyngioma that went undiagnosed for more than six years while she was under the care of an endocrinologist (who promptly left town once the tumor was finally discovered). She was operated on--twice--by someone not competent to do the surgery, and then she finally died before reaching 20 years old.

A good friend was subjected to an idiotic and very painful surgery to remove her tumor-riddled pleura while she was dying of Stage 4 ovarian cancer with rampant metastasis, no longer even having chemo. She was told the surgery would "help" her, but instead it made every remaining breath very painful and she was short of breath to the grueling end: she should have been given palliative care instead, but that was not offered as an option and she was too ill to argue.

My mother was fed DES while I was in there gestating (thanks!), told that it was to prevent miscarriage even though she had no indications of any miscarriage risk.

I was cycled through every antibiotic known to man, for more than two years in my young teens, for some minor never-diagnosed malady that had as its only symptom a skewed differential count.

Some years back, my doctor wanted to put me on statins for "high" cholesterol, but I had concerns even then, after reading about statin-induced memory problems, so I chose to instead  wait and see (and do some research on my own). It turned out that with my cholesterol profile I already have the lowest CHD risk (according to Castelli, 1988)--would SaraMD have tolerated such misbehavior, or would she have summarily sent me out the door?

The latest thing is to not do routine labs (chem panels; CBCs) and I was told this includes me even though I have mild anemia due to kidney anomaly. Therefore I run my own labs to keep track of things (thanks to MyMedLab.com), and in this way also discovered that I am hypothyroid--which is now being treated.

So yes, it's true: I do not have 100% faith in doctors. Instead, I have the crazy idea that I am hiring them on a consultant basis, but that I have full responsibility for making the ultimate decisions about my care, given that I am the one who will have to live with the results. Because of my sister's case, I took numerous college courses in biology, emphasizing physiology and medicine and chemistry, and can therefore read competently in the field and do my own research.

I don't know about most people, but I am an educated patient, and I am paying my doctor to be my consultant and medical resource, and hopefully a partner in my care. As an adult, I run my life and take full responsibility for my actions. I find SaraMD's tone to be quite patronizing, and she has no fear of me appearing on her doorstep. 

But to all doctors: you are not the bosses of us! Once you internalize that fact, and view patients as brain-possessing human beings who have come to you to pay for your advice, not decrees, and who want help in understanding their medical situations, everyone will be a lot happier, patient and doctor alike. I shouldn't need to take so much responsibility for my own care, but given my experiences above, I feel I have no choice. I simply do not view doctors as omnipotent, and I think the good ones would be the first to agree.

 

I would have informed you that the statin data on primary prevention is thin and contingent on what your estimated ten year actuarial risk of a coronary event was as well as your personal health preference.  I would also discount the memory complaints (large randomized trials dispute this and there is no measuring memory so people can claim what they like) and the glucose intolerance data (weak and without consequence like diuretic or beta blocker therapy for hypertension).  I would correctly state the safety data and the dubious value of serial blood testing and after that conversation we would decide whether to initiate therapy.  Does that make you any more bitter than you already are?

An informed patient is a luxury but those who are rightfully paranoid due to past negative experiences are expectedly more difficult to make comfortable with a diagnostic and treatment plan, require more time for explanation, reassurance, etc. It's just the give and take of the doctor patient relationships that we as healers expect to encounter but I really don't encounter that very often. In the area where I practice, there is a supply and demand issue. Patients are grateful for the help. They are our neighbors, our friends, our fellow church members, etc.  We do our best. In a practice of nearly 40,000 patients shared by my partner and myself, we don't have many initio's or Mitzi's, but I have a few and we pride ourselves on most of them  having found a place to rest with us, where they can feel comfortable and can comfortably confess when they aren't.  I'm sure it's natural selection to some extent, but we've always prided ourselves on being able to listen and come to sort of an agreed upon plan. If it doesn't work, we back up and try something else or they go some place else. There are other patients waiting for someone to cancel so they can get in more quickly and though we care about every individual, we need to care for those who feel they need us and encourage those who think else wise to keep looking until they find someone they feel comfortable with. For a few, that will be "never".  

Most of us  have never really found diagnostics to be that difficult though, the politics of medicine and the rare patient with fears fostered by bad experiences are the challenges . Humans encounter humans on a daily basis. Not all policemen, soldiers, shoe salesmen, teachers are bad people. Not all physicians are bad people. If you are uncomfortable, keep looking until you find someone you are comfortable with. I thank God for the medical profession from a patient perspective. I'd be dead today if I had not been able to have two C-sections, a sigmoid colectomy for a diverticular perf, etc.  If I'd been on my way to  California in a covered wagon, I'd be one of those poor unfortunate folks whose grave is marked with a rock and a cross made of two sticks, soon forgotten. There is good and bad in everything. Never stop looking for the good.

Just my two.

