Why Can't We All Just Get Along?

As far as doctors go, I consider myself fairly knowledgeable when it comes to alternative therapies. Other doctors consider me somewhat left-wing in my practices and policies although in a generally right-wing profession such as medicine I guess that really doesn't say much. I regularly recommend that my patients try chiropractic, massage therapy, acupuncture, or naturopathic medicine. I am a huge breastfeeding advocate, and support mothers who can breastfeed their babies beyond infancy. I am very anti-circumcision. I appreciate the benefits of such 'crunchy' parenting beliefs as co-sleeping, baby-wearing, and attachment parenting in general.

So because I know few people in real life who think the way I do (not to mention the very real problem of not really having the time to make any friends in the city I've been living in since starting residency), I often rely on the internet for information and to find people with common interests. In particular, I am a fan of message boards. One such message board that I won't mention (it's not my intent to start a war) seemed to be exactly what I was looking for-- there were reviews of cloth diapers, vegetarian and vegan recipes, information on natural health and healing and all kind of great information probably considered 'off the beaten path'. Just one problem.

They hated me.

Well, maybe it wasn't 'me' they hated. After all, I hadn't contributed anything at that point. It was more a matter of hating what I (voluntarily or not) represent. I first realized this when I ventured into a forum on vaccination. Vaccines weren't something I had spent much time thinking about through my medical training-- in emergency medicine, the only vaccine that had a role in the emergency room was the Td booster, which we offered to everyone who came in requiring sutures who hadn't received the vaccine in the past 10 years. I didn't really concern myself with people who refused it-- just explained the indication and documented that it was offered and declined.

In family medicine, however, they became more routine. But still, I hadn't thought much about them. They were routinely given at 2, 4, 6, 12 and 18 months. Only once did a patient take me up on my quick "do you have any questions or concerns about the vaccinations scheduled for today?". He was concerned about the mercury in vaccines. I assured him that vaccines in Canada no longer contained thimerosal with the exception of the flu shot, and he was happy with that. At his next visit, the same father asked about the use of formaldehyde in vaccines. I told him that I didn't know, but that I'd be happy to look into it for him. We delayed his son's vaccinations that day.

The 'Vaccination' forum would have been much more appropriately named the 'Anti-Vaccination' forum. A few clicks was all it took to realize that the nature of the forum went far beyond having evaluated the literature and deciding that the risks of vaccination outweighed the risks of contracting vaccine-preventable diseases. That, I can respect. But instead these people have decided that the entire medical profession is, at best, a bunch of ignorant and obedient pharma shills. At worst, we are voluntary conspirators pushing dangerous interventions on people to benefit our own pockets.

I have to admit that when it comes to something as seemingly benign and beneficial as vaccination, we're probably not as critical as we should be. We know what we've been taught-- and that is that vaccines have been proven safe and effective, that adverse effects are rare, and that the benefits of vaccines far outweigh the risks. It's not 'dogma', it's not a belief system, it's simply presented in the same way as every other one of a million other pieces of medical information that we, as physicians, are expected to know. And as with anything else, we should be prepared to discuss it intelligently with our patients rather than simply shutting down at the suggestion that there may be more to it.

But the anti-medical sentiment runs far deeper than the vaccination forum. Among the opinions presented as fact are:

• Well baby visits are simply an opportunity to push vaccinations and berate parents who choose not to vaccinate.
• Well baby visits exist solely for the financial benefit of physicians
• Physicians receive kickbacks from pharmaceutical companies for prescribing their products
• Physicians make up statistics to coerce patients to agree to certain interventions
• Physicians are "unethical liars telling women rubbish to suit their own purposes" in regards to childbirth
• Obstetricians are "knife-wielding surgeons who are bound and determined to slice you open no matter what your wishes"

It actually makes my stomach hurt. Poll a thousand medical school applicants and I can bet you that not one of them mention the desire to have people accept their word without question or perceive them as superhuman among their reasons for pursuing a career in medicine. But many of them will talk of a desire to feel like they're helping people, and working to better patient's lives. During medical school we are never taught trade names for drugs-- we refer to all medications by their generic names and discuss only broad categories rather than specific therapies (i.e. "use a beta blocker for this condition" rather than "use metoprolol" and certainly never "use Lopresor") and have no contact with the influence of drug companies. Again, unless things are dramatically different in the U.S. the ideas expressed on this board are ridiculous.

