I was thinking today. Dangerous thing to do, I know, but that’s me: living on the edge.
Anyway…
I was thinking about this article which describes how thoroughly Linus Pauling jumped the shark in his dive into not-medicine. That led me to think about not-medicine and its relationship to medicine, and my relationship to not-medicine, and to my patients who have fallen for the proponents of not-medicine.
To start with, why I am I writing "not-medicine" instead of "alternative medicine" – or more nastily, "woo" (as I always used to)? "Woo", because I have been somewhat swayed by the notion that a derisive approach (embodied by calling it all "woo" or similar) is aggressive and unhelpful. So I’ve (mostly, I think)) stopped that. "Alternative medicine" because that implies it’s a viable alternative, as though it’s simply a choice between two forms of medicine, when most clearly it is not. A number of wags (Dara O’Briain and Tim Minchin come to mind, though other non-comedians have also said similar, and I have no idea who was first) have said things along the lines of (I’ll quote the relevant bit of Tim Minchin’s beat poem "Storm")
By definition, I begin
Alternative Medicine, I continue
Has either not been proved to work,
Or been proved not to work.
You know what they call alternative medicine
That’s been proved to work?…… Medicine.
And that really is true. We (doctors) want it all, in a way. If something really does help, and doesn’t cause unacceptable harm, we want to use it. We want to help our patients get better with it. We – honestly – don’t hold to any ideologically-based notions on what sort of thing it must be.
But… we must be able to be sure that it really does help, and that it doesn’t cause unacceptable harm. We have to be as sure as we can be; not just have a good feeling about something because it seems pretty good. Or even if it seems really good. Example: S-Adenosyl methionine, or SAM-e is a purported treatment for depression, but one I wouldn’t use (currently) even were it available to me. Studies of parenteral SAM-e have shown rapid efficacy against treatment-resistant depression, and if I recall correctly, it appeared to be tolerated relatively well too. So why wouldn’t I use such a thing? Because I don’t have the data; not because I haven’t looked, but because the studies that have been done are of parenteral SAM-e, and the efficacy, safety, and tolerability of oral SAM-e have not been established. I’m not just splitting hairs here: it’s not sensible to simply assume we can extrapolate from one to the other.
Ok, if it were me at the other end, I’d probably be frustrated by my shrink’s reticence in such an instance, but the point is, I have to be that cautious and conservative. I can’t just be swayed by what sounds good. I can’t be swayed by anecdotes, or by a few case reports (which really, are just anecdotes that’ve been scrubbed up enough to be published); I have to be able to be confident that I know roughly that the thing I’m recommending is sufficiently likely to afford benefit, and sufficiently unlikely to cause serious harm, that it is worth my recommendation.
Otherwise people might just as well stop seeing doctors, and order what they want from online pharmacies.
I must admit the flipside: just because I don’t, or won’t recommend or endorse something, doesn’t mean it is ineffective or dangerous; it simply means that I lack, and can’t find, the data to let me be sure of the potential risks and benefits.