Melissa 

 

For those who do respond to us with understanding, and a willingness to admit they haven't seen our condition before, but are willing to work with us (not just on us, like the body is a machine that responds exactly like all the other machines in its class- ours do not), we become faithful and willing patients. But there are "different" people in this world, who swell like a balloon when given a COX-2 inhibitor (my Mom) or nearly die from rhabdomyolysis when given a statin (a cousin). Doctors who are willing to work with us, admit what they do not know, help as they can but do only what needs to be done- those we appreciate. Thanks, Melissa. I hope I find a physician like you someday.

 

Thanks to everyone for the heartfelt comments on a difficult but important issue.

A question for the docs out there: When you get a new patient, do you automatically present to them your philosophy on integrative/alternative/complementary medicine, and perhaps give them a summary handout to take with them?

Similar question to the patients out there: Dou you automatically describe your philosophy when you get a new provider?

Nice ad hominem attack.

I provided reasons that I do not believe doctors are omnipotent (do you consider this an insult? seriously?), noted that I am the one who will have to live with my health decisions, and that I am the one hiring and paying the doctor, and for that you call me "bitter"? That's the best you can do?

No, I am not bitter; I am a realist, and a grown-up, and well-educated, and independent-thinking, and blessed with a decent science-oriented brain that I choose to use. I do not worship idols, and I do not obey orders without question. If that means "bitter" to you, so be it, but I think it's a misuse of the word.

 

You have insulted my profession of 35 years and I have defended it.  If you read my reply you would understand that I would have treated you as an educated individual and would have given you the option of making a decision.  Instead you have indicted various physicians as being incompetent based on your singular account of misdiagnosis without data. Do you think they train medics to diagnose endometriosis?  Was an effort to palliate pain with pleurodeisis really a miscarriage of judgement?  The antibiotics you were exposed to did you no damage and were expected by your mother.  If you want to be your own doctor that is fine - you can consult someone like myself and get advice and then do what you want.  In actual practice that is what every patient does once they leave the office.  I don't understand why it makes you so angry.  If a physician speaks frankly to an adult patient does that make her any less of a "realist" than the angry patient.

Pat,

I rarely have to discuss philosphy in the office setting. Folks have chest pain, high blood pressure, palpitations. They just want a competent work up and some consideration and caring. In our area, time to discuss the philosophies of medicine would be fabulous, but not realistic. I suppose, if they aren't getting what they need, we would venture into that arena, but it's not part of the work-a-day grind that patients our physicians in our area are accustomed to. Take yesterday for instance. I arrived at 8:30 am to the office, worked straight through lunch, added on another new patient at 10:30, ran to the hospital for an emergency from 1:50 to 2:45, patients waited for me to return, two rescheduled and then finished my office day. I only got home at five yesterday, a luxury, because two patients gave up and rescheduled due to that emergency. Many nights, like so many other physicians, I eat lunch at 7 pm.  In the grand scheme of things, as long as patients are feeling better, getting better and feel as if their needs are being met, no need for that philosophical discussion.

Melissa

As a just-retired doc, Melissa, I am familiar with (and sympathetic to!) the pressures you describe, though I realize there are variations by practice setting, etc. This may be a more feasible tactic for FP or general-medicine docs than specialists, though I have seen it done by the latter. My choice of terms was perhaps not the best: rather than "my philosophy", I really mean "my views" or "my stance" or "my approach". Can be a very short discussion if managed well, and a take-home sheet helps make it efficient. I do realize, of course, that some patients  would be happy to debate this for hours.

Thanks for the reply,

Pat

I think it is quite disingenuous to imply that there is no regulation and no way to discover which supplement and herbal providers are reliable sources. There are places like consumerlabs to get up-dated info about supplement quality including current research with links to on-going research which includes studies with placebo-controlled arms. There are also highly qualified MDs like Stephen Sinatra, an Interventional Cardiologist, who are engaged in on-going research related to the benefits of supplementation and also researchers like Alan Gaby who recently published his magnum opus “Nutritional Medicine” about the beneficial effects of supplements. Nor to forget Andrew Wile MD and the Integrative Medicine program at U Arizona.  I have personal experience of having AHA/AAC guidelines thrown at me without any discussion as to alternatives. I have the advantage of having intellectual resources to bring to bear on my treatment choices and am partly to blame because I did not do the prior research and subsequently spent a year recovering from serious side-effects of pharmaceuticals like amiodarone. There was really no way for me to have known so much harm could be done in such a short period of time and I consider it unconscionable to hand me drug monographs after the fact. To then have to start on a lonely search for a sympathetic ear, to have to cope with a medical establishment seriously compromised by the politically powerful pharmaceutical industry which also influences governmental regulation is not something I wish for anyone. There are alternatives and I am grateful that there are MDs who care to practice functional/integrative/alternative medicine even though they are severely restricted by the medical and insurance establishment forcing me to pay for my care while I pursue my goal of never ever having emergency room treatment or hospitalization again. And I am also grateful to the legislature of New York State for crafting the MOLST regulation, a medical order crafted by me, signed by my Integrative MD, that ensures in the event of an unforeseen emergency, my care cannot be high-jacked by a medical professional who does not agree with my natural/integrational choices on how to manage a chronic progressive disease.

