Defending the Pie

(The pie is a metaphor. I’m only mentioning this because the last time I mentioned pie, I received several irate emails, the gist of which were that pie is not to blame for the collapse of society. -PB)

Primary Snake Oil

The silliest thing about the practitioners of Complementary and alternative medicine is that they don’t know when to leave well enough alone. Currently, with the exception of the occasional over-enthusiastic chiropractor who breaks somebody’s neck or tears an important artery that he has never even heard of, Complementary and Alternative Medicine is a low-risk enterprise, the business model of which is to take a panel of essentially healthy patients with predominantly psychosomatic complaints, stroke their egos a little, mumble either some pseudo-scientific rigmarole or some whacky Eastern nonsense, and send them on their way totally cured and none the wiser. The worst that could happen is the patient still feels bad but, since lawyers have yet to work out a way to demonstrate in court that your qi was irreparably damaged by your acupuncturist, as long as the needles are reasonably sterile and there is really nothing in your homeopathic pills but sugar and a one-in-one-billion chance of one molecule of sheep spleen, you are as a CAM practitioner (if you will pardon the expression) shitting in high cotton.

It is with great interest therefore that I read about naturopaths and chiropractors, among others, trying to pass themselves off as primary care physicians. I see the usual billboards in my town from the chiropractors advertising themselves as the complete medical solution for the entire family and there is even a small subset of back-crackers billing themselves as pediatricians. Naturopaths, for their part, are even recognized as Primary Care Physicians in some states (particulary in the Northeast) and are attempting the usual inroads elsewhere. Leaving aside the obvious, that chiropractors and naturopaths are physicians in the same way that I am a Starfleet Admiral, it is puzzling that, with such a good racket going, the witchdoctors would be trying to sneak into a job for which their training is inadequate and which opens them up to all of the hassles of real medicine like deadly earnest malpractice suits (not to mention suffocating government control, and declining reimbursements).

Suppose you used a chiropractor or a homeopath as your primary care provider. In the best of circumstances, and loosely following the mid-level model for delivering primary care, the CAM practitioner would be a low-level gatekeeper, assuming they knew their limitations which is not usually the case. The typical education model for a CAM practitioner with an advanced degree in his modality, also known as lipstick on a pig, leans heavily on their own particular flavor of snake oil and throws in just enough of the traditional medical curriculum to say, “See, nobody here but us scientifically trained doctors,” but not enough where anybody should feel confident that they would even know when to refer to a real physician.

Even if you came across the rare naturopath or chiropractor who knows that he is selling hokum and is therefore keenly aware of his limitations, if he wanted to be a primary care physician he would do nothing but add another layer of expensive and completely useless medical care to an already overdoctored society. Except for the rare public service of calling 911 like any good Samaritan would if somebody showed up at his clinic with chest pain, he is contributing nothing, and the only difference between he and his more adventurous and less self-aware colleagues in that he will quickly refer to real primary care physicians for real medical problems while they might sit on the truly sick patient for a long time before getting spooked, scratching their heads and wondering why the Ginkgo friggin’ Biloba isn’t doing the trick.

Benefit to society: Zero. My neighbor can call an ambulance and most people know when to go to the doctor. Hell, the real trick is getting them not to go. There is, you see, more to primary care than referring to a real doctor or a specialist. Certainly knowing when to call a real doctor shouldn’t be all the credentials you need to label yourself as as primary care provider. You do actually have to treat something and adjusting qi to improve the subjective well-being of your bored patients isn’t it.

For their part, the chiropractors and naturopaths will point to the existing mid-level providers, many with only a couple of years of formal medical training who are also making inroads into the primary care field, and invoke the doctrine of “me too,” reasoning that since they have a fancy four-year degree they are more than qualified to work as primary care physicians. Whatever the qualification of Physician Assistants and Nurse Practitioners however, their training at least follows the rational model of medicine and is not encumbered by snake oil. A Physician Assistant may only have only two years of formal training but all of it is good which cannot be said for CAM practitioners. Chiropractic school may be four years long, for example, but as most of it involves instruction in a completely debunked treatment philosophy as well as desultory clinical years where all the student sees are mostly well patients with the aforementioned psychosomatic complaints, it is not exactly medically rigorous and in no way prepares the practitioner to understand, let alone treat, even the simplest of presentations. Not only is their first instinct is to throw useless woo at medical problems, under the theory that if you have a hammer you nail, but they don’t even know enough to know their limitations which is perhaps the most dangerous character flaw in the medical world.

