MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

This is a question most clinicians must have asked themselves. The interest of patients in this area is enormous, and many do seek advice from their doctor, nurse, pharmacist, midwife etc. In a typical scenario, a patient might plug up her courage (yes, for many it does take courage) and ask:

What about therapy xy for my condition? My friend suffers from the same problem, and she says the treatment works very well.

The way I see it, there are essentially 4 options for formulating a reply:

1.       Uncompromisingly negative

2.       Evidence-based

3.       Open-minded

4.       Uncritically promotional

Let me explain and address these 4 options in turn.

1.       Uncompromisingly negative

I know that it can be tempting to be wholly dismissive and simply state that all alternative medicine is rubbish; if it were any good, it would have been adopted by conventional medicine. Therefore, alternative medicine is never an alternative; it is by definition implausible, ineffective and often dangerous.

Even if all of this were true, the uncompromisingly negative approach is not helpful, in my experience. Patients need and deserve some empathy and understanding of their position. If we brusque them, they feel insulted and go elsewhere. Not only would we then lose a patient, but we would run a high risk of exposing her to a practitioner who promotes quackery. The disservice seems obvious.

2.       Evidence-based

Clinicians might consider their patient’s question and reply to it by explaining what the current best available evidence tells us about the therapy in question. This can be done with empathy and compassion. For instance (if that is true), the clinician can explain that the treatment in question lacks a scientific basis, that it has nevertheless been tested in clinical trials which sadly do not show that it works. Crucially, the clinician should subsequently explain what effective treatments do exist and discuss a viable treatment plan with the patient.

The problem with this approach is that many, if not most conventional clinicians are fairly clueless about the evidence as it relates to the plethora of alternative therapies. Therefore, an honest discussion around the current best evidence is often difficult or impossible.

3.       Open-minded

This is the approach many clinicians today use as a default position. They basically tell their patient that there is not a lot of evidence for the treatment in question. However, it seems harmless, and therefore – if the patient is really keen on going down this route – why not? This type of response is, I fear, given regardless of the therapy in question and it largely ignores the evidence – some alternative treatments do work, some don’t, some are fairly safe, some aren’t.

Condoning alternative medicine in this way gives the impression of being ‘open-minded’ and ‘patient-centred’. It has the considerable advantage that it does not require any hard work, such as informing oneself about the current best evidence. It’s disadvantage is that it neither correct nor ethical.

4.       Uncritically promotional

Many clinicians go even one decisive step further. Under the banner of ‘integrative medicine’, they openly recommend using ‘the best of both worlds’ as being ‘holistic’, ’empathetic’, ‘patient-centred’, etc. By this, they usually mean employing as many unproven or disproven treatments as alternative medicine has to offer.

This approach gives the impression of being ‘modern’ and in tune with the wishes of patients. Its disadvantages are, however, obvious. Introducing bogus treatments into clinical routine can only render it less effective, more expensive, and less safe. Integrative medicine is therefore not in the best interest of patients and arguably unethical.

Conclusion

So, how should we advise patients on alternative medicine? I know what I would say and probably most of my readers can guess. But I do not want to prejudge the issue; I prefer to hear your views, please.

12 Responses to How should we advise patients on alternative medicine?

  • I find that people under the influence of the alternative medicine mindset are generally resistant to being told “facts”. Many exhibit Dunning-Kruger certainty. They will not do well with being lectured to. They may respond better to being questioned. This technique is suggested by Peter Boghossian’s “Street Epistemology”. I have not had a chance to try this out but asking questions may be more effective in getting a person to think than making assertions. One can also avoid endorsing nonsense. This is just a thought for how to deal with confronting “burning stupid”.

  • “Consult an ‘alternative practitioner’ if you wish – I understand some patients find they feel better after consulting with an caring empathic practitioner, but I know of no plausible evidence that the pillules, pricking, pummeling or preternatural powers offered will have any effect whatsoever on your condition, and I cannot therefore offer any recommendation to spend time or money on them.

    Most doctors and medical scientists recognise that care and compassion brings solace, but ‘alternative medicine’ therapies have not been shown to have any benefit beyond acting as placebos.
    If you are particularly distressed and need support, I will try and arrange counseling.

    Oh, and get a copy of Real Secrets of Alternative Medicine from Amazon! And if you want to understand the ethics of modern medicine and alternatives, Edzard Ernst’s More Harm than Good?

