Western Doctor Dilemmas

Dr. James Duthie FRACS

Imagine making an appointment to see an electrician. You talk to them about the layout of your house and the fact that you want modern, artistic lighting, but do not want fuses used as they disrupt the natural flow of electricity through the house. Furthermore, you want uninsulated copper wire used for the same reason. And do they know that many people have started using wood instead of wire to conduct electricity with a number of benefits? You have, after all, done “a lot of research” on this. By research you mean that you managed to find someone on the internet that agreed with your a priori concepts.

The analogy is obtuse, but to complete the arc; the electrician could confidently laugh at your unsafe and ineffective plans, and ask you to leave the office. Not so for the physician.

All western doctors must be facing these issues on a regular basis, and although thankfully few patients are real fanatics, here is one example http://www.stuff.co.nz/world/europe/9026927/Cancer-free-after-court-ordered-treatment

The difference between the electrician and us is our duty of care. If the client burns their house down with hare-brained attempts at wiring, the electrician is not at fault. We are at fault even if the patient’s feelings are hurt during our consultations, let alone if they refuse appropriate treatment. The instinctive, and very human response is to let difficult people live with the consequences of their poor decisions. But as doctors, we are bound by more than our instincts, rather, by the lofty values of our profession. There is a tension between us telling people what is good for them, and creating a relationship where patients will perceive us as trustworthy advisers.

We need to remember that patients do not present to medical professionals solely for the purpose of having a pathology scientifically treated. People see their doctor because they want to feel better. This is a very vague notion, but in practice means that even if you do not give them a pill for their high cholesterol, they may feel better if you explain why they don’t need one. It explains why people stop taking anti-hypertensives when their hypertension was asymptomatic. It also means that if a questionable herbal supplement gives them confidence that their fatigue/pain/cancer will be cured; they will pay for it irrespective of any scientific basis.

There is a clash of cultures between medicine and alternative therapies, and when dealing with patients who have unorthodox ideas, egotism is our enemy. The assertion that Saw Palmetto is no better than placebo for lower urinary tract symptoms does not make patients taking this treatment feel better. It makes them feel stupid, especially if they believe they have noticed an improvement since starting on it. Yes, it could be placebo effect, or reversion towards the mean, but pointing this out risks making a patient feel gullible and stupid. No one likes to feel stupid, neither patients nor doctors. This is why we are irritated by patients presenting pseudoscience to us, and then berating us for not being experts on it. We have spent years in the prime of our lives sacrificing much to become experts in our fields. It seems it should be beneath us to have to defend or justify our expertise to an amateur who has spent a few hours “surfing the net”.

Ultimately, we must still advocate for these patients, even if we find their behaviour insulting. We must still hold their well being above our impatience or irritation, however justified. A blunt presentation of the “hard facts” is very likely to drive these patients away, and so must be poor medicine. Good medicine would see the patient engaging in effective treatment for their pathology, so there must be a better strategy.

I have contempt for charlatans and their companies that prey on the vulnerable to peddle their placeboes. “Placebo” may indeed be too kind, as some of these treatments may indeed be toxic. I despise the complete lack of legal or moral responsibility that alternative practitioners exploit in most countries. I try not to have contempt for the people using these treatments because, as previously stated, they simply want to feel better and a placebo may achieve this for them. I don’t think we should blame people for having a positive response to a placebo; indeed they may make our job easier. I perhaps feel subconsciously robbed that, as a community, we have agreed not to prescribe placeboes and can no longer capitalize on them in the way that unethical agents can.

The solution? We all need an approach that neither compromises our core values, nor disempowers or devalues our patient’s ideas. We can and should guide towards treatments proven to work, but not be so arrogant as to dismiss misgivings about current standards of care. Yes we can cure most cancers now, but we also unleashed thalidomide on the world.

We should be heartened our patients confide their alternative therapy regimes to us, as it indicates trust. It helps to have a consistent approach for these situations that acknowledges this trust and avoids embarrassment for all involved. If it appears to be a harmless placebo, why not ask: “does it work?” A surprising majority of patients reply: “I don’t know” in my experience, and reconsider their regimen.

The worst outcome is a patient abandoning effective conventional treatment of a life-threatening illness. Paternalism aside, we are duty-bound to attempt to avert this situation. We can only have a clear conscience when we have allowed a patient to voice their ideas, however flawed, before sensitively introducing an evidence-based approach, trying not to alienate them. We are attempting to “make them better” in the broadest sense of the term. If we instead stand firm in the fact that we are clever and informed and they are stupid and ignorant, that we are right and they are wrong, that science is superior to subjectivity, then shame on us.

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