where I puzzle out some thoughts on alternative medicine **
Before medical school, I was a dramatherapist. Healing with the arts. I never believed that art cured anything, not diabetes, not ADHD, not even depression or anxiety. What I liked about it was that it's pretty. That people I worked with had a bit of time when they actually enjoyed themselves, and that it gave folks some tools to use, and some skills that they could come back to in their lives.
What sucked was parents who had been on waiting lists for years to have their kid assessed for autism, or who had been diagnosed with something or other, and who would come to me all hopeful when they either couldn't get into see a doctor or psychologist, or when the treatments offered were unpalatable or ineffective. Hoping that I had some special magic that the doctors had overlooked.
I hate to burst anyone's bubble, but improv games have no special powers.
I do think that "because it's pretty" is a good reason. I think that art is worthwhile. Folks will disagree on what's pretty, but I'm glad that there are people out there who do art. (I'm also very glad that it is no longer me).
I told myself that when I got to be a real doctor, I'd be patient and empathetic with people who wanted gentle care and alternative medicines. I was sure that I would be the hippy doctor who knew both the herbal options and the drugs.
I have 2 vegetarian kids, both of them were supposed to have been caught by midwives.
But something happened at medical school. I learned things. Like evidence. And I now agree with Joe Schwartz's claim that "If it works, it's not alternative; and if it doesn't work, it's not medicine"
And I now have a thin tolerance for woo.
Not that I am uncritical of medicine. It's screwed up in several ways:
* Diseases/conditions that rich white guys suffer from are researched and funded to a disproportionate degree. If you're a middle-aged man with crushing chest pain (or baldness or erectile dysfunction), it is far more likely that you will get excellent care than a girl with depression, or an auto-immune disease. Let alone a kid with malaria someplace else.
* Much of medicine is not actually evidence-based. There are lots of things that are difficult or unethical to study. We rely on evidence from experiments during WWII, and lots of decisions are made based on tradition that has *never* been researched. If medicine were only that which could boast good evidence, we wouldn't do much at all.
* Evidence is routinely ignored. Airline pilots have strict work hour maximums. Driving while tired has apparently been demonstrated to be like driving drunk. And yet, surgeons. WTF? Also: white coats. Grody. But we are still wearing them.
* Doctors aren't always very nice to patients. (see above on work hour maximums)
But most of those criticisms can also be levelled at alternative medicine. There is no research, it's almost entirely based on tradition, and evidence is routinely ignored. I suppose there might be nicer altie practitioners, But some doctors are nice, and if I had more time, I'd be nicer too.
One of the ways a routine disregard for evidence is irritating me this week is in the area of pregnancy and childbirth.
Like people who will eat soft cheese or drink some alcohol while pregnant, but won't get a flu shot.
This baffles me.
Soft cheese caused 6 premature deliveries and 1 stillbirth due to Listeria infections in Quebec during an outbreak last year. Pregnancy causes changes to the immune system that make listeriosis 20 times more common than in healthy adults. -- I.e. it's an infection that is almost entirely seen in pregnant people, neonates, immune compromised folks and the elderly. A stillbirth is a horrible event. Even if it's rare, it's probably worth skipping or heating the brie.
Alcohol is known to cause birth defects, and no safe consumption level can be ethically determined. Natural or no, alcohol causes birth defects.
Flu shots during the third trimester have never been correlated with anything negative for either pregnant people or fetuses. They have been shown to decrease complications from the flu in young infants.
I get that "maybe it'll make it more likely I'll get cancer or my baby will be autistic" are scary thoughts. Cancer and autism are terrifying prospects for many people. But influenza and listeria are somewhat preventable and sometimes fatal.
Death didn't used to be something that happened to old people from cancer and heart disease. Back when everything was natural, organic, traditional, spiritual or whatever, it was young women and children who did lots of the dying. Of infection. Of things that are treatable and preventable now. Dying of cancer and heart disease at a ripe old age (or even at 50) is a fantastic achievement. Way better than dying of an infection from some soil bug at a week old.
