EDITORIAL * EDITORIAL
Alternatives to medicine W. Grant Thompson, MD, FRCPC, FACP
In this issue (starting on page 121) Verhoef, Sutherland and Brkich show that many patients attending a gastroenterology clinic sought alternative medical care for their gastrointestinal complaints and for other disorders. This phenomenon is by no means confined to gastroenterology patients and raises several important issues for all physicians. Why do patients seek alternative care? Although notions of neuroticism, ignorance and gullibility come to mind, scepticism and dissatisfaction with conventional medical care are more realistic explanations. One of the great ironies of modem medicine is that physicians are victims of their successes. As doctors develop more dramatic and effective treatments for some disorders and permit them to be exaggerated by the press, the public's expectations become inflated. Surely pain and suffering are no longer acceptable! The report by Verhoef and her colleagues confirms the observation of Smart, Mayberry and Atkinson' that patients with functional gastrointestinal complaints are more likely than those with an organic problem to seek alternative care. Crohn's disease and functional bowel disease are chronic, remitting problems, but the former fits more comfortably into the popular illness paradigm. Crohn's disease is more physically disabling than an irritable gut. The disorder is there to see and explain, and few doubt that it requires the care of a physician. It is in the sphere of functional illness that medical ignorance and failure are most unsympathetically viewed. Headaches, low back pain, fibrositis and chronic abdominal pain exist and torment, yet medical science seems powerless to explain or reliably cure. To make matters worse, many sufferers have heard of an acquaintance in whom a brain tumour, arthritis or ulcer was missed. Surely such a fate awaits them! What are we to make of the tendency of some Dr. Thompson is a professor of medicine and chief of the Division
patients to turn away from conventional medicine to alternative care? One attitude is to look the other way. Unconventional practitioners may do as well as doctors for these patients and free physicians to deal with more serious disease. After all, most of the nostrums proposed by alternative practitioners are harmless. Like many medical treatments they merely capitalize on the placebo response. Unfortunately the issue is not so simple. First, functional illnesses are very common. They constitute 30% to 60% of referrals to gastroenterologists.2 Other specialties are similarly challenged by noncardiac chest pain, fibrositis, headache, fear of cancer, abdominal pain, sexual dysfunction and so on. Ceding responsibility for these problems to practitioners of unscientific medicine would have undesirable consequences. Only physicians can make diagnoses. Some patients with functional disease may need to have more serious illness excluded, and none are immune to its development. Only physicians are trained to evaluate the safety and efficacy of treatment. Only in the discipline of medicine is scientific inquiry conducted into the nature of illnesses, thereby providing a basis for valid understanding and treatment. Second, alternative medicine is not a single approach. One may feel that taking a high dose of vitamin C or removing preservatives from the diet is a harmless exercise, but some megavitamin therapies and diets are dangerous. How should one view herbal cures for cancer that lure patients and their families south of the border in a last, desperate, financially draining grasp at life? To be sure, there are potentially harmful aspects of treatment in conventional medicine, but only physicians can critically look at risk versus benefit. Third, who pays? A corollary of legitimizing alternative care is the right of all citizens to access. How can one justify medicare payments to those
ofGastroenterologv, Ottawa Civic Ilospital, LUniversity, of Ottawa.