But it's a sentiment that goes both ways. Allopathic medicine is slow to accept, let alone endorse, many branches of 'alternative' or 'complementary' medicine. It took years for acupuncture to finally be endorsed by the medical community in spite of years of evidence in support of its benefits. Recently, when my family medicine group discussed a case where a woman came into my colleagues office asking about her opinion on the naturopathic remedies that had cured her condition, my colleague had to admit that she had no idea what to say or how to handle the situation. I suggested having a naturopath come in to speak to our group about some of the principles of naturopathic medicine and alternative healing-- it's something I've always wanted to learn more about and clearly it was an area of weakness for my colleagues as well. Instead my suggestion was met with uncomfortable silence. Instead it was decided by the group that we'll be having an MD give us a talk on alternative medicine. Um... right. Talk about defeating the purpose.

The attitude that practitioners of alternative medicine have against physicians and the attitude that physicians have towards much of alternative medicine is only hurting the patient in the long run. A recent study showed that 63% of patients over the age of 50 were using some form of complementary or alternative medicine, and nearly 70% of these had not discussed it with their doctor. Many of these women on the anti-vaccination board were advising each other to lie when asked if their child was up to date on their vaccinations to avoid questioning and condemnation. That can't be good for anyone.

Traditional allopathic medicine has much to learn from the world of naturopathic and alternative therapies-- we should be keeping an open mind and ensuring that we have (at minimum) a basic knowledge of the therapies and techniques available. Alternative medicine would gain more acceptance by traditional medicine by shelving the adversarial attitude and through more rigorous scientific testing of their therapies.

It's too bad that each side has to feel so darned threatened by the other.

Why the Nurses Love Me

Yesterday morning I was rounding on a patient who is on the surgical floor, awaiting an ERCP. I was discussing some issues with the charge nurse when a middle-aged man in scrubs approached the desk.

"Who is Sue?" He boomed, clearly expecting immediate attention.

The charge nurse turned to him. "We've both been working here over 20 years and you still don't know my name?"

The man in scrubs shrugged, clearly unmoved. "Nurses are generic."

And with that, he grabbed a chart, spun on one heel and left. Nurses rolled their eyes in the general direction of his back.

"Who the hell was that?" I had to know, if for no other reason than to avoid him carefully in the future.

"Dr. Pompous,"* she replied. "He's the oral surgeon. He doesn't come in much, which is probably why you haven't met him yet."

Thank God. So Sue and I go back to our discussion of how to best reverse my patient's anticoagulation until Dr. Pompous blows back into the nursing station.

"I want her NPO today before I touch her." He announced. I had been in mid-sentence, a fact which clearly did not faze Dr. Pompous. He stepped in front of me to address Sue as though I wasn't even there.

I saw red. This kind of bullsh*t might be shrugged off my the nurses, but I didn't have to play the academic hierarchy game anymore.

"Oh, I'm sorry," I said loudly, "I thought I was speaking here."

Dr. Pompous stopped in mid-sentence. He turned to face me with an eyebrow raised, clearly trying to size me up.

"I'm sorry," he said, clearly not sorry in the least. "I'm Dr. Pompous. And you are?"

"Dr. Couz," I replied, putting the emphasis on the title. I didn't explain further.

That changed the game a bit. He sputtered a bit, then backed down and let me continue my conversation with the charge nurse.

If I were a little gutsier, I would have replied: "I'll try to remember your name, but surgeons are generic."

Freaking surgeons.

* Names have been changed to protect the innocent... and the pompous.

Some Patients Just Don't Get It.

A hypothetical conversation:

Random Person: The thing I hate most about my family doctor is that he's always running behind. I have to wait at least an hour every time I have an appointment. It's so inconsiderate.

Me: Yeah, that's rough. But people frequently come into their family doctor with 3 or 4 problems that they expect to have managed in one appointment, even if their appointment was just for a prescription refill. It's hard from the doctor's point of view as well.

Random Person: So then the asshole doctor just rushes the patient out the door. It's so rude.

Me: Which would you prefer... to have the doctor allow you as much time as you need to deal with all of your problems and not feel rushed, or run perfectly on time?

RP: I shouldn't have to choose. These doctors are only in it for the money. They schedule too many people. If they'd just schedule patients further apart, like every 20 minutes or so, they'd run on time and wouldn't rush me out the door. But they're too greedy, and want to make more money.

Me (trying to supress hysterical laughter): Actually, very few doctors in Canada (in urban centres, anyway) are still paid on a fee-for-service basis. So they get paid the same regardless of how many patients they see per hour. They're paid based on the number of people enrolled in their practice.

RP: See? So they SHOULD be booking less.

Me: How long does it take you to get in to see your doctor?

RP: If it's urgent, within a day or so. But for other stuff I have to wait 1-2 weeks. And for general physicals, sometimes I have to book a couple of months ahead. It's awful.

Me: (no longer able to avoid sarcasm) Well, when your doctor starts seeing half the number of patients a day so that you don't feel rushed and don't have to wait, I'm sure it will be much easier to get in to see him quickly.

Sigh.