And the anti-vaccination thing. How is risking that your kid is going to die of complications of chicken pox, measles, whooping cough or even HPV (it happens, even in Canada) somehow less scary than autism, or vague "bad things"? Even if the crappy study linking autism to MMR vaccination had been good and not faked, autism just makes you weird. Tetanus will make you dead.
So what's the problem? Why do people understand that some things are too risky during pregnancy/birth, but that others are risks worth taking? Why do so many people take the bigger risks? I'm genuinely curious about the thoughts, fears, desires behind the thinking that things are good if they are "natural". Where is the disconnect between evidence and patient decision-making? How can information be communicated in a way that actually impacts choices? How can that be done without having to send everyone to medical school before they become parents? (If I'm any indicator, it just makes for neurotic parents anyway)
Coming back to the dramatherapy, I suspect it may be about stories. The emotional impact of stories about people we feel like we know influences us in ways that data isn't going to. Doctors don't hear the amazing and empowering stories about altie treatments/procedures going well. But neither does the public hear about how horribly wrong things can go. I'm open to suggestions about how things can be better communicated. With the hope that informed choice can be more often both and not neither.
** I don't have all the answers, obviously. But I can use google to check my stats if you insist. I may be very very wrong. Feel free to do my research for me if you're into that sort of thing.
What sucked was parents who had been on waiting lists for years to have their kid assessed for autism, or who had been diagnosed with something or other, and who would come to me all hopeful when they either couldn't get into see a doctor or psychologist, or when the treatments offered were unpalatable or ineffective. Hoping that I had some special magic that the doctors had overlooked.
I hate to burst anyone's bubble, but improv games have no special powers.
I do think that "because it's pretty" is a good reason. I think that art is worthwhile. Folks will disagree on what's pretty, but I'm glad that there are people out there who do art. (I'm also very glad that it is no longer me).
I told myself that when I got to be a real doctor, I'd be patient and empathetic with people who wanted gentle care and alternative medicines. I was sure that I would be the hippy doctor who knew both the herbal options and the drugs.
I have 2 vegetarian kids, both of them were supposed to have been caught by midwives.
But something happened at medical school. I learned things. Like evidence. And I now agree with Joe Schwartz's claim that "If it works, it's not alternative; and if it doesn't work, it's not medicine"
And I now have a thin tolerance for woo.
Not that I am uncritical of medicine. It's screwed up in several ways:
* Diseases/conditions that rich white guys suffer from are researched and funded to a disproportionate degree. If you're a middle-aged man with crushing chest pain (or baldness or erectile dysfunction), it is far more likely that you will get excellent care than a girl with depression, or an auto-immune disease. Let alone a kid with malaria someplace else.
* Much of medicine is not actually evidence-based. There are lots of things that are difficult or unethical to study. We rely on evidence from experiments during WWII, and lots of decisions are made based on tradition that has *never* been researched. If medicine were only that which could boast good evidence, we wouldn't do much at all.
* Evidence is routinely ignored. Airline pilots have strict work hour maximums. Driving while tired has apparently been demonstrated to be like driving drunk. And yet, surgeons. WTF? Also: white coats. Grody. But we are still wearing them.
* Doctors aren't always very nice to patients. (see above on work hour maximums)
But most of those criticisms can also be levelled at alternative medicine. There is no research, it's almost entirely based on tradition, and evidence is routinely ignored. I suppose there might be nicer altie practitioners, But some doctors are nice, and if I had more time, I'd be nicer too.
One of the ways a routine disregard for evidence is irritating me this week is in the area of pregnancy and childbirth.
Like people who will eat soft cheese or drink some alcohol while pregnant, but won't get a flu shot.
This baffles me.
Soft cheese caused 6 premature deliveries and 1 stillbirth due to Listeria infections in Quebec during an outbreak last year. Pregnancy causes changes to the immune system that make listeriosis 20 times more common than in healthy adults. -- I.e. it's an infection that is almost entirely seen in pregnant people, neonates, immune compromised folks and the elderly. A stillbirth is a horrible event. Even if it's rare, it's probably worth skipping or heating the brie.
Alcohol is known to cause birth defects, and no safe consumption level can be ethically determined. Natural or no, alcohol causes birth defects.
