Lakeside Medical Musings

My Science vs. Their Beliefs

In thirty-two long years of full-time medical practice, I have never had a malpractice lawsuit filed against me.  (Knock wood.) When younger physicians asked me how I was able to manage this against-all-odds feat, I would put my hand on my grizzled chin, cock my head to the side, and gaze upwards to the stars.  “Compassion, knowledge and empathy are the keys to avoiding getting sued,” I would reply, as if speaking from an oracle.  After a few portentous seconds, I would then burst into laughter and say, “No, seriously, I have been very lucky. All physicians make mistakes in medical care and sometimes patients have bad outcomes. As an internist, you are really lucky if you never get sued.   It certainly helps if your patients like you, and if they feel you like them and care about their outcomes, but luck plays a big part in it.”

There is one thing I did throughout my office-based practice years that actually did reduce my risk of getting sued.  I never hesitated to tell patients who had fundamentally different views on medicine than I did that they would be better served by another physician with whom their views were more compatible.  One such patient was a good friend whom I played golf with almost every Saturday morning, and I saw him in the office to take care of his several, quite serious, medical problems.  After two years of taking care of him, it became very clear to me that he did not want to be inconvenienced by my requirement that patients come in for essential follow-up visits; he just wanted me to call in refills for his medications.  As uncomfortable as it was for me when I had to tell him to find another physician, I did not want to feel badly about my golfing buddy dropping dead from prescriptions that I had refilled without appropriate monitoring. He understood my feelings and found another physician, and we continued to play golf together.

Today I want to tell you about a memorable patient of mine who favored alternative medicine over traditional medical care.   This is especially topical with all the publicity that the measles surge is getting in the press. I have to say, if I was still in an office practice today, I would not have anti-vaccine patients in my practice.  The reasons for this are about the division between science and “belief,” not about the patient’s right to make basic choices for themselves and their families, versus the good of the public health; that is a different topic altogether, one for a future blog post. The anti-vaccine devotees do not base their stance on readily available medical data.  That is not to say that data and medical recommendations don’t evolve, but for me, I want to make my healthcare decisions based on the best available data-driven information, not on the photogenic Dr. Oz darlings of the media world, or on the conspiracy theories behind the pharmaceutical industry, or on a paranoid view of the entire medical community. On CNN last night, I watched as an anti-vaccine advocate explained her “belief” that vaccines don’t actually prevent illness and are toxins that the medical community knowingly introduces into a naturally healthy body.  When confronted with the fact that the United States went from 100,000 cases of measles per year prior to the vaccine becoming available, to virtual eradication after vaccinations became required for school children, she stated that she felt this statistic was related to the natural ebb and flow of diseases, not to the efficacy of the vaccine.  Seriously? What does an intelligent person even say to that kind of statement? And this is a spokesperson for this movement??

According to Dictionary.com, the definition of a belief is “an opinion, a conviction; confidence in the truth or existence of something not immediately susceptible to rigorous proof.”  It further states that a belief is “a mental attitude of acceptance or assent toward a proposition without the full intellectual knowledge required to guarantee its truth.”  Should critical medical decisions be based on science, which IS “immediately susceptible to rigorous proof,” or upon belief, which is not?  We have numerous studies available to us, based on rigorous proof, that vaccines are not the cause of autism in children, see here,  and that vaccines have saved hundreds of thousands of lives around the world by eradicating such once-terrible scourges as smallpox, typhoid, polio, and, yes, measles.  I vote for science every single time, over belief, even when science evolves or changes based on new data.

So here’s my story. Early in 1992, I was beginning a typical afternoon seeing patients in my Roswell office. I was in the process of transitioning my practice from in-town Atlanta out to the suburbs where Ruth and I had bought a house with easy access to tennis courts and a golf course, my idea of non-call weekend heaven.  Mornings in my Atlanta office were very busy, but afternoons in my Roswell office were still pretty slow as I was in the early stages of building a practice out there. How slow? Well, I remember I had only two patients scheduled for that entire particular afternoon, one a new patient and one an established patient coming in for a follow-up on her medications.

