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It
was time for a yearly physical. I
walked into the waiting room of my internist’s office and checked in
at the window. The receptionist
politely asked me to have a seat. Anxious to get this over with, I turned and
scanned the room for a seat. If it were an office with windows, I would
normally opt for a seat with a view, but this one has four walls and my only
interest is to make eye contact with the nurse that calls my name.
It’s not that I abhor going to see the doctor; it’s just that
usually it seems to be a waste of time.
I don’t mean to sound cynical and am in fact thankful for typical
appointments with nothing to report. My symptoms or complaints tend to be
related to Multiple Sclerosis, and for the most part they are a bit illusive.
How do you evaluate fatigue? Fatigue
for one person may be very different than another.
Otherwise my test results are usually within normal range.
The appointment usually ends with an obvious reminder, “Your
symptoms are most likely related to MS.”
Today
I sat down, picked up a magazine, and read half heartedly about the latest
debacle in government. For what
ever reason, waiting rooms are stocked with sports or news related magazines
and the occasional home décor. A
better choice would be to have subject matter that would lower one’s blood
pressure, not increase it. As
I’m flipping through the pages, I am aware of how apathetic I’ve become
towards the issues of the world. “Is my lack of interest a reflection of a
disregard for social concerns or am I just saturated with constant negative
reporting?” Suddenly, I am startled by a woman sitting to my right; she
excuses herself and puts her magazine down, as she walks into the examining
room. Silly, but I felt a bit of
jubilation; she had left me a Better Homes and Garden to look through.
I quickly returned the news magazine to the table and began flipping
through BHG for an article that would take my mind off serious issues.
One
sounded intriguing; a discussion about the pros and cons of eclectic design.
I wondered why I’m so drawn to an eclectic design.
Undoubtedly the affinity I have for old world décor is a result
of living with my grandparents in
Portugal
for a few years. My tendency is to recall these childhood memories with a
palpable perfection.
Traveling
also influences the atmosphere of my home.
It engages my emotions, bringing me closer to the local customs;
making me feel alive. I enjoy
learning first hand about different cultures and exposing my son to these
cultures as well. Whether we
choose to fly to
Europe
, take a train to
Canada
, drive over the border to
Mexico
or walk to our local home goods store, it is probable that we will encounter
an item from another country, an item reflecting a particular tradition.
That is why eclectic design is so appealing to me; it incorporates
beautiful and at times meaningful items from many cultures around the world.
These artifacts not only serve as reminders of my experiences abroad, but
also represent the idea that our world is diverse and full of wonder.
When I think about it, every aspect of my life is affected by an
eclectic philosophy. I use what
works for me and leave what doesn’t.
According
to this article in BHG, there are a few guidelines to follow in order to
achieve a successful eclectic design. Rule
number one; it’s essential to identify a common thread and continue it
throughout the room. Rule number
two; keep it organized and uncluttered; present your items with respect for
the individual piece and its origins. Just as I was beginning to read rule
number three, my name was called out. I
quickly put the magazine down and followed the nurse down the hall and into
the examining room. She asked me
to remove my close and put a gown on. I could wrap myself three times in this
one. I tied the strings, but it
was pointless really, it fell off my shoulders and inevitably opened from
behind. This didn’t bother me;
I was never very bashful in front of physicians.
It felt like a business transaction in many ways.
You go in, take care of business, and you leave; hopefully with a
healthy evaluation.
However,
today was a little different. Fatigue comes and goes, but lately it had
lingered longer than usual. Lately
it had been affecting my ability to function at work and home.
Usually I just assume it is MS related and muddle through it.
But lately it’s been bothering me more so.
I decided to discuss my symptoms with the doctor and ask her to check
other non-routine lab work. Maybe
I had hypothyroidism or perhaps I was anemic.
Both conditions could be easily treated.
In essence I was hoping the doctor would find a benign condition or
cause; identify it, treat it and resolve it.
She agreed these conditions were plausible in lieu of all my symptoms.
She agreed to do a full work-up, including thyroid tests and iron
levels. I was to see her again
once the results of the lab work came back.
A
week later I was back in the examining room. While I was waiting I remembered
that article that I had read in the previous visit.
It occurred to me that health care providers would benefit from an
eclectic approach to medicine. Today
I was hoping for something more. I
had been experimenting with alternative health practitioners on my own from
time to time, and I wondered if she was knowledgeable about alternative
medicine. I decided to ask her
how she felt about it, willing to take the risk of being ridiculed.
I wanted my doctor to work with me and respect my beliefs.
I wanted to take these visits and change them from a business
transaction to a healing experience and felt that maybe it was up to me to
open the door. . She entered the
room with a pleasant smile on her face; explaining that the lab work was
normal and although this was ultimately good news she could at the same time
understand my frustration. She
knew I was looking for the answer. Regrettably
she had nothing else to offer.