Flu shots during the third trimester have never been correlated with anything negative for either pregnant people or fetuses. They have been shown to decrease complications from the flu in young infants.
I get that "maybe it'll make it more likely I'll get cancer or my baby will be autistic" are scary thoughts. Cancer and autism are terrifying prospects for many people. But influenza and listeria are somewhat preventable and sometimes fatal.
Death didn't used to be something that happened to old people from cancer and heart disease. Back when everything was natural, organic, traditional, spiritual or whatever, it was young women and children who did lots of the dying. Of infection. Of things that are treatable and preventable now. Dying of cancer and heart disease at a ripe old age (or even at 50) is a fantastic achievement. Way better than dying of an infection from some soil bug at a week old.
And the anti-vaccination thing. How is risking that your kid is going to die of complications of chicken pox, measles, whooping cough or even HPV (it happens, even in Canada) somehow less scary than autism, or vague "bad things"? Even if the crappy study linking autism to MMR vaccination had been good and not faked, autism just makes you weird. Tetanus will make you dead.
So what's the problem? Why do people understand that some things are too risky during pregnancy/birth, but that others are risks worth taking? Why do so many people take the bigger risks? I'm genuinely curious about the thoughts, fears, desires behind the thinking that things are good if they are "natural". Where is the disconnect between evidence and patient decision-making? How can information be communicated in a way that actually impacts choices? How can that be done without having to send everyone to medical school before they become parents? (If I'm any indicator, it just makes for neurotic parents anyway)
Coming back to the dramatherapy, I suspect it may be about stories. The emotional impact of stories about people we feel like we know influences us in ways that data isn't going to. Doctors don't hear the amazing and empowering stories about altie treatments/procedures going well. But neither does the public hear about how horribly wrong things can go. I'm open to suggestions about how things can be better communicated. With the hope that informed choice can be more often both and not neither.
** I don't have all the answers, obviously. But I can use google to check my stats if you insist. I may be very very wrong. Feel free to do my research for me if you're into that sort of thing.
Labels: medicine
posted by lothyn at 29.7.09
4 Comments:
I'm sorry that you were ruined by science. I was ruined by science and
now nobody likes me. My hippie friends don't like me because I won't
go along with iridology or homeopathy. If I had sciency friends, they
wouldn't like me because I believe in the placebo effect, Buddhism and
acupuncture. (Also, after foolishly attending a movie screening by
some 9/11 conspiracy theorists, I now believe that the WTC bombings
were a controlled demolition. That takes care of anybody else who
might associate with me.)
But to stop examining my bellybutton for a minute: I believe the
reason that we fall for the alternative therapies is that we don't
trust doctors or the medical establishment any more. We don't trust
Big Pharma. Thanks to research and articles funded/manipulated by
advocacy groups (SSRIs, anyone?), we don't even trust science any
more. I think that's way dangerous. I don't think we all have to be
shipped off to medical school, but some understanding of what science
is and how it works would be nice.
I agree that stories are important, and I think that is missing from
people's visits to their doctors. Patients don't want to be patients.
They want to be people. I think the book "The Careless Society:
Community and Its Counterfeits" by John McKnight is educational here.
He talks about the way that institutions (like hospitals) substitute
expertise for caring and relations, and as a result suck energy from
relationships. I think there is a lot of truth to that, and it is one
factor people turn to "alternatives" in a misguided attempt to take
their relationships back.
I will quibble with your assertion that because in the good old days
things were organic/natural/etc we should embrace high-technology
solutions. Yes, the good old days were dismal in some ways (and maybe
less dismal than we would like to admit in others -- people were smart
in the good old days too). But I do not see the reason you can't keep the
science and still bias the medicine towards more natural, DIY
treatments. (Well, maybe I do see the reason. But I don't trust Big Phama
either, even though it likely saved my life on several occasions.)
I think another factor in medical decisions has to do with risk:
http://www.schneier.com/blog/archives/2006/11/perceived_risk_2.html
His factor 1 is pertinent to the MMR nonsense. If my kid takes a
vaccine and goes autistic as a result, an intentional action caused a
bad thing to happen. If my kid does not take a vaccine and steps on a
nail and gets tetanus, then it was an accident.