Reprint requests to: Dr. W. Grant Thompson, Division of Gastroenterologv,. Ottawa Civic Hospital, 1053 Carling A ve., Ottawa, Ont. Kl Y 4E9 CAN MED ASSOC J 1 990; 142 (2)
105
who claim no scientific basis for their treatment and critically review neither their diagnosis of the symptoms nor the efficacy of their care? The final and most important implication of the alternative care phenomenon is that all patients' complaints must be taken seriously. Whether the patient needs only the reassurance that no cancer exists or the management of a complex psychosocial condition, physicians are best suited to assume responsibility for overall care. Melzak and Wall,3 Engel4 and others have shown that pain perception is far more complex than the receipt in the brain of a message from a damaged part. Such diverse psychosocial factors as anxiety, depression, threatening life events, fear of cancer, counterstimuli, secondary gain and the need for attention greatly modify when and to what degree a person appreciates pain. Thus, we must pay attention to the psychosocial conflicts that accompany the symptoms - and this applies to both functional and organic disease. We must become more critical of medical technology and therapeutics. New machines and treatments are often overrated as advances in medicine. Most patients have conditions for which no technology is of benefit. This reality needs to be made plain to the public and to the media. Drug costs soar, and the population is said to be overmedicated. We need to dispel the belief that there is a quick fix for every human complaint and ensure that our prescribing is in accord with proven benefit, minimal risk and common sense. Lowering public expectations of medicine may reduce disappointment at medical failure, for failure is inevitable at least once in everyone's life. The art of medicine remains central to the physician's role. Only we have the authority to explain, reassure and dispel or modify fear. Good communication, sympathy for our patients' suffering, whatever the cause, and consideration of their psychosocial predicaments will cause fewer patients to turn to alternatives. The obligation "to cure sometimes, to relieve often, to comfort always"5 cannot be delegated.
References 1. Smart HL, Mayberry JF, Atkinson M: Alternative medicine consultations and remedies in patients with irritable bowel syndrome. Gut 1986; 27: 826-828 2. Thompson WG: Irritable bowel syndrome: prevalence, prognosis and consequences [E]. Can Med Assoc J 1986; 134: 111-113 3. Melzack R, Wall PD: The Challenge of Pain, Penguin, Harmondsworth, Middlesex, England, 1982 4. Engel GL: Psychogenic pain and the pain-prone patient. Am J Med 1959; 26: 899-918 5. Strauss M: Familiar Medical Quotations, Little, Boston, 1968: 410
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CAN MED ASSOC J 1990; 142 (2)
14> The Physician Manager Institute 1990 PMI-l The Foundations of Management All chiefs of staff, department heads and program directors are encouraged to attend this program. Content for this Institute corresponds to needs that were voiced in a national survey of practising physician managers, and covers areas fundamental to the practice of management. PMI-ll Leadership Skills Development This Institute has been developed in response to requests from participants at the first offerings of the Institute. It delves more deeply into the crucial area of leadership, and presents skills and knowledge for managing individuals and groups. It is highly recommended that participants in this Institute first attend the PMI-I. PMI-Ill Conflict Management, Negotiation and Politics This Institute has been designed to address the concerns of physician managers as they are drawn into situations which demand skills in politics, conflict resolution, and negotiation. PMI-Ill will provide participants with a theoretical framework, useful techniques, and insights from experienced educators and practitioners. PMI-IV The Planning and Managing Change: The Physician Manager in a Shifting Environment New in 1990, this Institute focuses on change as it affects health care organizations. As the content of PMI-Ill and PMI-IV builds directly on material covered in PMI-l and PMI-11, participants are strongly encouraged to first attend those sessions. PMI-l February 18 - 21, Lake Louise, Alta. April 29 - May 2 (12:30), Niagara-on-the-Lake, Ont. July 15 - 18, St. Andrews, N.B. August 5 - 8, Whistler, B.C. September 23 - 26, Niagara-on-the-Lake, Ont. PMI-ll February 22 - 24, Lake Louise, Alta. May 2 (2:00) - May 4, Niagara-on-the-Lake, Ont. July 19 - 21, St. Andrews, N.B. August 9 - 11, Whistler, B.C. September 27 - 29, Niagara-on-the-Lake, Ont. PMI-lll February 25 - 27, Lake Louise, Alta. May 6 - 8, Niagara-on-the-Lake, Ont. July 22 - 24, St. Andrews, N.B. September 30 - October 3, Niagara-on-the-Lake, Ont. PMI-IV May 9 - 1 1, Niagara-on-the-Lake, Ont. August 12 - 15, Whistler, B.C.