At
that point I asked her how she felt about alternative approaches and if she
had any personal knowledge of such therapies.
To her credit she compassionately listened to me and proceeded to
explain that she had no professional knowledge of alternative therapies, but
that she could relay an experience one of her secretaries recently had.
Apparently she had been experiencing sharp pain in her right arm for
years. She went to several
physicians including specialists. Her
efforts led to no avail. She was
so desperate that she decided to try an acupuncturist as a last resort.
After a few sessions the pain resolved and the use of her arm was back
to normal. Dr. Jones had to
admit that based on her personal knowledge of the case, the outcome was
phenomenal. Choosing her words
carefully she acknowledged my belief in the benefits of certain alternative
therapies but cautioned me as well. I
saw the apprehension in her face. Alternative
therapies were foreign to her and have often been admonished and ridiculed by
western medicine. Traditional
western medicine has no place for alternative therapies; it’s not part of
the construct.
There
is a level of comfort one enjoys, albeit illusory, in believing that science,
especially the western medical model, is the only model we can truly trust.
Anything outside of the parameters is unwelcome, considered dangerous,
archaic, and pointless to investigate. For
example, why would we use herbs if we have drugs?
Isn’t the use of whole herbs a symbol of an archaic medical system?
Hasn’t modern medicine developed drugs as a result of the less
effective use of herbs? Haven’t
we transcended the need for herbal preparations altogether? Many western
practitioners would answer yes to these questions. And if this is their
premise, than it becomes clear as to why good solid research on the use of
botanicals and other alternative therapies has lagged behind.
If your perspective is one of transcending the ancient medical models,
than there is no room for exploring what they have had to offer for
millennia.
Dr.
Jones had at least allowed for the possibility that acupuncture may have
helped in a very real observable way. In
contrast, there have been other physician encounters where I had been
admonished for using supplements such as; CoQ and Primrose oil. There is
reason to take comfort; it is an easier way to practice medicine.
It may not however be ultimately in the best interest of the patient.
Doctors are taught to offer all potentially helpful options and to
educate the patient with regards to the risks and benefits of such options.
At the very least the health care provider should be aware in a
general sense of alternative options and have connections with reputable
alternative practitioners who are licensed and respected within their field
of expertise.
Being
a patient who has a pharmacy background has been at times a struggle for me.
On the on hand it has been helpful in guiding me through decisions
with respect tom own health. On
the other hand having a chronic disease like Multiple Sclerosis, I am
painfully aware of conventional medicine’s shortcomings.
There are not many options available and the ones that I have tried
have brought with them side effects that I wasn’t willing to live with.
Having no other option I turned to acupuncture in desperation.
To my surprise it not only helped, the effect was significant.
There were no side effects—only improvement.
Professionally
I was trained to disregard alternative therapies and to caution patients
against them, but here I am with a personal experience that proves to me and
me alone that there are effective alternatives that are being overlooked or
ignored. As a pharmacist I walk
a thin line.. Morally I feel
obligated to offer information to patients about alternative therapies when
appropriate. At the same time I
feel I hold back for fear of being reprimanded by the board of pharmacy or
worse still by disgruntled physicians who may not appreciate my suggestions.
First do no harm has at
times become; first protect yourself
legally; and that’s unfortunate.
We
have been forced to practice defensive medicine.
Our medical system, as technologically advanced as it is, is in
disarray. Thousands of MRI’s, CAT scans, X-rays, blood work are being
performed every day; many needlessly. Prescriptions
are being handed out like candy; at times just to pacify the patient.
Unfortunately these patients soon realize just how expensive the piece
of paper they hold in their hands really is.
At
the pharmacy I’m approached by patients all the time with various
questions. In an attempt to more
effectively provide them with helpful information, I usually ask brief
questions about their conditions and if they had discussed their concerns
with their physicians. Often
time the answer is no. Excuses
may range from, “I could see that he was busy, so I didn’t want to bother
him” or “We did discuss it, but I’m not sure I understand” or
“I’m concerned about any side effects or drug interactions” or
“Isn’t there anything else I could take that’s over the counter” or
“This is too expensive, I can’t afford it”.
In addition, many patients are seeing several doctors and often times
each doctor is unaware of what the others are prescribing.
In an attempt to save money the patient frequents several pharmacies
in order to get the best price. All
of this leads to a disorganized medical system which leaves the patient in a
vulnerable position as well as their health care providers.
If Dr. X isn’t aware that Mrs. Smith is taking diazepam, he may
write for another sedative, alprazolam.
If her primary care physician prescribed the diazepam for muscle
spasms and her psychiatrist prescribed alprazolam for anxiety, the patient
may believe that these two drugs have nothing in common and it doesn’t even
occur to her to mention it to either doctor.