Blah blah blah. Do I ever shut up?
- Paul
I think it's also about the stories our live tell us, you know? Like, if I grew up in a city and live and work in a city then I associate concrete and computers and offices and doctors with things that are stressful and difficult, but I probably go on vacation places that have beaches and trees and dirt and stuff and I don't think about the incredible materials research and technology that went into designing the stuff my tent is made of, I just think about being in "nature" where it's calm and not stressful.
I wouldn't be surprised if people who spend more time living with "nature" like farmers or rangers or whatever actually have more skepticism towards the idea that natural = better.
My dad is an autism doc (among other tricky diseases), and I have a LOT to say about this.
YES, I say, to most of your points. People fear the MMR mostly, I think, because it's been too long since anyone they know has come in contact with measles encephalitis (or even just measles). It has started to seem only like something you "have" to do because the government wants you to do it, not something you want to do so your kid doesn't get very sick or die. On the other hand, my vaccine-believing dad is furious at the ways the medical establishment stubbornly refuses to address the fears of those who are concerned about (but not dead-set against) vaccination in a thoughtful way. In particular, he thinks making Hep B vaccinations just after birth routine does a good deal more to convince fence-sitters that the system is out of control than its epidemiological value justifies. He also thinks refusing to split up the MMR has the end result of leaving fewer kids vaccinated (since some parents will forgo the combined vaccine but would be okay with spreading it out). Even if the combined MMR is safe, if the desired result is an immunized herd, it would be better to get more kids ultimately vaccinated, even if that means some will spend slightly longer unprotected against, say, rubella, which really only the girls need at pregnancy age anyway. (FWIW, I had all shots on the normal schedule.)
This all speaks to another problem that gets (fairly or not) associated with "Western" medicine -- the sense that doctors don't listen to their patients. Of course, good doctors do listen to their patients, but the reputation is: I have all the knowledge, you have none. It does happen. I know my father was thrilled when video cameras became common, because it became possible for patients' parents to show their doctors changes in their kids' behavior (after changes in diet or drug regime) that couldn't be easily seen in a clinical setting, where the kids were riled up by travel, etc. Before, it was too easy for a doctor to say the parents were imagining changes (that the doc didn't see, since the doc had very few and compromised opportunities to see it). So rather than considering how few data points they had, they'd tell the parents they had imagined the change. Pretty frustrating for the parents.
I did read notice of an interesting paper recently, suggesting that ineffective "alternative" treatments are more likely to make the rounds than effective treatments (of any kind) in part because they are ineffective, so people have more opportunities to see their peers using them (since the peers' health problems aren't gone "yet"). I'll try to find a link.
Yikes! Thank you for all these thoughtful comments.
Paul: It's always a pleasure to read what you write. You've given me a reason to give John McKnight a chance. Years ago, Marcie summarized another piece of his as "How to get more out of the people you oppress" and he's been kind of shunned around here since. But I like what he has to say here.
I also liked the piece on risks, (now that I've finally read it -- a month later) and I think that a lot of it applies to medicine, and to vaccines, and has got me thinking a lot about medical errors.
Jake, I agree that the everyday rituals of our lives shape what we know and how we think. I wish I knew any farmers. I wish most of my information about the world didn't come from people just like me. I'm so guilty of this.
Bionic Baby Mama: Thanks for dropping by! Yes yes yes about compassion and attentiveness being really key to trust and to healing. Smugness doesn't serve anyone. I'm not sure about the vaccine schedule though: I know that here, HepB vaccines are only given after birth to babies whose moms *have* chronic HepB infection, or who were born in an endemic area (and have a reasonable risk of being +ve). Otherwise it's given in grade 4 or grade 7. And I agree about Rubella, except that it's not to protect the vaccinated so much as the kids' mothers, who since they have little kids, may be pregnant again just when the older ones are catching assorted daycare lurgy (or german measles). I can't quite give up on thinking it's a good idea too. That said, approaching people who choose not to vaccinate themselves or their children with contempt, withdrawal of care, and the assumption that they are stupid and don't care about their kids, is just unhelpful to everyone. People make choices because they are doing the very best they can for their families.
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