1024px-Scylla-and-Charbydis

Between Scylla and Charbydis

What is past is prologue

As I move into senescence it becomes easier to look back than to look forward. The future offers decline, death and, to judge from what many others have told me, an eternity of damnation. Well, at least I will be with friends and family. The past, which becomes more appealing and wonderful with time, offers refuge from the storm. In my memory I am always so much better than I am now, so why not spend time in the past.

My first time

The first two years of medical school I commuted on public transportation. It was time to review notes with no distraction, always the case on the way home. Despite a change of clothes, no one would sit next to me after gross anatomy lab, reeking of preserved cadaver. Preserved cadavers have a penetrating fragrance that saturates the skin and hair and will drive away even urine-stained crazies.

One day someone interrupted my reading to ask if I was a medical student. I hate that. Seriously, if I wanted to talk would I have a book open on my lap? Leave me alone. This was before digital music. Kids today can put in ear phones and, combined with sunglasses, have a quasi-legitimate excuse to ignore those around them. I am so envious. But I was raised to be polite. I said yes, and he said he too was in medical school, the local naturopathic school.

I had no idea what he was talking about. Naturopathy? What is that?

He then proceeded to tell me that, contrary to what I was taught, warts are actually the result of the body walling off toxins and expelling them.

I remember thinking at time, this is a loon, and the last thing you do is egg-on a loon when you can’t run away. So I smiled grimly, made non-committal grunts, and was relieved when he got off the bus. Turns out he wasn’t a loon, but was repeating the teaching of his school. It is the school that has the loons.

Naturopaths believe that warts are the result of toxins in the body and an immune system that is not running efficiently:

The warts were the response to the presence of the toxin, but the toxin had “seeds” in other parts of his hands. The detox was pulling those seeds to the surface, and as they exited his body, he was witnessing what would have manifested into warts at a later date and time.

I never saw that ‘medical’ student again, thank goodness. Naturopathy? Toxins? Who is going to believe that shit except the feebleminded? I just shrugged my shoulders and got back to work, forgetting all about it.

Naturopathic death

1980-1990 were my years for medical school, residency and fellowship. I call them my lost years. Most people lose a decade to drugs or alcohol, I lost mine to internal medicine. My kids used to watch I Love the ’80s. I recognized virtually nothing on that show from the popular culture in that decade: the styles, the movies, the shows, the music, the memes were all new to me. If I had any contact with naturopathy or alternative medicine those years, I can’t remember it. But then I trained in county hospitals and the poor and underprivileged do not partake of naturopaths.

Although they do see their local healers and I did see some Salmonella arizona infections in Hispanics from using rattlesnake pills for cancer.:

The ingestion of rattlesnake powder capsules is frequent in Mexico in view of their alleged curative properties in various diseases, among them different malignancies. Based on previous reports showing both bacteremia and septicemia in patients with malignant diseases ingesting such capsules, we conducted a study to evaluate the presence of microorganisms in 16 different preparations of rattlesnake powder capsules, obtained in six different cities of our country. We found that all the samples were significantly contaminated with gram-negative coliform bacteria: Escherichia coli, Klebsiella pneumoniae, Enterobacter agglomerans, E. cloacae, Salmonella arizona and Salmonella of groups B, E4 and G. Eighty one percent of the capsules were contaminated with Salmonella sp. The most frequent was S. arizona with a natural reservoir in snakes.

And I remember seeing an Asian patient with pupura fulminans who, when I went to examine her in the ICU, was covered with sliced cucumbers, put there by the mother. I never really did figure out just why, but given the bacteria on fresh produce it was not a good idea to put cucumbers on dead flesh.

I did not become reacquainted with naturopathy until early in my practice I was called in to see a “leg infection”, which was actually a dead leg. Wet gangrene, with the horrible smell only rotting human flesh can produce.

It was a 24-year-old woman who had an osteosarcoma of her leg and, rather than be cured with amputation, went to a naturopath who said she could be cured by, among other things, drinking alkaline water, the so called pH miracle, and herbs. It didn’t. She had been brought in by her mother when she became unresponsive but perked up with fluids, letting us know her naturopath still assured her that he could cure the tumor, that the rotten leg was her body ‘rejecting’ the tumor. She refused surgery. That night the tumor, or the infection, eroded into a major artery and she bled to death in her sleep.

Looking into the ‘treatments’ that led to her death was the WTF moment that got me interested in pseudo-science and pseudo-medicine.

As an aside:

The author of the “pH Miracle” book series, who espoused alternative medicine while treating terminally ill people at his Valley Center ranch, pleaded guilty Wednesday to practicing medicine without a license.