Physicians
will routinely ask if you are taking any other medication. Time and again I
see that physicians are not aware of their patient’s complete drug history
and even less aware of what they take over the counter. It is our
responsibility as pharmacists to bring this to the doctor’s awareness, but
we are hindered by not having access to the patient’s complete medical
history, which includes other pharmacies that they go to.
In these cases it seems obvious that the person most capable of
resolving these issues is the patient herself, by being forth coming with the
information. I’m all for patient responsibility, but what do you do with an
elderly population that has a difficult time remembering and understanding
medical jargon?
And
what of individuals whose English is their second language and have
difficulty understanding as well? By
no means are these the only patients that we have to be concerned with.
The population at large still sees the physician as a patriarchal
figure, an expert when it comes to their health.
They mistakenly assume that practitioners have an ongoing dialogue
amongst one another in which they routinely partake in conversations
regarding their patients.
This
naive understanding of the medical system, contributes to a patient’s
vulnerability and less than optimal medical care.
I am a strong supporter of patient responsibility—to a certain
extent. They are responsible for
communicating openly with all their health care practitioners and asking
questions, until they are satisfied that they understand all options
regarding therapy they are receiving. However
how is it possible for someone outside the medical field, to understand
completely what is best for them? It
seems that every nightly news show is full of contradictory research conclusions.
Part of the problem is sensational headlines, whose only purpose it to
captivate the audience’s attention. Viewers
are left with the misleading headline in their minds and aren’t aware of
the details in the research, which offers a more comprehensive analysis.
Of course we are taking for granted that the study itself was well
designed and accurate. Patients
are bombarded with contradicting information on a regular basis.
Even if they want to take an active role in their healing process,
they are overwhelmed with questions that seem to have no end. To make matters
worse, according to Dr. John Abramson of
Harvard
Medical
School
, many popular studies that have been done in the recent past have had
significant flaws at best and outright fraudulent at worst.
How are patients to know the difference if practitioners themselves
have a hard time deciphering the good ones from the bad?
What
I once thought to be research that was done impeccably, with the highest
scientific standards, published in trustworthy peer reviewed journals, is no
longer true. I went to college
in the eighties, a time in which I was made to believe that scientific
research was almost sacred in nature. Scientists
were seen as objective individuals who would above all else do everything
within their power to avoid any bias toward a particular outcome. Dr.
Abramson explains in his book Overdosed
America
that we are standing on shaky ground. Research
that once was done by nonprofit organizations, such as universities and
hospitals, is now being done by drug companies.
Our regulatory agencies which once were forbidden to take money from
drug companies are now being subsidies by them.
The journals that once had my full confidence, are now receiving
millions of dollars from drug companies in exchange for advertisements.
Physician’s prescribing habits are not only being monitored by
insurance companies but also by drug companies and their sales people, in
order to more efficiently target marketing.
In addition, practicing physicians have routinely been recruited to
participate in clinical studies. They
were modestly reimbursed for their time if at all; now participating in
clinical research means big dollars. Not only are the drug companies doing
their own research, but they are hiring
their own doctors to do the follow-up clinical studies.
This does not mean that all results are unreliable, but one has to
question the validity of studies financed through private companies.
Where are the safeguards against bias?
Practitioners
that are hesitant to recommend or even tolerate the idea of alternative
medicine should consider the issues that have arisen over the last few
decades within our own medical system. Healthy
skepticism is necessary when evaluating any
therapy now more than ever before. Fortunately
many physicians have the capacity and aptitude to thoroughly evaluate a
study. Statistical analysis is
now taught at most medical schools. Unfortunately, evaluating alternative
therapies is a bit more complex, only because their knowledge base in these
therapies is negligible. Most
medical schools don’t have these courses available.
There
are some medical school curriculums which offer courses on alternative and
complimentary approaches. These
are few and are most often offered as electives within the required
curriculum. Some schools are on
the cutting edge of training their physicians in a more comprehensive
fashion. Often these
opportunities are available to medical school graduates when they finish
their standard training. These
already established physicians chose to do a fellowship in integrative
medicine. One such school is the
University
of
Arizona Integrative Medicine Program
.. This program was founded by
Dr. Andrew Weil a foremost expert in the field.
In an attempt to educate the practitioner at large, the program also
offers continuing education courses on various therapies in complimentary and
alternative medicine (
CAM
). Educational institutions such
as this one are at the forefront of a changing paradigm in medicine.
They are doing much to dispel the negative stereotype that
CAM
approaches have received over the last forty years or so.
They have taken a hard look at
CAM
therapies and identified those that are efficacious and beneficial.
