Magic and other detritus

Tuesday, November 3 2009

This month is National Blog Writing Month, or some such, but I’m not participating. You probably already knew that, as sporadic as my posting has been.

The thing about being sick is that even though it forces you to take time off to care for yourself, the stuff that you’re not doing doesn’t magically disappear. It’s still there waiting for you when you’re better. When I had a job that offered sick days, I took ‘em – and I knew that some of my coworkers thought I was goofing off or faking. But I still had all my work to do when I came back to work. Just less time to do it.

The same with this bout of the flu. Lots of stuff got put aside for a while, and so I’ve been playing catch up the last week or so. And now I finally have a few minutes to spare for bloggering.

By the way, Grand Rounds is up at Non-Clinical Jobs. Thanks to Dr. Kim for hosting, and including my late-submitted post.

On to more important matters: Dr. Rob posted yesterday about “Not Like Magic“, arguing that the allure of so-called alternative medicine is that patients want “magic”. I’ve met Dr. Rob, I have a lot of respect for his blogging, but I have to say that this post is what the Internets call a “FAIL”.

Two physicians try to figure out why patients spend money on woo, and the best they can come up with is “people want their problems to magically go away”? If this is the full extent to which Dr. Rob and co. understand their patients’ behavior, we’re in trouble: after all, Dr. Rob is one of the good guys.

Some days I feel like I’ve accomplished enough with this blog that I can move on; yesterday, I realized I have to  spend the rest of my life writing it. The rest of this is long, so click on the break for more….

So, why do patients spend money on alternative medicine? Well, I don’t – not much anyway. I think most alternative medicine is crap, so I stick to the hard stuff. But nonetheless, I can think of at least four six reasons why patients might turn to alternative medicine,  and none of them are particularly magical:

• The first and most obvious reason is that physicians aren’t usually very good at persuasion. Physicians tend to present their recommendations in a ‘take it or leave it’ fashion – without any real sophistication. They tend to rely on the fact that they are selling scientifically-proven medicine to be persuasive enough – more or less assuming their patients ought to do the rational thing. The people who sell alternative medicine, on the other hand, are typically quite good at persuasion. They have to be, of course, because they don’t have science on their side. There’s a reason snake-oil salesman have the reputation they do; it’s the same reason  legitimate drug companies spend a lot of money trying to persuade patients to buy name-brand drugs for diseases they don’t have.
• On a related note, patients want to know how things work, and physicians sometimes don’t explain things well. Often, this is because an explanation would be too technical. After all, you would have to get into the nitty-gritty of cellular biology to explain why antibiotics kill bacterial cells but not human cells. But just saying, “this drug kills bacteria” isn’t an explanation for how it works – it’s just a way of saying it works. And sometimes, this is because the physicians just don’t know. For example, I used to take a drug called mesalamine. I asked my gastroenterologist how it worked. “It reduces inflammation in the gut”. How exactly does it do that? I asked. “We don’t know the precise mechanism”. Now I understand that just because we don’t understand the mechanism doesn’t mean it’s not scientifically valid, but to a lot of people my gastro might as well have been admitting it worked by magic. And lots of people would also have trouble differentiating that explanation against some of the alternative medicines and supplements that claim to do the same thing. Those products always have very compelling, scientific-sounding explanations for how they work, even especially if they don’t work at all.
• Patients decreasingly trust our health care system. It seems like every week there’s another story about a medicine that was approved by the government, but later pulled because it killed people. Moreover, there is widespread popular perception that pharmaceutical companies are entirely devoted to profiting from people’s suffering, and are protected and encouraged to do so by the federal government. The fact that alternative medicine is a not regulated by the government is, to many people, a very good thing. Alternatives compete in a much freer market than prescription drugs, and the companies that sell alternative medicine know they aren’t tainted by the appearance of oligopolistic collusion to exploit human misery. They spend a lot of money positioning themselves as caring, compassionate alternatives to pharma. Granted, they exploit people’s cynicism and suspicion, but that doesn’t mean pharma’s reputation is undeserved.
• Pharmacies often don’t differentiate alternative medicines from ‘real’ OTC medicines. In virtually every pharmacy I’ve ever been to, you could find products like Zicam right next to the Sudafed, Claritin, and other real medicines. This legitimates a lot of products that aren’t at all legitimate. I know and you know that drugstores will sell us anything we want to buy, but the fact that there is a trained pharmacist on the premises, who in theory has some professional obligation to science and humanity, makes it seem like there is also some sort of check on what OTC products are available.
• Patients want to feel in control. Alternative medicine can help them feel in control, even if it doesn’t actually help them with their problem. If I feel sick, I have to call my doctor’s office, get an appointment, wait forever to see him, see a nurse first, get my five minutes with the doctor, get a prescription, go to a pharmacy, wait a little more for the pharmacist, and finally go home and take my medicine. Even if I know exactly the prescription I need – mycelex, for example – I still have to go through all of this. And even if I have to take the same drug every day for the rest of my life, my insurance company still requires that I see my doctor every six months to renew the prescription. All this rigmarole might be necessary to real medicine, but a lot of patients end up feeling like a cork in the ocean – without any explanation of why it’s all necessary. If we can skip all that and just buy whatever claims to cure our symptoms OTC, we might feel a lot more in control, even if the product doesn’t really do anything.
• Finally, alternative medicines sometimes – gasp! – work. For the longest time, I couldn’t eat salad or any raw vegetables without getting horrendous gas and diarrhea. My doctors couldn’t explain it, and couldn’t offer me any help, so I tried ‘alternative’ supplements (which, of course, were shelved right next to the Immodium and Pepto Bismol). After few false starts, I found that Bean-O solved my problem: I had much less gas and no diarrhea after eating vegetables. So long as I took Bean-O, I could eat salads again, and raw apples, and green beans – all foods I had avoided for years. Maybe it’s just a placebo effect, or a spurious correlation, and lately I’ve been doing without as much Bean-O – but as best I can tell, it really helped me for a long time. It worked, and it was worth the money.

That’s six reasons, just off the top of my head. I am sure there are more, and none of them to do with magic. I know it’s easier to deal with other people’s odd decisions if we can dismiss them as irrational, but that isn’t actually a real excuse from the obligation to empathize with our fellow human beings. We at least have to try.

What’s especially troublesome in this case is these physicians’ utter failure to appreciate their patients. Instead of sitting around bullshitting each other, couldn’t they have asked this question of some of the people they’re supposed to be helping? No – instead they came up with pat explanation that has the twin benefits of making themselves feel better about their chosen profession, whilst denigrating those who aren’t quite reverent enough.

As I’ve said, I like Dr. Rob, I usually like his blogging, but in this case I hope he will consider his wrists well and truly slapped. Maybe next time he wants to know why patients do things, he will – just maybe – think to ask.

Tags: biog, docs, ills, meds

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