"Alternative medical income" (a.k.a. "woo pays the bills")

I've written a lot about alternative medicine, much of which I consider to be woo; i.e., treatments for which there is no medical efficacy and the belief in which often requires magical thinking. I've expressed my disappointment in medical physicians who fall prey to and become purveyors or woo, doctors such as Dr. Deepak Chopra, Dr. Joseph Mercola, those pushing to "integrate" woo into medical school curricula, and physicians who sell expensive "screening tests" such as breast MRI whose value has not been shown in valid, well-designed clinical trials. All of these activities represent, to me, a betrayal of what we should stand for as physicians and, yes, healers.

Unfortunately, thanks to declining reimbursements from insurance companies and the government, more and more physicians are being tempted to make up lost income by turning to woo, and the results are not pretty, as a recent article in TIME Magazine shows:

Removing hair from unmentionable parts of ladies in Westchester County is how my friend Jerry spends a good part of his week. Not that there's anything wrong with that, except Jerry (not his real name) is a cardiologist, trained at one of the finest medical programs in the country. Trained to save lives. His expertise is the complex and delicate management of congestive heart failure, but he gets paid a lot more to do a laser Brazilian.

Another friend tells me about the "magnetized" water and testosterone ointment he sells to folks who have seen his antiaging ads in shopping circulars. He was a brilliant pathologist; I once entrusted my patients' lives to his call on biopsy specimens. He began making a few extra bucks with naturopathics, then enough to quit real medicine altogether. I trust little about him since he started with the magnetic water because I know he knows better: he passed physics to get into med school. But now he can finally afford that Range Rover he's had his eye on.

If I want to buy a stock or mutual fund, I can call up my old friend the ob-gyn. I know three anesthesiologists who became financial analysts with investment firms. Two radiologists run imaging businesses, and a good orthopedist friend dropped out to put up magnetic resonance imaging (MRI) facilities. Each trained hard for at least nine years to join his field of medicine. In no case could leaving have been an easy divorce.

So here is the cause of your doctor's pain in 2007. Behind him or her is a 15-year trend of diminishing fees that shows no signs of abating. Graduating med students aren't blind; they see established physicians with busy practices dropping out. Looking ahead they see more headaches--more controls and regulations, more scrutiny, more liability, less money. So what has the resourceful American doc done?

Welcome to the world of alternative medical income. Some docs leave medicine; six weeks of securities-trading classes and you can be a stockbroker. Most try to do something quasi-medical. Three top bailout categories of this sort have emerged: cosmetics, diagnostics and what I call "nothing-really-works-anyway therapies" (NRWATs).

I know, I know. A lot of you out there are thinking: Boo-frickin'-hoo! (Except that you're probably using the real F-word.) And maybe you have a point. Even in these days of declining reimbursements and rising malpractice premiums, the vast majority of doctors nonetheless do better than around 90% of the wage earners in the population, the exceptions being, unfortunately, many pediatricians and primary care doctors in non-procedure-oriented specialties. Certainly, even in academics, I manage to make a comfortable income. To some extent, I sympathize. But I can also understand how some who don't have a big a commitment to evidence-based medicine as I do and a straight salary that doesn't depend (much) on my clinical productivity might find the prospect of a little (or a lot of) income on the side pushing woo or doing cosmetic semi-medical procedures like laser hair removal to be highly tempting, and they do:

Headaches, heartaches, backaches, aching feet, fatigue, anxiety and those vague, burning pains in your legs at night--these are the nemeses of real doctors. Many people have these symptoms, but the cruel truth is that there is no reliable cure for any of them. Clever doctors watching their incomes melt away have taken notice, establishing all sorts of lucrative NRWAT practices. They've become chiropractors, osteopathic manipulators, prolotherapists, postural therapists, acupuncturists, even Therapeutic Touch practitioners. Each of these therapies proclaims the existence of force fields, bodily reactions, energies or auras that simply cannot be measured or observed scientifically. The "patients" who pay these docs run the gamut from the hopelessly deceived to the downright self-indulgent. But lest we look down too haughtily on NRWAT providers from the moral high ground of real medicine, we must admit that their patients come back again and again, seemingly happy with the treatments. And they pay them with real money--which seems, alas, to have become the whole idea.

That is true; many, if not most, patients who are into woo like therapeutic touch are often quite satisfied, leading reasonable people to ask: What's the harm? A lot of this stuff, as the author of this article so perceptively calls this woo, "nothing really works anyway therapies." And patients will pay, cash on the barrelhead, without all that nasty paperwork that insurance companies or Medicare demands in order for a physician to claim reimbursement. It's very easy to see how using the authority of one's M.D. to peddle a little seemingly harmless tonic might be very tempting indeed when income remains stagnant or declines in response to forces that a physician has no power over. And, besides, what isthe harm, anyway? Most of these treatments (but certainly not all) probably do no harm, although in the case of cancer and serious diseases they most definitely can delay the use of known effective treatments. But most physicians don't treat cancer with woo; they treat backaches, headaches, anxiety, and other milder ailments. It's not as though many of these physicians are recommending the Hoxsey therapy instead of chemotherapy for cancer, for example, fortunately. I reserve special contempt for physicians who use woo to treat cancer instead of evidence-based medicine. But how far towards woo is it acceptable to go?