Sponsored by the Canadian Medical Association and the Canadian College of Health Service Executives For further information, contact: Department of Educational Services Canadian Medical Association 1867 Alta Vista Drive Ottawa, Ontario KlG 3Y6 613-731-9331
Executive Development Canadian College of Health Service Executives Suite 201, 17 York Street Ottawa, Ontario Ki1N 5S7 613-235-721 8
Alternatives to medicine W. Grant Thompson, MD, FRCPC, FACP
In this issue (starting on page 121) Verhoef, Sutherland and Brkich show that many patients attending a gastroenterology clinic sought alternative medical care for their gastrointestinal complaints and for other disorders. This phenomenon is by no means confined to gastroenterology patients and raises several important issues for all physicians. Why do patients seek alternative care? Although notions of neuroticism, ignorance and gullibility come to mind, scepticism and dissatisfaction with conventional medical care are more realistic explanations. One of the great ironies of modem medicine is that physicians are victims of their successes. As doctors develop more dramatic and effective treatments for some disorders and permit them to be exaggerated by the press, the public's expectations become inflated. Surely pain and suffering are no longer acceptable! The report by Verhoef and her colleagues confirms the observation of Smart, Mayberry and Atkinson' that patients with functional gastrointestinal complaints are more likely than those with an organic problem to seek alternative care. Crohn's disease and functional bowel disease are chronic, remitting problems, but the former fits more comfortably into the popular illness paradigm. Crohn's disease is more physically disabling than an irritable gut. The disorder is there to see and explain, and few doubt that it requires the care of a physician. It is in the sphere of functional illness that medical ignorance and failure are most unsympathetically viewed. Headaches, low back pain, fibrositis and chronic abdominal pain exist and torment, yet medical science seems powerless to explain or reliably cure. To make matters worse, many sufferers have heard of an acquaintance in whom a brain tumour, arthritis or ulcer was missed. Surely such a fate awaits them! What are we to make of the tendency of some Dr. Thompson is a professor of medicine and chief of the Division
patients to turn away from conventional medicine to alternative care? One attitude is to look the other way. Unconventional practitioners may do as well as doctors for these patients and free physicians to deal with more serious disease. After all, most of the nostrums proposed by alternative practitioners are harmless. Like many medical treatments they merely capitalize on the placebo response. Unfortunately the issue is not so simple. First, functional illnesses are very common. They constitute 30% to 60% of referrals to gastroenterologists.2 Other specialties are similarly challenged by noncardiac chest pain, fibrositis, headache, fear of cancer, abdominal pain, sexual dysfunction and so on. Ceding responsibility for these problems to practitioners of unscientific medicine would have undesirable consequences. Only physicians can make diagnoses. Some patients with functional disease may need to have more serious illness excluded, and none are immune to its development. Only physicians are trained to evaluate the safety and efficacy of treatment. Only in the discipline of medicine is scientific inquiry conducted into the nature of illnesses, thereby providing a basis for valid understanding and treatment. Second, alternative medicine is not a single approach. One may feel that taking a high dose of vitamin C or removing preservatives from the diet is a harmless exercise, but some megavitamin therapies and diets are dangerous. How should one view herbal cures for cancer that lure patients and their families south of the border in a last, desperate, financially draining grasp at life? To be sure, there are potentially harmful aspects of treatment in conventional medicine, but only physicians can critically look at risk versus benefit. Third, who pays? A corollary of legitimizing alternative care is the right of all citizens to access. How can one justify medicare payments to those
ofGastroenterologv, Ottawa Civic Ilospital, LUniversity, of Ottawa.