I always began appointments with my new patients, as well as patients coming for their yearly physicals, in my consultation room.  I found that patients had an easier time talking in this setting, fully dressed in their street clothes in a comfortable chair, as opposed to sitting on an exam table wearing only a patient gown.  My new patient was a 32-year-old woman with short dark curly hair for whom walking was clearly painful. I introduced myself; she gave me a wan half-smile and, in answer to my questions, she began to tell me her story.  She had recently moved to Roswell from upstate Connecticut.  She had a lot of pain in her knees and was having trouble getting around.  She had been to her naturopath who had done a series of tests in his office; he told her that her medical problems were due to the fourteen different parasites he had found in her body as well as four micronutrient deficiencies.  The naturopath put her on a cleansing program and prescribed dietary supplements and an entirely different diet.  She spoke at length to me about how much she believed in naturopathic medicine and how this approach had kept her so healthy.  But even after following, to the letter, the recommendations of the naturopath, her joints were still very swollen and sore, and she thought it was time for a second opinion.   I listened intently, but it was clear to me that I would not be a good match for this patient.  When she finished telling me her history, I told her that it sounded like she did, indeed, have a significant medical problem, but I was not a believer in naturopathic medicine, and I knew of no reputable office test that could, within five minutes, diagnose the existence of fourteen parasites.  I told her I did not believe in “cleansings” or put any stock into the supplements that she raved about. I told her that I honestly felt she would be better served seeing a physician who shared her medical beliefs.  I was kind, but I was firm, even though my office waiting room was empty of patients.  She looked at me and started to cry.  She told me that she didn’t have medical insurance and had already spent a large amount of money with her naturopath, and now she didn’t know what to do.  She promised that she would follow my medical advice, she was feeling so poorly, and please, would I try to help her?  I told her that I was uncomfortable doing so, but I would examine her, and we could talk after that and decide what would be best for her.

When I entered the exam room, she was sitting on the exam table in her gown.  I began my usual physical exam, starting at her head and moving down her body.  When I examined her knees, I was shocked to find huge effusions in both knees.  (An effusion is fluid inside the joint, also referred to as “water on the knee,” and it feels very much like a water balloon.  You push on one side of the knee and the fluid moves to the other side.)  It was no surprise that she was in so much pain. I finished my exam, and I told her that her knees were, indeed, quite inflamed, and I needed to do blood tests and drain some fluid from her knee to send to the lab for analysis.  I told her this would not be a quick process, and it would require a number of visits.  I also told her that I might need to send her, at some point, to a medical subspecialist, but I could start all this now.  “What do you want to do?”  I asked her.  She told me that she wanted me to take care of her but due to the cost, she would prefer that I not send her to a subspecialist.  I told her I couldn’t promise that because I didn’t yet know the scope of what was wrong with her, but I would do my best.  I aspirated some fluid from her knee and drew a number of blood tests.  I gave her some anti-inflammatory medication and scheduled her to see me the following week.

Over the next few days, as the lab results came back, all indications pointed to Lyme disease.  I had never seen a case of Lyme in Georgia, so I called one of my Infectious Disease physician friends and told him what I had found.  His response was amusing.  “There is a lot of Lyme disease diagnosed in Georgia.  There isn’t a lot of Lyme disease in Georgia, but there are a lot of diagnoses of Lyme disease!”  Lyme disease was the “disease du jour” in the early 1990’s, and there were “quack” clinics that had popped up all over the place that specialized in giving this lucrative diagnosis and managing its subsequent very expensive infusion treatment procedures. Until a few years ago, there was a similar scam running in Charlotte.  See here. But my ID physician friend said it sounded to him like this patient did, in fact, have Lyme disease.  Her risk factor was significantly higher since she had recently moved from Connecticut, a state which has a very high, and very real, incidence of Lyme.  He told me the antibiotic regimen that I should follow and to stay in touch with him if I had any questions.  I didn’t give antibiotic infusions in my office, and the patient didn’t have insurance coverage to receive it at the hospital, so after a good number of phone calls, I arranged for her to receive the infusions at the county health department at no charge.  The treatment was four weeks long, and I saw her weekly to check her for side effects of the medications and to monitor her progress.

Four weeks later, she came back to my office for her last visit.  She walked into my office without a limp, and she had a huge smile on her face.  She was lucky that the infection had been caught and treated at an early enough stage, and she seemed to be fully recovered.  I have to say, there is nothing in a medical career that is more rewarding than making a difficult diagnosis and being able to treat the problem to a full and positive resolution.  The patient beamed, and so did I.  She thanked me profusely, again with tears in her eyes, but this time, they were tears of happiness, not of pain and despair.  I told her that I didn’t need to see her again for this problem, but I would be available if she got sick or needed routine preventative care.  She lowered her eyes and said that she had given a lot of thought to this but felt that she probably was more comfortable, in the long run, seeing her naturopath and thank you very much for everything, but she would be going back to that doctor.  I was floored, but I controlled my emotions and said, “Whatever you think is best.  Good luck to you, and stay healthy.”