As Dr. RW points out, this very question was studied in a survey published three months ago in Medical Economics entitled, What Would You Do? Alternative Medicine. Here was the scenario:

Frank, a 55-year-old teacher, has colon cancer that has metastasized to several lymph nodes and extends through the middle tissue layers of the colon wall. In addition to resection, he has undergone two rounds of chemotherapy. He says that he found the side effects of chemotherapy intolerable, and he wants to be treated instead at an alternative center that rejects what its founders call "toxic" treatments in favor of "natural" remedies, including chiropractic, whole-grain diets, and meditation. After acknowledging that his oncologist has expressed disapproval of the alternative treatments, Frank asks you, his primary care doctor, to serve as a collaborative physician with the alternative center.

If you were Frank's doctor, what would you do?

And here were the responses:

How do these results relate to doctors embracing woo? First, look at how few physicians would stick by their guns and try to guide the patient away from woo and back towards sound evidence-based medicine. A mere 21%. And look how many would collaborate with the altie center without any caveats. That number truly depressed me when I saw it, particularly when coupled with at least one of the comments in the article, who justified his collaborating with the center by saying, "He's going to die anyway." Contrary to what some doctors answering the survey said, the prognosis for this tumor described, although not fantastic, is by no means a death sentence. By the description given, this was probably a Stage IIIB or IIIC colon cancer (depending on whether four or more lymph nodes were involved), for which the expected five year survival is in the 30-40% range. True, that's not that good, but it's very incorrect to say the patient "is going to die anyway." One third or even more of patients like "Frank" can be "cured."

The second point is that nearly 80% would collaborate with woo simply because it's what the patient wants, even when they know there's no good evidence that it does anything therapeutic. My problem with this, of course, is that collaboration implies approval. But there's another pernicious effect. From a willingness to collaborate with woo-meisters, it's not all that huge a step for a physician to wonder if there's anything so wrong with going beyond collaborating and becoming an active participant in giving the patients what they want, even though they know it's not good medicine, particularly if it's for diseases for which "conventional" has a paucity of effective treatments. Sometimes physicians don't go quite this far and instead start incorporating woo like therapeutic touch or even homeopathy into their practices in addition to standard evidence-based medicine, fearing that their woo-steeped patients will leave them otherwise. Att least such patients are getting appropriate conventional care, reason such practitioners, but even this approach is an ethical minefield, because, again, the physician is putting the imprimatur of scientific medicine on woo. As Dr. RW points out, though, it's possible to respect your patient's world view even when it's steeped in woo and still remain true to yourself:

A common justification by mainstreamers for their pseudoscience promotion is that doctors must respect patients' beliefs and choices. Implicit in that argument is the tired canard that telling the truth about unproven methods and respecting patients' choices are mutually exclusive. My own experience with patients is different. It is possible to tell the truth with respect and agree to disagree. If the patient is deeply steeped in woo I simply acknowledge our opposing world views and explain that in order to maintain a sense of professionalism I must remain true to the world view I believe in and was trained in and in which is western science. In this manner it is possible to respect patients' beliefs without agreeing with them. It is not necessary to promote quackery, even implicitly, to treat patients with respect. I've found that even patients who are extremely into woo accept this approach.

And so have I. In reality, most of the time, when a woo-steeped patient comes in for a consultation, my approach is to explain my viewpoint and try at least to get her to accede at least to surgery, because most significant number of women with operable breast cancer are cured with surgery alone and the consequences of not at least removing the primary tumor can be horrific.This can be accomplished in a nonconfrontational manner while respecting the patient's beliefs. However, like Dr. RW, I will not collaborate in a treatment that science tells me to be either ineffective, unproven, or so scientifically implausible as to be not worth investigating if it is being chosen instead of what I know to be effective care. If the patient is doing it on the side, I will not object as long as I know it doesn't interfere with treatment (drug interactions with herbal remedies, for example), but neither will I facilitate access to such remedies. I will simply ask to be informed and remain nonjudgmental.

Still, I'm in the proverbial "ivory tower," in an academic medical center. Such woo-steeped patients are actually surprisingly few compared to what I had expected when I started here, and that's probably because most patients seeking woo probably don't come to academic cancer centers when diagnosed with cancer. Sometimes I ask myself if I could maintain my purity of devotion towards EBM if I were in the trenches in a private practice. After all, here I'm paid a straight salary; although I make less than I could potentially make in private practice, I don't do too badly. I'm at the moment largely buffered from the financial effects of declining reimbursements, and the university is self-insured, meaning that I don't have to worry about how much malpractice insurance costs despite practicing in a state that's a malpractice free-for-all that obstetricians are leaving in droves. If I had to face what my colleagues in private practice face, I have to wonder whether I could resist the urge to make a little on the side with woo.

Heck, being in academics, I sometimes wonder if the only reason that I've resisted other ethically dubious incursions into unproven or dubious therapies that are mainstream, not alternative, medicine, such as this or this, is because my laboratory investigations are a bit on the esoteric side and my clinical responsibilities are intentionally kept light.

I like to think that none of that would matter, but, then, I could never really know that unless I tried to survive in private practice for a while.