Why all the fear and loathing among physicians around alternative medicine? For those who’ve never been to this site, HCRenewal is ordinarily a terrific blog that features smart postings by physicians and health IT professionals. But there is one issue that makes them see red -- alternative medicine.
In a recent post, “New CMS Chief Donald Berwick: a Trojan Horse for Quackery?” Kimball Atwood frets that Don Berwick, who was recently appointed to head the Centers for Medicare and Medicaid Services, is such a strong supporter of patient choice that he may be too comfortable with patients' preferences for complementary and alternative medicine. In Dr. Atwood’s view, a February 2009 appearance by Dr. Berwick at Bravewell Collaborative-sponsored Summit on Integrative Medicine and the Health of the Public, where he shared the podium with Dr. Mehmet Oz, Dr. Dean Ornish, Senator Tom Harkin, was evidence that he was either naïve or had “gone over to the dark side."
The “dark side?” Don Berwick?? C’mon.
Berwick can hardly be suspected of harboring a softness for homeopathy. And at $40 billion a year in revenue, the alternative medicine industry hardly constitutes a major threat to the hegemony of allopathic medicine. More to the point, while alternative medicine is undoubtedly mostly quackery, so is a good bit of allopathic medicine, at least if you define quackery as medical practices that are not based on valid evidence.
Just look at the recent history of widespread medical practices that turned out not to work -- or worse, not only did they not work, they also harmed patients. High dose chemo for breast cancer comes to mind. And don’t forget lidocaine for cardiac arrythmia and cardiac stents to prevent heart attacks. Bee pollen and homeopathy may turn out to be pseudoscientific bunk, but at least for the most part they’re not as dangerous as some widespread medical therapies that aren't based in sound science and valid evidence.
Atwood argues that physicians have a duty to prevent their patients from making what he sees as foolish choices when they turn to alternative medicine, but there's a larger ethical issue at stake here. If it's an ethical transgression to prescribe a placebo or allow a patient to take a silly, useless, but essentially harmless alternative nostrum, what about failing to make sure a patient understands the poor evidence behind, say, spinal fusion surgery for uncomplicated low back pain, or the potentially devastating tradeoffs involved in taking a PSA test? Even more worrisome, what about the common practice of giving PSA tests without the patient’s knowledge, much less informed consent?
When Don Berwick talks about patient-centered care, and making sure the patient's preferences are taken into account, far from advocating alternative therapies, he is arguing in favor of fully informing patients and helping them decide. Especially when the patient is faced with an invasive elective treatment. There’s a large body of literature showing that all too often, patients are not well informed about the tradeoffs involved in elective decisions. Bottom line: Too many patients undergo serious treatments, and face real risks, without fully understanding what they are getting into.
Take the paper published this week in the Annals of Internal Medicine. Nearly three-quarters of cardiac patients who underwent angioplasty or had a stent put in believed, incorrectly, that without it they were more likely to suffer a heart attack and die. Wrong. Elective stents and angioplasty are for treating symptoms of angina. They don’t prevent heart attacks or death. (Maybe the really astonishing part of this study was that 37 percent of the cardiologists were as poorly informed as their patients -- they thought stents and angioplasty were preventive, too.)
When it comes to the ethical duties of physicians, do we really need to fret about low risk alternative treatments? It’s probably more important that doctors and patients share decisions, and that we make sure that patients have the tools they need to make their own choices about any treatment, whether it's alternative or mainstream medicine.