And as part of the trials he:

admitted in his plea that he didn’t have any post-high school educational degrees from any accredited schools.

The defendant also admitted that he was not a microbiologist, hematologist, medical doctor, naturopathic doctor or trained scientist.

Note how naturopath is lumped in with real doctors, as if being a naturopath would have made his practice legitimate. Well, it would in the eyes of the law, just not in the eyes of reality. This is yet another hint that NDs are slowly winning the PR battle.

The legislature defines π as exactly 3.14

As NDs have increased their scope of practice to rival that of real doctors, due to unearned legitimacy granted to them by legislatures, I have seen more and more patients who also have seen NDs for some of their care. Some patients have NDs thrust upon them by Zoomcare, one of the acute care clinic chains in the city, which actually hires naturopaths to see their patients. Scary. In my opinion it is like giving a blind and deaf person a gun and saying pull the trigger whenever you want. You know it will not end well.

I have yet to be impressed with the ND care I have seen to date. I suspect I am not the first option for their Infectious Disease referrals, but insurance often leaves patients, and thus the referring provider, with no choice. Let’s take a stroll down Reminisce Rd.

Lots ‘o supplements

Most ND patients do not suffer from poly-pharmacy, but they do suffer from poly-supplement. More often than not, the brand of the poly-supplement is the same, having been purchased directly from the ND. I had one patient who literally had a carry-on suitcase filled with dozens for supplements she took multiple times a day.

This brings up a problem, the solution for which I am uncertain and will discuss more as this continues. Under what circumstances and in what manner can I, and should I, work with NDs and other alternative practitioners? As with this example, selling supplements directly to your patients is a clear conflict of interest and is a sign of an unethical provider. Do I work with such a person?

There are plenty of analyses on this blog to show that NDs are predominantly educated in pseudo-science, have no training or experience in real medicine, and when evaluated give inferior care. Yet they are having an increasing role in patient care, pod people in white coats and stethoscopes who superficially look like doctors but in reality have the skill set of 8 year old with a Deluxe Medical Kit. Maybe less. Should I work with providers I consider not just incompetent, but whose practice has the added dimension of being divorced from reality?

Patients are not always seeing me for ND-related ailments or referrals, they are usually sent by their physician. The ND is a supplement to their real care, and just as useful:

Most supplements do not prevent chronic disease or death, their use is not justified and they should be avoided.

The ND is a peripheral part of the patients care but not relevant to the consultation. It is not my role, unless asked, to comment on that aspect of their healthcare and might be counterproductive. Yet if the patient drinks too much or smokes or has other risky behaviors, I should comment. But not commenting on the ND care? Is that right? I would rather the patient smoked and drank to excess than see an ND. Not really. I think. But what is my responsibility to work with health care workers who, in my opinion, are at best worthless and at worst dangerous? Especially as most patients have no issues with their ND and the last thing I need to do is poison the well with the patient as regards my care.

Anyway, what to do about the poly-supplement use? I usually look at the supplements for drug-drug interactions, and take the opportunity to mention in passing which ones could contain toxic metals (Ayurvedic) and the fact that supplements are often not regulated and often adulterated so predicting interactions is problematic. But unless I see something really dangerous, like silver, it is not a battle that is worth fighting head on. Better to pick at the edges?

Second opinions

Occasionally I see patients for a second opinion on their ND-generated lab tests. Guy walks into a doctor’s office. The doctor says he’s crazy. The patient says I want a second opinion. The doctor says you’re ugly as well. I always think of that joke when I am asked for a second opinion.

NDs, as best I can tell, are prolific in their testing of every bodily fluid and structure they can access. I am old school and try to limit testing to the disease(s) I am considering from my history and physical. Not NDs. They seem to go on a hunting expedition looking for some abnormality. Hair, blood, urine, saliva & stool all get sent to ’specialty’ labs and, not unsurprisingly, they find abnormalities that need treating. It would be interesting to compare the costs of labs in ND vs. MD office visits.

Testing is harmful. Real doctors, with actual medical education, have issues with testing:

Clinicians rarely had accurate expectations of benefits or harms, with inaccuracies in both directions. However, clinicians more often underestimated rather than overestimated harms and overestimated rather than underestimated benefits. Inaccurate perceptions about the benefits and harms of interventions are likely to result in suboptimal clinical management choices.

If you are ordering labs for the imaginary diseases that NDs love, I would wager the issue of estimating harms does not even enter into the calculus.

I remember one patient whose lab results had short explanations as to their meaning and what interventions were needed to correct abnormal values. For CO2, it said “Keep breathing.” A first: good ND advice I cannot argue with.

One patient fell into the clutches of an ND/DC (double your pseudo-science) that used live blood analysis.

