One of the most difficult things in so-called alternative medicine (SCAM) can be having a productive discussion with patients about the subject, particularly if they are deeply pro-SCAM. The task can get more tricky, if a patient is suffering from a serious, potentially life-threatening condition. Arguably, the discussion would become even more difficult, if the SCAM in question is relatively harmless but supported only by scarce and flimsy evidence.
An example might be the case of a cancer patient who is fond of mindfulness cognitive therapy (MBCT), a class-based program designed to prevent relapse or recurrence of major depression. To contemplate such a situation, let’s consider the following hypothetical exchange between a patient (P) and her oncologist (O).
P: I often feel quite low, do you think I need some treatment for depression?
O: That depends on whether you are truly depressed or just a bit under the weather.
P: No, I am not clinically depressed; it’s just that I am worried and sometimes see everything in black.
O: I understand, that’s not an unusual thing in your situation.
P: Someone told me about MBCT, and I wonder what you think about it.
O: Yes, I happen to know about this approach, but I’m not sure it would help you.
P: Are you sure? A few years ago, I had some MBCT; it seemed to work and, at least, it cannot do any harm.
O: Yes, that’s true; MBCT is quite safe.
P: So, why are you against it?
O: I am not against it; I just doubt that it is the best treatment for you.
O: Because there is little evidence for it and even less for someone like you.
P: But I have seen some studies that seem to show it works.
O: I know, there have been trials but they are not very reliable.
P: But the therapy has not been shown to be ineffective, has it?
O: No, but the treatment is not really for your condition.
P: So, you admit that there is some positive evidence but you are still against it because of some technicalities with the science?
O: No, I am telling you that this treatment is not supported by good evidence.
P: And therefore you want me to continue to suffer from low mood? I don’t call that very compassionate!
O: I fully understand your situation, but we ought to find the best treatment for you, not just one that you happen to be fond of.
P: I don’t understand why you are against giving MBCT a try; it’s safe, as you say, and there is some evidence for it. And I have already had a good experience with it. Is that not enough?
O: My role as your doctor is to provide you with advice about which treatments are best in your particular situation. There are options that are much better than MBCT.
P: But if I want to try it?
O: If you want to try MBCT, I cannot prevent you from doing so. I am only trying to tell you about the evidence.
P: Fine, in this case, I will give it a go.
Clearly this discussion did not go all that well. It was meant to highlight the tension between the aspirations of a patient and the hope of a responsible clinician to inform his patient about the best available evidence. Often the evidence is not in favour of SCAM. Thus there is a gap that can be difficult to breach. (Instead of using MBCT, I could, of course, have used dozens of other SCAMs like homeopathy, chiropractic, Reiki, etc.)
The pro-SCAM patient thinks that, as she previously has had a good experience with SCAM, it must be fine; at the very minimum, it should be tried again, and she wants her doctor to agree. The responsible clinician thinks that he ought to recommend a therapy that is evidence-based. The patient feels that scientific evidence tells her nothing about her experience. The clinician insists that evidence matters. The patient finds the clinician lacks compassion. The clinician feels that the most compassionate and ethical strategy is to recommend the most effective therapy.
As the discussion goes on, the gap is not closing but seems to be widening.
What can be done about it?
I wish I knew the answer!