Random Thoughts

Haven't been posting too much lately. Have been too focused on longer posts and not enough on the many little thoughts kicking around in my head.

Sunshine
It's sunny again! Also, I get to walk to my placement for a couple weeks, which is amazing. I used to walk everywhere - for a while nearly an hour each way to-and-from work - and I loved it. It's been a nice change of pace to be getting some exercise in the sun, especially given the lack of exercise I've been getting otherwise.

Overdiagnoses
Medicine suffers from both a hive mentality as well as a lack of accountability for those who choose to follow their own path. Many conditions are overdiagnosed in the population, some due to widespread misdiagnoses by broad swaths of clinicians, others due to outliers whether ahead of the curve or behind it. Psychiatry is particularly susceptible to these problems, given the subjective nature of the field. I'd like to draw attention to one diagnosis that I've seen more than I would expect and in situations that don't seem to be applicable: Borderline Personality Traits.

True Borderline Personality Disorder is very disruptive and can be exceptionally hard to treat even with the emergence of DBT as an established, evidence-based therapy. Borderline Traits are, by definition, not significantly disruptive. There's room for this diagnosis, but often I've seen it employed when a patient is simply difficult. Borderline Personality Traits in isolation don't typically get treated, so perhaps it's not the most troubling diagnosis. Still, I find this trend a little too close to pathologizing traits which are, at the end of the day, not really a pathology, just something we as clinicians don't really like very much.

Hockey!
It's playoff time! The junior team I support is crushing it. The AHL team I'm supporting - bandwagon style mind you - is doing pretty well too. The NHL playoffs are actually interesting, with Chicago, LA, and Anaheim all bowing out in the first round! I only went 5/8 in my first round predictions though, so that's pretty bad... picked the Blackhawks and Panthers, which didn't work out. Also picked Anaheim and I really wish I hadn't, because I've always thought Nashville gets dismissed too easily. They're a really good team now that they have some real forwards in Forsberg, Johansen, and Neal. Looking forward now to the 2nd round match-up between Washington and Pittsburgh, not because of any Crosby vs Ovechkin bull, but because both teams are playing really, really well right now.

Naturopathy
The story of the Albertan parents who tried natural medicine for their child with meningitis is everywhere, so it's worth taking a second to touch on. There's a role for "natural" interventions, traditional medicine and alternative medicine. It can and frequently does co-exist with conventional medicine without much difficulty. However, it's hardly a harmonious co-existence. Fault for this can be placed on both sides, but the fault is far from symmetric. Conventional medicine is too dismissive of what benefits can be gained from non-conventional approaches. At a sheer minimum, placebos work and while there's moral hazard in actively participating in prescribing placebos, I don't think there's anything wrong from encouraging people to use their own placebos, if it seems to improve their quality of life. Reiki is high-quality bull-crap, but it's not going to hurt anyone so long as they still use conventional medicine when appropriate. Our resistance to alternative approaches means we're providing what is likely adequate, but suboptimal care.

The flip side is that non-traditional medicine overpromises. Most non-traditional interventions are not based in evidence and some can be quite harmful, but a balanced, honest discussion of pros and cons does not appear to be forthcoming. Worse, many practitioners seem unaware of the problems with the treatments they're offering (and getting paid for). That can lead to some serious issues, as the Alberta case demonstrates. These are fortunately not that common, but still far more common than they should be.

Point is, on both sides of the aisle, conventional medicine and non-conventional medicine, we could do a lot more to work together for the benefit of our shared patients. However, there should be no false equivalence - we need to change our attitudes, they need to change their actions.

Drinking the KoolAid

Complementary and alternative medicine gets brought up a lot at my school, usually not in an overly positive manner.

There's reason for that animosity. Every physician has a story of a patient that had a less-than-ideal outcome because they opted for care that either diminished the effectiveness of conventional medicine or replaced it entirely. In some instances, deaths have occurred. When there are people promoting and even profiting of those outcomes, it's hard not to get angry.

When you listen to the people providing these alternative medicine services, however, they believe strongly that they're helping. Many of these practitioners go through extensive training before they practice, training which reinforced the theories underlying their practice. When you're told over and over again that something is right, and most of the people you interact with believe in it as well, it's hard to accept or even contemplate that it might be wrong. So, these alternative medicine practitioners continue to believe they're helping in spite of contradictory evidence because it's simply inconceivable that that contradictory evidence could be right. They drank the KoolAid.

Here's the thing - every field has their own KoolAid, including medicine. For those who like to go back to the evidence, some of the KoolAid is easy to point out. There are many procedures or approaches in medicine that lack supporting evidence or have even been shown to be ineffective. Yet they are still a part of our practice. Traditional medicine does tend to be more responsive to evidence - clearly unhelpful procedures do work their way out of the system, over time, but it takes far longer than it should. I have had physicians, in front of a full class of medical students, discuss a procedure, admit that the available evidence shows that it works no better than a placebo, and then insist that it still has a role in medicine.

More importantly, there are certainly some things that we're doing that are ineffective or unhelpful and we have no idea that they are ineffective or unhelpful.

Complementary and alternative medicine should be scrutinized, but so should conventional medicine. I think conventional medicine holds up much better under that scrutiny - that's why I'm getting an MD and not an ND - but we should always be willing to hold conventional medicine to the higher standards we'd like to see applied to complementary and alternative medical practices.