He had been seeing a DC/ND for a variety of symptoms that turned out to be asthma: cough, shortness of breath, wheezing and peak flow less than half predicted. Hell, an ID doc can diagnose asthma, bread and butter primary care, but not an ND/DC. His DC/ND diagnosed him with a blood infection, based on live blood analysis, and offered the patient a colonic detox as a cure. My patient thought he should get a second opinion for his blood infection (which kind of freaked him out) before he submitted to a cleansing enema, always a good policy.

That one was fun, not only because I got to diagnose asthma, but the patient was interested in the truth the ND/DC did not want him to know: live blood analysis is total BS. He was relieved to not have a blood stream infection and asthma instead, but also a little chagrined at spending almost a grand on the testing.

Another second opinion generated by labs is Lyme; these patient interactions are variable in their outcomes. Some patients are happy to know that they don’t have Lyme because they had unreliable testing:

commercial laboratories that conduct testing for Lyme disease by using assays whose accuracy and clinical usefulness have not been adequately established. These tests include urine antigen tests, immunofluorescent staining for cell wall–deficient forms of Borrelia burgdorferi, and lymphocyte transformation tests. In addition, some laboratories perform polymerase chain reaction tests for B. burgdorferi DNA on inappropriate specimens such as blood and urine or interpret Western blots using criteria that have not been validated and published in peer-reviewed scientific literature.

We know who they are talking about here.

Other patients? It is a chore to have a confrontational interaction with patients, but some want to be treated and are not pleased when I disagree with the validity of bogus ND labs.

I was recently asked if I wanted to see a patient in follow up, someone who was a non-compliant, heroin using, belligerent, drug seeker who had a serious infection. I told the ER ‘want’ doesn’t enter into it. They have an infection, I am an ID doctor, and I have a responsibility to see the patient. Send them my way.

So for second opinions I do not mind getting ND patients since I am being asked for my best opinion in the role of a science-based MD and I have no hesitation in pontificating on the case at hand. I just hope I am not too gleeful when I explain why everything the ND said is an alternative fact.

Increasingly I am also getting second opinion requests regarding the diagnosis and management of real diseases being managed with ND therapies. Those are more problematic, and there is often this spectrum of interventions, from homeopathy to herbs to supplements to vitamins to occasional real medicines being given by the ND. I remember reviewing the chart of one patient who I was seeing for the question of an infection acquired from travel to Africa. The patient had been on penicillin for a month ‘in case there was an infection present’. An understanding of infection so lacking I am left slack-jawed and speechless.

What to do when the patient has the ND not as a supplement to the real doctor, but the ND IS their doctor? I do not want to be complicit in approving ND care, but I may be the only ID doctor the patient can see and I want the patient to see a real doctor (me) so I can’t say no. But it is an awkward ethical position, participating in care that I know is bogus yet legal. I tend to feel a little weaselly with these cases, mostly ignoring the steaming pile of ND care in the room and focus on making sure the patient gets the best medical diagnosis and treatment I can provide. If asked about the ND care, I give an honest answer, but I do not go out of my way to discuss it. It is, I think, the lessor the two evils, but it leaves me feeling dirty.

Between a rock and a hard place

A while back I had an even more uncomfortable interaction, the identifying details of which are not germane. A couple of months back I was asked if a patient with numerous medical problems had an infection. After an evaluation I concluded she didn’t. Three months later I get a call from a nurse, who wanted to know if the patient has an infection because the ND, who works in a doc in the box, want to give an immunosuppressive medication for the patient’s autoimmune disease and wants my blessing that it is safe.

I told the nurse, who did not know what the name of the drug was or why it was being given, that this should be a doc to doc conversation and that I needed more information on what was to be done. I then got a fax with the name of the drug, a monoclonal antibody which I had never heard of, asking if it was safe to give the drug.

This time, rather than being asked to be complicit in approving mostly harmless ND therapies, I was asked to be complicit with a medical therapy given by ND, care that I would think no ND, and most MDs for that matter, should provide without true expertise in the disease. These biologics are tricksy.

Let me be clear, because I looked it up, it is totally within the legal scope of practice, thanks to the Oregon legislature, for this ND, with no medical education or training, with no expertise in either the disease or its treatment, working in a doc in the box, to give this complicated patient an expensive and dangerous immunosuppressive drug. And they want me to OK it with a fax.

I have yet to ask our legal and ethical people about the questions these situations raise. I suspect these dilemmas are only going to become more common and more difficult as pseudo-medical providers increase their presence in health care. I am going to have to go between Scylla and Charbydis, trying to help the patient without validating the ND.

Or, screw it, open an Integrative Clinic and embrace the dark side.

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.