Sure, anybody can see somebody with a cold or some other minor complaint and the odds are good that nothing they do, provided they don’t get too jiggy with it, will do much harm. But let’s suppose that you have never rotated on a medical service or done your share of critical care. Suppose you have never worked in an emergency department or spent a few sloppy months on the labor and delivery floor. Imagine, if you can, seeing a provider for your family’s medical care who is treating your kids but has never had a lick of formal pediatric training or so little that she has never seen the really bad pediatric diseases that look like a little bit of nothing when they first present. Does your chiropractor, for example, know the odds that a fever in a neonate is some flavor of bacteremia that needs aggressive treatment?. Let us further suppose that while your chiropractor has spent hundreds of hours learning how a little normal misallignment in the spine can cause “dis-ease,” he has never had to recognize appendicitis, pancreatitis, or the first subtle hints of colon cancer. In short, while a lot of primary care is routine stuff, little potatoes that the school nurse would have to work at to screw up, not all of it is and if all you’re barely qualified for is to pass sick patients to somebody else as some kind of completely redundant middleman, maybe you should stick to the entertainment business and leave medicine to those with training.

Seriously now, there are whole groups of trained physicians, radiologists and orthopedic surgeons for example, who have not only legitimate training in general medicine but the legal license to practice any kind of medicine in which they feel comfortable who wouldn’t dream of doing pap smears or treating some kid with an ear infection because they are a little rusty in that kind of thing. Internists do not moonlight as obstetricians even if they have delivered a few babies in medical school and for my part, although I have done six months of surgery rotations in my training as an Emergency Physician, I’m not taking out anyone’s gallbladder anytime soon. I’m not adequately trained and I could not look the patient in the eye and ask for their trust.

Remember, also, that your primary care physician has a minimum of seven years of formal medical training. Your family physician has, in fact, done a lot of inpatient pediatrics, internal medicine, and a few months in the Pediatric and Adult Intensive Care Unit. The only legitimate question is whether a residency-trained primary care physician is over-qualified for many of the patients they see. The purveyor of snake oil doesn’t even rise to the threshold of qualification.

Mid-level providers and physicians practice in the real world of medicine and when confronted as we all are from time to time by the limits of our knowledge or abilities refer to a higher level of care. The Complementary and Alternative Practitioner, in a tacit acknowledgment that his therapies are ridiculous, will always defer to real medicine when he at last realizes that he is an ineffectual bufoon but only after exhausting his repertoire of snake oil. The danger is that there is no higher level of care in complementary and alternative medicine, just a hodge podge of smooth-talking clowns to whom the customer may be sent, and unless the chiropractor or naturopath honestly assesses his abilities (which would preclude him from even wanting to be in primary care) we’ll have a subset of sick patients who need real medical attention but are not getting it. Now, while this may be good from a strictly Darwinian point of view, allowing the oldest and sickest to die before they can become to much of a burden on society, this is not exactly a ringing endorsement of Complementary and Alternative Medicine.

Currently, the only benefit at all from CAM is that it keeps otherwise healthy people with no real medical complaints from clogging a medical system that is already overloaded, in part because of patients for whom nothing really needs or can be done. And it’s fine. I have long passed the stage in my life where I view it as a personal mission in life to cure others of their stupidity. It’s a free country and if you think you have it all figured out, then knock yourself out. The only money you are wasting is yours and you obviously have more of it than you know what to do with. The problem comes when public money and “quasi-public” money from private insurance pools is used to pay for this kind of things which is, I suppose, the Holy Grail of the Complementary and Alternative Medicine practitioner. That is, to get their claws into the the trillion dollar pie, which, unlike most economic pies, is indeed finite and not big enough to feed everybody all they want. For my part, I don’t think we even need to eat the whole pie but should instead save some for later.

The trouble is that when you leave a pie out and turn off the lights, the rats will edge towards it for their share. I’d like to protect the pie from the rats, both in real medicine and most especially from the exotic rats in the world of Complementary and Alternative Medicine.

Defending the Pie

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