Monday, February 29, 2016

Tales of the Profession, part 1

So I just finished reading the evaluation comments from an educational speech I gave back in April. Most of the comments reflected a general pleasure at an opportunity to learn more about a strange and complicated therapy that clinicians don't really get to learn about much (homeopathy). Of course there are always a few folks one can't reach--that always challenges me to consider improvements to my teaching methods.

Today I'm focused on a few specific comments that concern me, and they should perhaps concern you too.

Let me provide some background. The talk was a one hour presentation about homeopathic medicine to a group of medical providers, mostly nurse practitioners and physician assistants, some nurses and a handful of physicians. One hour. What does one talk about? There are several possibilities. One could focus on the science, such as clinical trials, or studies that summarize many trials. I could address specific criticisms of homeopathy, like the highly diluted remedies or the method of remedy selection itself. But I think that would put the cart before the horse--after all, if one doesn't even know the basics, how would one understand the criticisms? The science  would seem out of context.

I could teach the historical development of homeopathy, and that could include the "how" of homeopathy, how it works in practice. But this was a talk to clinicians, and not merely a history lesson. These people want to know how to begin to use it. When I first started out, I used simple, low potency, over-the-counter remedies for self-limiting conditions like colds and bee stings. It's how a lot of professional homeopaths begin their interest in the art.

So I decided to disclaim the science up front, and the history. That is, why not just tell folks that this is how it's done and the history and maybe a little bit of the scientific proof could be included, but I only had an hour so I'd focus on the nuts and bolts. "Try this at home!"

So, back to the comments.

Several people--and these were a minority--worried over the scientific rigor. "Where are the studies?! " Others seemed concerned with things unrelated to homeopathic medicine, such as the interactions between St. John's wort and medicines. (I was careful from the start to explain the difference between homeopathic medicine and herbal medicine, since these are often confused, even by professions who ought to know better these days!) Another: "He did not present any proof homeopathic medications work..." which is true. As I noted, I had an hour. I chose to focus on the open minds.

But wait! Isn't scientific proof important? In the 1980s the New England Journal of Medicine reported that perhaps 85% of medical practices were unsupported by any evidence. This created the "Evidence Based Practice" revolution. EBP has since spread and become the dominant force in medical practice, which is mostly a good thing. Unfortunately it's also created a rigidity of thinking, a prejudice, that closes minds to thinking outside the box. How can one listen with an open mind and an open heart if there's a requirement for a list of double-blind placebo controlled trials first? If I'd had all day, I could have provided that kind of structure, or assigned readings ahead of time. work with what you have. What concerns me is that these are people who might be closing their minds to possibilities, and to the customs and habits of their patients. Instead of listening and learning, they just frown.

(By the way, a ton of medicine is still not based on clinical trials. Much is still based on expert opinion, consensus statements, and the like.)

I have learned so much from my patients, and some of the stuff they have tried that "cured" or helped them I have to admit sounds pretty weird. But medicine is weird. Humans don't read the studies and they don't follow the textbooks. Science moves ahead in small steps, and no matter how detailed it gets it'll never cover every imaginable situation in real life.

What makes me feel good about that talk and the audience comments is that a lot of the folks who attended took it for what it was: a chance to learn a little bit about a big subject in a short time. Those people aren't stupid; they will have more questions about the science and applications of homeopathy. Some might even be willing to "play around with it" safely, like I did when I was learning. Or if it seemed unappealing, well at least they understand more about what their patients might be doing!
What makes me feel bad about it is that there still people out there, practicing medicine, whose minds are still locked in a model of medical prejudice that calls Science its god. But it isn't a god. It's a method, and it worries me that there are still so many people who apply that method in a limited way.

People say they "believe in science." That's rubbish. Saying one believes in science is like saying one believes in wrenches. Both are tools. Science is a philosophical tool that enables us to probe the limits of knowledge. If one really believes in the utility of the tool, then one should profess to keep an open mind. That doesn't mean "anything goes", that we can just make up "facts" or believe in facts we like. It means we recognize the limits of our knowledge, and understand how influenced we are by our culture and by commerce. Big corporations have bought a lot of "science"; that doesn't make it good science. Just because a phenomenon cannot be easily explained doesn't mean it's wrong or without merit.

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