Wednesday, December 06, 2006

When woo overlaps mainstream medicine can patients sort it out?

Emily in the latest Grand Rounds says this about my post on alternative medicine: Dr. R.W. Donnell, in Notes from Dr. RW, urges readers to beware of "woo" - scientifically unsupported alternative medicine - particularly when it's combined with allopathic offerings. Dr. RW, and others, I'd like your thoughts. Not to plug alternative medicine - ANY modalities used on patients should be tested if possible in randomized studies - but how can patients be sure that "standard" procedures and treatments are evidence-based? What about that full-body scan, or the drug that's been around so long no one's ever tested its safety in an RCT? Is that not, in effect, a form of woo, too?

How can patients be sure if a treatment is valid? In many cases they can’t----they have to trust us. That’s the whole point about fiduciary duty. Many of the woo providers of the world are easy to spot because they make no pretense about being based on Western science. What the patient sees is what the patient gets. The ethical problem, the real deception, comes from the mainstream’s more subtle promotion, hiding the woo behind its reputations and scientific credentials. It’s one thing when the shaman down the street tells patients they need a colon cleanse. It’s quite another thing, and far more concerning when Vanderbilt----Vanderbilt, mind you---promotes Qigong or UCSF promotes herbal tea to “boost the immune system.”

Emily correctly points out that conventional medical treatments aren’t always evidence based. She asks “Is that not, in effect, a form of woo, too?” The breach between evidence and practice to which she refers, let’s call it the quality chasm, while every bit as serious as woo, is not in fact woo in most cases. The quality chasm is not a result of outlandish or implausible claims, (e.g. that water has memory) and that’s what distinguishes it from woo. The quality chasm results from an extremely complex interplay of cognitive and system barriers to the consistent application of best evidence in practice. Mainstream medicine recognizes the need for widespread system change and promotion of evidence based medicine. Although there’s no simple fix to the quality chasm, many in mainstream medicine are trying, which is in ironic contrast to the fact that mainstream medicine also increasingly promotes woo. For the mainstream, especially academic medicine, to promote woo is to engage in unethical scientific pretense and active deception of patients. It seems to me that the solution to woo in the mainstream is much simpler than the quality chasm: Mainstream medicine just needs to say NO.


Anonymous said...

From the perspective of a science-literate patient, I'm afraid there is much woo perceptible in conventional medicine as well as attempts to treat the wallet as opposed to the patient. It ain't just limited to alternative providers (woo-artists).

Medicine men (and women) are so defensive of their arcane knowledge (and, to be fair, time-limited) that we patients are often asked to accept judgements that seem just as outre as the woo-ers'; if I weren't able dig into the science I'd have no way to know if I were being misled or not.

We all know that for centuries medicine was indistinguishable from what we now think of as woo. All a physician had to rely on was an authoritative manner and placebo effect; the science just wasn't there.

We are now reaping that whirlwind; anyone who adopts the authoritative manner and layman-plausible "explanations" is perceived as the same as any other doctor/shaman.

She's right... there's much woo in modern medicine.

R. W. Donnell said...

Thank you for your comment. If you think I'm defending mainstream medicine you've misunderstood me. Quite the opposite. Mainstream medicine is increasingly pushing woo. That was my whole point.

Anonymous said...

... and you've missed mine. Mainstream was almost entirely woo until the middle of the last century and is only slowly turning to science. Huge areas of unsupported "but we've always said x" remain.

emmy said...

Thank you. I agree with you that I should be able to go to my very well paid specialist and expect hard core science, not middle-eastern voo-doo. However most cancer experts including the American Cancer Society tend to push the woo. It was almost insulting. Kind of like them saying "We are limited in what we can do to help you so why not try anything that comes around the bend." I hate to see that approach repeated in other areas of medicine.

Notes from Dr. RW said...

You seem to be referring to the evidence gap----the breach between evidence and practice. Is that right? I want to be sure I get your point. If that's your point I agree totally.

And I don't want to minimize the importance of the evidence-practice gap, but it's a separate issue from what I was calling "woo." "Woo" as the term is generally used, and as I'm using it here, is the promotion of outlandish or implausible claims (nebulous energy fields, mind over matter aka non-local healing, the memory of water, meridians, etc).

Both woo and the evidence gap are problems, but are conceptually and operationally different enough to merit clear distinction.

Karin said...

Posted this in the older thread before I found this one...

I think that mainstream hospitals are offering alternative medicine treatments for many reasons. First of all, they realize that people are turning away from allopathic medicine because they perceive it as cold, unfeeling, and focused on profits. Allopathic medicine can physically treat the disease but all too often leaves the patient feeling sicker than they were before the treatment, stressed out, and angry at an uncaring medical system. Alternative medicine, whether it works or not (I personally believe that some is great and some is quackery) is focused on treating the whole person, mind, body, and soul. We have plenty of scientific evidence that stress is bad for the immune system and overall wellness, and much of alternative medicine is geared towards lowering stress and helping the body heal itself. To me, combining them is a GREAT idea, because it balances the physical effectiveness of traditional medicine with the mood and immune-boosting qualities of alternatives. In the case of herbal treatments, it also allows doctors to keep better track of what supplements a patient is taking, and even collect data on outcomes to determine whether, for example, women with breast cancer who take Herb Z along with chemo live longer than women who just do chemo. Complementary medical programs provide the opportunity to do the very scientific research you say you want.

Karin said...

Also, I believe complementary programs reduce the number of patients who forego scientifically-tested treatments because they are blind believers in alternative medicine. I am a mental health professional who worked with cancer patients for the past year and I've seen this only twice, but both times I was horrified. In one case a 30 year old woman with a small breast cancer decided not to have surgery and to do alternative treatments; you can guess what happened. The other case, I only met the husband, but his wife has colon cancer and is refusing chemotherapy even though the cancer is progressing significantly, in favor of crackpot alternatives. If that's not horrible enough, her moronic choice is going to leave her adopted-from-bad-circumstances-in-foreign
country child without a mother. Her husband is devastated and furious, but she will not listen to him.

I don't think these cases happen often, but if putting a bit of what you call "woo" into traditional medicine can save a few lives, that's yet another reason to support it IMO.