  • Since you are referenced in this article professor Ernst, perhaps you, or some of your esteemed colleagues could elaborate further on the concept of NIC (negative informed consent) .

    From the article: “Negatively informed consent (NIC) provides a solution to this conundrum [3,4]. The principle of this approach is that patients make an informed decision to forego some of the details of their treatments, including the possibility that their drug is a placebo. This opens up the possibility of homeopathic prescribing by doctors without damaging trust within the doctor-patient relationship. Whilst this will not be an option favoured by everybody, it should be available to those who opt-in.” http://www.bmj.com/content/351/bmj.h3735/rr-84

    • I think it is self-explanatory. Yet it is not my concept, nor one I suggested. Perhaps ref 3 and 4 lead you further, if needed.

    • No patient should trust a doctor who fails to tell them what the implications for the proposed treatments are – and that includes the understanding that most doctors and medical scientists (and the Chief Medical Officer) do not recommend homeopathy, and regard any beneficial effects of homeopathic remedies as due to placebo responses.

      Patients can only give properly informed consent with that understanding.

      Tough, but that is what ethical professional intellectual integrity demands. What’s not to like?

  • Very we’ll formulated.
    As Sam Harris has suggested; it is the ‘well-intentioned’ moderates who allow the fanatics to persist i.e. ANY faith proposition, promulgation and acceptance opens the door to fanaticism and allows nonsensical propositions to flourish.
    The best tact is #1….unless you need the business….then swallow your ethics, sell the shit yourself and avoid the middleman.

  • Option 2 should be the correct one, but not only are many clinicians clueless about evidence, most patients don’t even know what evidence is. This is not to disparage them. The education system fails to teach critical thinking, and in particular students who choose not to learn science have little exposure to it. What we need is mandatory inclusion of critical thinking in `general studies’ courses.

    How do we deal with the status quo? It would help if all the professional regulators did more than pay lip service to the principle of evidence based clinical practice. Even the GMC largely waits for someone to die before taking action against a doctor who prescribes quackery. It surely is far worse to risk real harm by prescribing useless treatments deliberately, than it is to make genuine mistakes when under intolerable pressure (thinking of Dr Hadiza Bawa-Garba).

    So again clinicians should choose option 2, but they will have to allow time to explain what makes good evidence, before they even get to talking about the evidence for a particular treatment.

  • Conversely, if you’re doctor-shopping and looking for someone who is honest and ethical – you could ask about a therapy, technique, whatever, that you know something about. If the conventional clinician is ‘clueless’ (as you say many, if not most are) and comes back with anything other than “I don’t know enough about it”…keep shopping.

    It’s a surprisingly easy and effective way to see how honest and ethical the practitioner is.

    • Could the doctor’s behavior in the scenario you described above be considered “plausible deniability” ?

      That doesn’t address whether the practitioner was intentionally ignorant, or, really simply unaware (naive).

    • This is not an effective way to see if a practitioner is honest or not, it is an effective way to introduce a shopping attitude in healthcare, based on bogus marketing claims of various treatments, that can be very easily found all over the place (e.g. online), an overall result that is not in the best interest of the patient.

      Not knowing the intricate details of a bogus treatment is not a valid reason to circumvene a doctor’s own firm obligation to protect the best interests of a patient. It is relatively easy and not very time-consuming for a doctor to find out guidelines for a condition or robust assessment of efficacy for a treatment. A doctor can always provide the most relevant science-based guidelines with respect to a treatment, all it takes is to look it up on a reliable source, usually some officially issued guidelines.

  • It is not hard to supply evidence-based healthcare advice anymore. I believe we should not confuse the complexity and multitude of various different alternative medicine modalities with the complexity involved in providing a substantially reliable source of overall information. The first is huge, whereas the second is very well manageable. All the hard work that has been put into research and clinical studies, culminating in systematic reviews and clinical guidelines, should be made available along with proper training on how to access and interpret them. Doctors of the last few decades have access to information systems that facilitate the dissemination of results to an unprecedented level. It should not be a problem anymore that clinicians might be clueless with respect to treatments. It is very easy to integrate the best available evidence and supply robust overall advice with the help of a proper information system.

    I am sad to say that alternative medicine is already up to date with respect to the available technology, to facilitate making money. I cannot say I have been very successful at finding something equally effective to facilitate making proper healthcare advice, though I hope certain projects of the sort are already on their way, or up-and-running and have simply evaded my attention.

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