Reprint requests to: Dr. W. Grant Thompson, Division of Gastroenterologv,. Ottawa Civic Hospital, 1053 Carling A ve., Ottawa, Ont. Kl Y 4E9 CAN MED ASSOC J 1 990; 142 (2)
105
who claim no scientific basis for their treatment and critically review neither their diagnosis of the symptoms nor the efficacy of their care? The final and most important implication of the alternative care phenomenon is that all patients' complaints must be taken seriously. Whether the patient needs only the reassurance that no cancer exists or the management of a complex psychosocial condition, physicians are best suited to assume responsibility for overall care. Melzak and Wall,3 Engel4 and others have shown that pain perception is far more complex than the receipt in the brain of a message from a damaged part. Such diverse psychosocial factors as anxiety, depression, threatening life events, fear of cancer, counterstimuli, secondary gain and the need for attention greatly modify when and to what degree a person appreciates pain. Thus, we must pay attention to the psychosocial conflicts that accompany the symptoms - and this applies to both functional and organic disease. We must become more critical of medical technology and therapeutics. New machines and treatments are often overrated as advances in medicine. Most patients have conditions for which no technology is of benefit. This reality needs to be made plain to the public and to the media. Drug costs soar, and the population is said to be overmedicated. We need to dispel the belief that there is a quick fix for every human complaint and ensure that our prescribing is in accord with proven benefit, minimal risk and common sense. Lowering public expectations of medicine may reduce disappointment at medical failure, for failure is inevitable at least once in everyone's life. The art of medicine remains central to the physician's role. Only we have the authority to explain, reassure and dispel or modify fear. Good communication, sympathy for our patients' suffering, whatever the cause, and consideration of their psychosocial predicaments will cause fewer patients to turn to alternatives. The obligation "to cure sometimes, to relieve often, to comfort always"5 cannot be delegated.
References 1. Smart HL, Mayberry JF, Atkinson M: Alternative medicine consultations and remedies in patients with irritable bowel syndrome. Gut 1986; 27: 826-828 2. Thompson WG: Irritable bowel syndrome: prevalence, prognosis and consequences [E]. Can Med Assoc J 1986; 134: 111-113 3. Melzack R, Wall PD: The Challenge of Pain, Penguin, Harmondsworth, Middlesex, England, 1982 4. Engel GL: Psychogenic pain and the pain-prone patient. Am J Med 1959; 26: 899-918 5. Strauss M: Familiar Medical Quotations, Little, Boston, 1968: 410
106
CAN MED ASSOC J 1990; 142 (2)
14> The Physician Manager Institute 1990 PMI-l The Foundations of Management All chiefs of staff, department heads and program directors are encouraged to attend this program. Content for this Institute corresponds to needs that were voiced in a national survey of practising physician managers, and covers areas fundamental to the practice of management. PMI-ll Leadership Skills Development This Institute has been developed in response to requests from participants at the first offerings of the Institute. It delves more deeply into the crucial area of leadership, and presents skills and knowledge for managing individuals and groups. It is highly recommended that participants in this Institute first attend the PMI-I. PMI-Ill Conflict Management, Negotiation and Politics This Institute has been designed to address the concerns of physician managers as they are drawn into situations which demand skills in politics, conflict resolution, and negotiation. PMI-Ill will provide participants with a theoretical framework, useful techniques, and insights from experienced educators and practitioners. PMI-IV The Planning and Managing Change: The Physician Manager in a Shifting Environment New in 1990, this Institute focuses on change as it affects health care organizations. As the content of PMI-Ill and PMI-IV builds directly on material covered in PMI-l and PMI-11, participants are strongly encouraged to first attend those sessions. PMI-l February 18 - 21, Lake Louise, Alta. April 29 - May 2 (12:30), Niagara-on-the-Lake, Ont. July 15 - 18, St. Andrews, N.B. August 5 - 8, Whistler, B.C. September 23 - 26, Niagara-on-the-Lake, Ont. PMI-ll February 22 - 24, Lake Louise, Alta. May 2 (2:00) - May 4, Niagara-on-the-Lake, Ont. July 19 - 21, St. Andrews, N.B. August 9 - 11, Whistler, B.C. September 27 - 29, Niagara-on-the-Lake, Ont. PMI-lll February 25 - 27, Lake Louise, Alta. May 6 - 8, Niagara-on-the-Lake, Ont. July 22 - 24, St. Andrews, N.B. September 30 - October 3, Niagara-on-the-Lake, Ont. PMI-IV May 9 - 1 1, Niagara-on-the-Lake, Ont. August 12 - 15, Whistler, B.C.
Sponsored by the Canadian Medical Association and the Canadian College of Health Service Executives For further information, contact: Department of Educational Services Canadian Medical Association 1867 Alta Vista Drive Ottawa, Ontario KlG 3Y6 613-731-9331
Executive Development Canadian College of Health Service Executives Suite 201, 17 York Street Ottawa, Ontario Ki1N 5S7 613-235-721 8
