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Tuesday Aug 19, 2014

Outside the Box: Integrative Medicine Might Just Expand Your Comfort Zone

Not long ago, a young woman came into my office. For years, she said, she just hadn't felt right, suffering from fatigue, joint pains, strange rashes, bloating, gastrointestinal upset, and mood and sleep issues. She had undergone many tests and imaging studies and had taken multiple medications, but nothing helped.

She wasn't seeing me for any of these issues, however. Sadly, she had resigned herself to always feeling this way. I finished her well-woman exam and made a suggestion: Stop eating gluten. She had never heard this suggestion.  

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Nearly 40 percent of U.S. adults use some form of complementary and alternative medicine, but are physicians ready to consider nonconventional therapies?

"It costs nothing, is practically risk-free, and it just may help you," I said.

A few months later, she was back and feeling normal. She had stopped eating gluten.

It is easy to find evidence both for and against a gluten-free diet. I am not interested in this evidence. For this "study," which had an N of 1, I can happily report a 100 percent success rate. To be fair, I have had plenty of other patients who did not respond to this diet change, but I have never hurt a patient by suggesting it, and I doubt I ever will.  

In an excellent article(onlinelibrary.wiley.com) titled "CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don't," Robert Cowan, M.D., recently made a practice-changing point: "If the only standard we apply is evidence-based medicine, or standard-of-practice medicine, or FDA-approved medicine … we will miss clinical opportunities which could well transform how we manage disease … (and) do a disservice to our patients."

Complementary and alternative medicine, he points out, is complementary and alternative simply by convention. This convention sprung out of the Flexner Report of 1910, which marginalized any medical schools not using a European, scientifically centered form of education, much to the dismay of William Osler, M.D.(www.ncbi.nlm.nih.gov) Abraham Flexner was not a physician, but an educator, and his report forever marginalized the art of medicine.

Part of that art is knowing when our treatment recommendation is based on actual evidence, balancing probable benefit (number needed to treat) with possible harm (number needed to harm), and doing so in a neutral manner.

There is a treatment of which I am particularly fond that helps manage a condition that confounds many family physicians: irritable bowel syndrome. It has almost no side effects (heartburn is the main one, easily avoided by providing the medication in enteric-coated capsules) and its number needed to treat is … wait for it … TWO. Any guesses?  The treatment is peppermint oil -- enteric-coated, of course.

In contrast, the number needed to treat high cholesterol with a statin to prevent a cardiovascular event hovers in the 60s, and the number needed to harm(www.thennt.com) and cause myalgia is as low as 10.

How 'bout them apples?

We spend the most formative years of our education getting steeped in Western conventional treatments, for which the evidence is rich, albeit sometimes skewed, as any statistician will tell you. Additionally, most of us, once in practice, have even less time to read all the evidence. And we ignore treatments that could very well help our patients, often with much lower risk and lower costs(www.bravewell.org)

I practice integrative medicine. This is a style of medicine that neither blindly accepts traditional medicine, nor blithely dismisses nonconventional medicine (often called CAM, or complementary and alternative medicine). It balances evidence of efficacy with potential for harm. It is patient-centered, not doctor-centered, and it forces me to shut down my ego, and my judgment, on a regular basis.

Whether or not you are ready to start challenging the treatments that sit squarely in your comfort zone makes little difference; I believe you have no choice. Although you may practice evidence-based medicine, your patients may not. According to a 2007 HHS survey, 38 percent of adult Americans used CAM in some form, and this same group spends more than $33 billion each year on CAM therapies and products(nccam.nih.gov) and $9 billion on CAM services(www.ncbi.nlm.nih.gov), generating 122 million office visits annually.

I don't eschew the medicine I spent so many years studying, but I stand in front of more than one altar. I prescribe statins. And peppermint oil. There are medical systems outside of ours, treatments we were not taught in training, that help more than they hurt. I encourage all family physicians to consider spending some CME time(www.abihm.org) investigating the therapies within integrative medicine. Our patients deserve it.

Heidi Meyer, M.D., is an employed integrative family physician at Kaiser Permanente, San Diego. She enjoys yoga; dark chocolate; weekends in Vegas; bonding with her ferocious 9-pound dachshund, Bella; and plotting a drastic overthrow of the house of medicine. You can follow her on Twitter @tweetyturt.

Posted at 10:26AM Aug 19, 2014 by Heidi Meyer, M.D.

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