A View from Mainstream Family Practice

1. A View from Mainstream Family Practice • Prepared for the Panel on Complementary Medicine by Dr Brian Dixon-Warren. Annual Cancer Conference BCCA Saturday 29 November 2003

2. Definitions:

3. Definition • Mainstream medicine is that taught in Western medical schools, & practiced in most Western hospitals, clinics, & physicians offices.

4. Definition: • Complementary medicine refers to practices which are not a part of mainstream medicine, & are not taught in most Western medical schools. For the most part they have not been endorsed by physician licensing & regulating bodies, nor by the academic medical community.

5. Belief Systems

6. Belief System • “All models are wrong; some are more useful than others.”

7. Evidence based practice: • All truths may be provisional, but to date the scientific method has been the most useful model for the treatment of disease.

8. Credentials: • Past-chair for 6 years of the Committee on Alternative Therapies & Allied Health; Council on Health Promotion, BCMA • 43 years in General/Family Practice • in various settings, currently Saturna Island, BC.

9. Focus of Presentation: • Patient Autonomy • Physician Integrity • The Placebo Effect • Patient Centred Care.

10. Patient Autonomy: • Has become an ethical imperative • Potentially liberating for both patients & physicians, but, in the presence of uncertainty, presents challenges to both.

11. Autonomy & Uncertainty: • For the patient increased uncertainty may generate anxiety & fear • Physicians have to give up authority & say “I don’t know”. • Working through this requires skill, & time.

12. Autonomy & Denial: • Denial is sometimes a normal psychological mechanism to deal with seeming intolerable situations. • Support of denial has become ethically dubious. • Respect for autonomy implies full disclosure. This requires care & time.

13. Autonomy & Complementary Medicine: • Disease management by mainstream medicine has limitations. • Patients have an autonomous right to seek additional solutions; for example in religious practices, or in complementary medical practices. • This poses a challenge to the mainstream physician.

14. Autonomy & treatment choice: • Autonomy implies informed choice. • Challenging in the face of the uncertainties implicit in complementary practices. • A large investment of time may be required to obtain reliable information about the numerous & constantly changing practices that are currently popular.

15. Physician Integrity:

16. Physician Integrity: • Physician licensing & regulating bodies are set up to protect the public. • In order to assure this, physicians are required to practice according to the guidelines of the provincial College. • Mainstream practices fall within the guidelines. Many complementary practices do not.

17. Physician Integrity: • Share with the patient the limitations of your knowledge, & the known uncertainties. • Share with the patient the limitations imposed by lack of time. • Refuse demands for inappropriate prescriptions. • Offer consultation &/or referral if necessary.

18. Physician Integrity: • Support the patient, even when you cannot support the process.

19. Evidence Based Practice: • Increasingly important in modern practice, & especially publicly funded health care. • Central to mainstream medicine.

20. Limitations of Evidence Based Practice: • Much mainstream practice is not evidence-based & is “traditional” • However, it is consistent with the huge body of peer reviewed research which supports an evidence-based approach. • This is in contrast to traditional complementary practices.

21. Advantages of mainstream Medicine • A commitment to rigorous methodology in research, together with peer review. • This provides a greater reliability & generalisability. • This is lacking in complementary medicine.

22. Limitations of the Evidence-based approach. • Gold standard research generally involves large populations, which are thought to be homogenous. • Conclusions require support by statistical significance. • “Outlier” results tend to be discounted.

23. Limitations of the Evidence-Based approach: • However, the “outlier” result may contain significance if the population is not homogenous.

24. Clinical Judgement: • “Every treatment is an experiment with an N of 1”. • In the face of uncertainty an “experimental” treatment may be appropriate, given fully informed consent, & close follow-up.

25. The Status of Complementary Medicine: • Perhaps complementary practices would be best viewed as experimental, & carried out subject to the same requirements as other clinical trials.

26. Pseudo-Science: • Complementary practices can be acceptable to the mainstream physician given the above safeguards. • Pseudo-science is not acceptable. • Unfortunately, this is all too common in public belief, & health care providers promotions.

27. Peudo-Science: • As Carl Sagan has pointed out: it is Science that has been a “candle in the dark of the demon-haunted world.”

28. “The Power of the Placebo”: • The history of medicine, until relatively recent times, has been the history of the placebo (The Shapiro’s)

29. The Placebo Effect: • Powerful • An underestimated factor in both mainstream, & complementary medicine. • Generally very beneficial.

30. The Placebo Effect: • May be expressed by psychological and physiological changes. • Examples: - • Pain relief • Relief of nausea & vomiting • Relief of bronchospasm.

31. The Placebo Response: • May be elicited by: - • a pill • an injection • an operation • a complementary practice, especially if exotic • most importantly by a shared narrative & a strong therapeutic relationship.

32. The Placebo Response: • Is maximized by three factors: - • Strong belief on the patient’s part - • Strong belief on the practitioner’s part, & • A strong therapeutic relationship between them.

33. The Patient-Centred Model: • Is based as much as possible on evidence-based practice for disease management. • Gives at least equal & appropriate attention to understanding & responding to the illness experience of the patient.

34. Patient-Centred Care: • The therapeutic relationship involves the creation of a shared narrative between the patient & the physician,- a story that they can both believe in. • This can help to evoke a powerful placebo response which will enhance quality of life, satisfaction for both, & healing.