Although
the number of clinical trials being conducted on
CAM
therapies are growing in number, there is an undercurrent of disapproval in
order to show that most of these therapies are ineffective at best and
harmful at worst. It is logical
that given the number of therapies available to the consumer, some will be
shown not to work and some may prove to be unsafe, but the amount of negative
reports in the media suggest a negative bias.
There was a news report a few years ago whose headline read “Study
proves that
St. John’s
Wort is no better than placebo”. In
that same study they also compared the efficacy of a popular antidepressant
medication. What the media
didn’t convey was that this antidepressant, which was widely used, was
shown to be less effective than placebo.
What would it mean to the drug companies if an herb was found to be
effective in mild depression? Millions
of dollars would be lost.
It
is difficult to discern credible reporting from what amounts to be agenda
driven advertisement. It is essential that we understand the obstacles that
we are faced with and take it upon ourselves to unscrupulously assess the
reliability and credibility of the report, whether it be conventional or
alternative. We need the support
and guidance of respected institutions to help us lead the way to a more
holistic model of medicine. At
the same time we need comprehensive resources to be easily accessible.
Having these support systems in place would not only afford us the
ability of providing quality care, but would simultaneously reduce our
exposure to liability.
According
to the
University
of
Arizona Program
in Integrative Medicine (PIM), the legal issues that health care providers
face when recommending or discussing complementary and alternative medicine
modalities in their office are as follows:
·
Malpractice liability for inadequate informed consent
·
Licensure and credentialing
·
Scope of practice (the legally authorized practice boundaries
for providers)
·
Professional discipline (discipline for professional
misconduct)
These
concerns are valid and one can understand the hesitancy that many
practitioners have. From their
perspective they would be jumping in a fire hoping to avoid getting burned.
In the midst of these obstacles there are seeds of hope.
We as patients and as healthcare providers must not capitulate to this
challenge. We must avoid
complacency and strive for a healthcare environment that is open to new
thought and offers more options. PIM
offers suggestions and guidelines to follow which will help in traversing
these murky waters. When a
patient asks about alternative therapies the following should be considered:
·
What is the curability rate with conventional care?
·
Weigh quality of evidence, invasiveness, and toxicities of each
therapy.
·
Patient clearly understands the risks and benefits of each
option and accepts those risks.
It
is also important to familiarize yourself with organizations that have been
established, in order to demystify
CAM
therapies. The Consortium of Academic Health Centers for Integrative Medicine
(CAHCIM) is an organization responsible for performing rigorous studies on
various medical therapies in order to create new models of clinical care,
these models would integrate biomedicine, the complexity of human beings, the
innate nature of healing, with the diversity of therapeutic systems from all
over the world. It understands
that the western medical model, although superb at treating many diseases and
conditions, also has limitations. At
the same time it acknowledges that for millennia there have been effective
medical models from around the world. Some
of the academic medical centers that are members of CAHCIM include:
University
of
Arizona
, Harvard,
Georgetown
, Duke, and
Columbia
University
to name a few. The following is a list of resources that are also a good
place to start:
·
American Botanical Council www.herbalgram.com
·
American Herbal Pharmacopoeia
·
Consumer Labs: Randomly
test dietary supplements and release their finding to the public www.consumerlabs.com
·
www.drweil.com : Extensive
website with information pertaining to both conventional and
CAM
treatments.
·
FDA Food Manufacturing Practices (GMP): Sporadically monitors
products off the shelf
·
Independent Drug Information Service (iDiS)
www.rxfacts.org
·
National
Center
for Complimentary and Alternative Medicine (NCCAM) www.nccam.nih.gov
·
National
Institute
of
Health
·
National Sanitation Foundation (NSF):
Dietary supplement quality verification, they use GMP compliance
standards
·
Overdosed
America
, Dr. John Abramson
·
Powerful Medicines, Dr. Jeffrey Avron
·
The Association of Official Analytical Chemists (AOAC)
·
The Compendium of Asian Patent Medicines
·
University
of
Arizona
Integrative Medicine Program
·
United States
Pharmacopoeia (USP): Dietary
supplement quality verification they use GMP compliance standards www.uspverified.org
·
World Health Organization
Given
the available resources and I’m sure there will be more to come, a
practitioner who has a sincere interest in offering his patients more
options, can feel more comfortable with the use of alternative medicine.
It saddens me to think how the western medical community has so often
disparaged and looked upon other medical models with disdain and total
disregard. We don’t have all
the answers, far from it. All
medical traditions have blind spots, strengths and weaknesses.
Western medicine would benefit from a visit to the therapist, there it
would hopefully have a revelation, and it would realize that it is not
omnipotent. Could it be
projecting onto other medical models what it is afraid to accept of itself?
We bare and share the same responsibility, which is to provide the
best medical care available to our patients.
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