I have a complex medical history; multiple surgeries, some chronic conditions, ongoing malabsorption/malnutrition issues. I am well educated, read many studies and journal articles, and really strive to understand the best information that there is regarding my medical situation.

When I go to a new doctor, I am up front about things. I am seeking their expertise and the benefit of their experience.  I will not be handing the management of my health to them; that is my job as I have to live with the decisions we make and my compliance with any plan we develop. 

My malabsorption issues require extensive nutritional supplementation, and doctors who roll their eyes at that -- it's happened twice -- are thanked for their time and our working together is over.

I'm on this site because my regular doctor recently noticed that my heart murmur sounded louder and she encouraged me to go to a cardiologist. I had a consult with my husband's cardiologist and he diagnosed me with a grade 3 MVP with regurgitation and a possible ventricular septal defect. I'm having an echo in two weeks for positive diagnosis and to then develop a plan. I'm in over my head when it comes to heart stuff, and because I know that this cardiologist has taken good care of my husband, I am going to trust his recommendations when it comes to treating the problems I have with my heart. 

I am not wild about "alternative" medicine but have found that a chiropractor was helpful with lower back pain treatment during and immediately following my last pregnancy, and also found (after thousands of dollars of conventional treatment, every test possible, and medication that made me really miserable) that acupuncture seems to be the only thing that gets rid of my seasonal migraines. As I told my brother, if acupuncture is a placebo, I just don't care... sumitriptan makes me so sick and the "placebo" works! 

I didn't go for that treatment at all until after months of conventional medical "care", including one doctor who told me I was "making up" my migraines... I was so desperate, I was ready to try anything as I was at risk of losing my job and was not being a very good mother either.

In general, though, I think most alternative medicine is woo for the gullible, and I'm not interested. I have observed something that more MDs would do well to emulate. The "alties" do spend more time with patients, they listen better, they often take better medical histories, and they are often warmer human beings. I don't know if it's the insurance racket of rush them in, rush them out, or what, but many MDs are cold, and they seem to not be interested in actually hearing the person in front of them. I'm sure that disconnect drives many people away from conventional medicine. Not all MDs have these issues, and I've been lucky to find a few that really do care.

This is an excellent article. Very often, by validating and taking seriously patients' concerns about prescription drugs, we gain their trust to the point where, should it become necessary, they will be willing to try "mainstream" medication. But lifestyle modification should be our first, second and third choice for intervention, whether we are talking about primary or secondary prevention. There is no downside to the Mediterranean diet, smoking cessation and regular moderate exercise. Primum non nocere must inform all of our recommendations.

Of course it will always be difficult to demonstrate memory impairment in a study, but the fact that glial cell function is affected should give us all pause. At a personal level, when I stopped 80 mg Lipitor I had about six months of remembering things and simultaneously experiencing significant surprise that I had remembered. Both my wife and I perceive that my memory is improved. With all due regard to the unconscious, I can say that at least I had no mind set at the time I quit that my memory might improve. I've also noticed a spectacular improvement in muscle strength, although, again I didn't quantify strength prior to stopping. I lift grandkids (who've only gotten heavier) more easily than before. 

Given that studies show 15-20 percent of even those with astronomical TC (mine is 600+) have no plaque, it seems the medical community is a little too eager to dismiss possible statin side effects and insufficiently interested in discriminating those with plaque issues from those with none. As you might imagine I am challenged every time I see a doctor to begin statins again. Every time I ask for at least a hypothesis of benefit, and there is none.  

I agree, there is only one medicine and the other so-called alternatives are quackery as in charlatans.  I am stunned at the BS people will believe. It seems that most Americans have no idea what scientific method is and why it is so important. The “alternative medicine” group are in it to make money, plain and simple. They use coincidence as if it were cause and effect to the detriment of their patients.

"Every time I ask for at least a hypothesis of benefit, and there is none."

You're kidding right.  Here's the hypothesis - every study done has shown reduction in cardiac endpoints.  The mechanism is converting "vulnerable" plaques with thin endothelium and large cholesterol laden cores into stable plaques without same which are less likely to rupture and result in an MI or death.  This "hypothesis" has been tested by outcome analysis in large clinical trials as well as serial intracoronary ultrasound assessments which show measureable differences in plaque composition after even short periods on intensive statin therapy.  I agree with you that some folks report side effects and can't tolerate therapy but please don't attempt to state that a physician cannot postulate a mechanism that could explain a beneficial effect of a medicine he/she is recommending you take0if that was the case you would surely find another wouldn't you?