In answer to your question, yes, I was angry and confounded. She clearly liked me, we had developed a good rapport over the four weeks, and she was overjoyed with her treatment outcome.  I had spent a lot of time, as well as my own money for lab tests, on this patient and, even after an incredible recovery, she still wanted to see her witch doctor.  Fourteen parasites??  She could have died from an undiagnosed case of Lyme disease! At the time, I thought the lesson I had learned was, “No good deed goes unpunished,” but as time has passed, I have concluded that I have no idea what I learned.  I hope her health continued to be excellent, but I never again retreated from my core belief that patients who want that kind of medical care, must get their care from those kinds of providers, and not from me. My science is no match, ever, for their “beliefs.”

 

 

8 thoughts on “My Science vs. Their Beliefs

  1. W. Loofbourrow

    John, if you haven’t seen it, check out http://www.naturopathicdiaries.com. I’m not a doc, just a scientist, and I have zero patience with quackopaths. As pointed out in many posts on quackwatch.com, the scumbags can cause real harm, and your firing patients who are True Believers makes perfect sense–they expect magic, not medical care, and if you don’t provide magic they might very well be inclined to sue.

    I suspect that quackopaths don’t get sued as often as docs simply because there is no standard of care. It would be kind of difficult for a mouthpiece to argue that, say, hydrotherapeutic quantum qi positive energy balancing caused harm given that it doesn’t actually exist in this particular universe.

  2. Martin Kettling

    This just floored me. To return to a path that left you in pain is not simply ignoring science, it’s discounting your own experience. This rises to a level of confirmation bias that I don’t quite know how to handle. I’m going to go sit down and hold my head awhile.

  3. Chip Sawicki

    This is a classic example of emotions vs. logic. For certain people, you will never be able to convince them that two plus two equals four if they “feel” like it equals something different… or at least not until they are in enough pain!

  4. John Post author

    I share your concern about the government’s right to require a behavior. Public health has always been an exception. Vaccinations and antibiotics are arguably the biggest contributions to health care improvements in the last 2 thousand years. I think your public school suggestion is the best and easiest approach to improving vaccination rates. I would only exclude those who have a medical reason to avoid vaccination, not a philosophical one. I would require private schools to follow this as well if they get any federal money or are accredited. Home schooling is a potential leak where kids could avoid getting immunizations but they would still need them if they were to participate in after school activities at public schools. In a society are large and complex as ours individual rights are sometimes lost for the good of society. Thanks everyone for reading and commenting.

  5. hermousiegoodness

    There was something on NPR this morning about how making a logical argument against a strongly-held belief (like, being against vaccines) can actual _harden_ a person’s position (gotta go find it and hear it again). One would like to think that an actual experience like this woman’s (she paid a lot of money to the naturopath for zero results; she got very favorable results from you in very short order) would cause her to change her mind…but I guess it’s that same sort of reaction to a logical argument. I am a scientist, and it is wildly frustrating to me to see people reject good science for nothing more than a gut feeling. I can’t imagine what it must be like to be trying to help people who turn around and reject the very things you know can be beneficial to them – even when they are already paying a price for that.
    I look forward to your post on vaccinations (looks like that will prompt some lively discussion). I myself predate the MMR vaccine, so I got to experience the joys of acquiring natural immunity – long enough ago that I’ve forgotten the details. It looks like you may have started practice at a time when the disease rates were really dropping – did you ever have to deal much with measles?

    1. John Post author

      I experienced the mumps and chicken pox but was vaccinated for Rubella and Measles so never had them. I honestly have never seen any of these diseases in my practice as they became quite rare. When my premature daughter came home from the hospital my son developed chicken pox on that very day. Everyone was fine, but it was very stressful. I am glad those days are over for me and should be for everyone else. I am not sure I will write a blog on vaccinations. There is so much already in the news that I don’t know how much I can add. It is frustrating to try to give someone informed consent about a treatment when the information does not support someone’s gut feelings or beliefs, you are correct.

  6. johnadams1782

    “Fillet of a fenny snake, In the cauldron boil and bake;
    Eye of newt and toe of frog, Wool of bat and tongue of dog,
    Adder’s fork and blind-worm’s sting, Lizard’s leg and owlet’s wing,
    For a charm of powerful trouble, Like a hell-broth boil and bubble.
    Double, double toil and trouble; Fire burn and cauldron bubble.”
    (Macbeth, Act 4, Scene 1)

    The above makes about as much sense as your patient’s belief in faith healers. As much as I (and I imagine you) believe in the power of the mind to AID healing, an apple a day won’t keep you or others in your profession away.

    You also mentioned the measles outbreak, and I have conflicting ideas on vaccinations. On one hand my libertarian viewpoints give me pause to give the power of government to force its citizens to do anything. That said, someone with Ebola should not be permitted to infect others. So, my somewhat convoluted view would be that if society is at great risk from someone’s actions, then that person has to be prevented fron imposing that danger. I guess an example might be that if parents chose not to allow their child to be vaccinated, then the public school’s should have the ability to ban the child from school.

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