Last week my colleague and I spoke at CME opportunity for Swedish Hospital physicians. Our topic, chosen for us by the coordinator of the CME courses, was “Probiotics, Food Intolerances, and Supplement Use in the Pediatric Population.” For most naturopathic physicians, these subjects are both an integral part of practice as well as some of the more controversial topics in conventional medical communities.
I went to the talk with a hopeful mindset, but was glad I prepared for the worst. Despite our transparency in clarifying both strengths and limitations of the research on these topics, we weren’t even able to finish our 20-minute presentation because of incessant verbal opposition. Had the questions posed to us been related to research, our clinical experience, and/or pediatric naturopathic medicine, we would have been glad to answer them. The majority of participants seemed interested in what we had to say; by a quarrelsome few, however, we were asked to define the word “natural” (which was not used anywhere in our presentation) and were told by one participant, “Let’s just be honest with everyone here: food has nothing to do with patient symptoms.” I couldn’t help but feel unjustifiably antagonized. I usually prepare myself for this sort of response, but have learned that many conventional medical practitioners are at least open, if not eager, to learn about naturopathic medicine and how to co-manage or incorporate our principles into their practice. The low point of the talk was being told by a participant that our 10+ years of clinical experience and training (compared with conventional medical education in this chart) added up to nothing more than the placebo effect.
Treat the Patient Not the Labs
First, I would like to point out that labs and research are meant to be used to inform – not dictate – primary care medical decision making. I believe it is important to use labs to further assess symptoms and, when necessary, to rule out more pathologic diagnoses. Any of my patients, friends, and family members know that I very rarely recommend a treatment outright without discussing the research available as well as pros and cons. I use objective measures to assess changes in patients including laboratory medicine, thorough physical exam, standard self-rating scales and questionnaires. At follow-up visits, I am equally skeptical of complaints getting better completely as I am of complaints remaining unchanged. I believe it is important to consult a healthcare provider for even the most minor dietary and lifestyle changes, because it helps to have an objective opinion from someone trained to assess health conditions.
Establishing and utilizing algorithms to make complicated medical decisions (especially in emergency or life-threatening situations) is very important; we need to have protocols to follow when our decision making can significantly alter the patient’s life or death. I use protocols a lot in situations where I am trying to prevent certain forms of cancer or prevalent causes of death (PAP and cervical cancer guidelines, breast cancer and colon cancer screenings, protocols for timing of lipid and blood glucose monitoring in diabetes, etc.), but I also think that algorithms and protocols used in less serious situations tend to discount the individuality of each person. For example, many patients come to my office with complaints of fatigue, headaches, allergies, skin conditions, and abdominal pain. Headaches alone can be related to blood pressure, electrolyte balance, dehydration, adrenal health, digestion, hormonal imbalances, histamine sensitivity, sulfite sensitivity, genetic mutations involved in methylation reactions in the body, blood sugar balance, and sleep (to name a few). If I gave everyone over-the-counter or even prescription headache medications to treat their headaches, I would be missing a substantial percentage of people who would benefit from other interventions. It is absolutely necessary to find the cause of imbalance, taking into account laboratory measures, standards of care and protocols when necessary.
The Placebo Effect
Many medical practitioners I have encountered shun the placebo effect in practice, but I also think it’s important to point out the power of the placebo. For example, check out this meta-analysis of placebo-controlled trials on resolution of sinus infections with antibiotics versus placebo. In general, placebo scores very high in relation to antibiotics, and antibiotics confer more side effects. An excerpt from the article:
“Five of the nine placebo-controlled studies involving 1058 participants found that most participants got better within two weeks, regardless of whether they received the antibiotic or not (roughly 9 out of 10 participants in antibiotic groups and 8 out of 10 in placebo groups)…The small benefit gained by antibiotics may be overridden by the negative effects of the drugs. In addition to patient-related adverse effects (like skin rash and gastrointestinal problems such as diarrhea, abdominal pain and vomiting), side effects include the risk of increased resistance to antibiotics amongst community-acquired pathogens (bacteria).”No one can deny that upon becoming a doctor (or health care practitioner), you either intentionally or unintentionally adopt a certain amount of power that accompanies your recommendations. With this power comes great responsibility to inform and not mislead our patients.
So what is the placebo effect? In my mind and experience, it is a complex set of emotional and physiological phenomena that cannot (yet) adequately be explained by simple, biochemical, environmental, or research-based methods. Does this mean we should discount these changes in patients as “made-up” or irrational? Absolutely not. Why do most people feel improvement of their symptoms while on vacation? Are they making it up? I argue no. These changes are actually happening, in the physical body, due to a change in feelings and mindset. We are now discovering through research the complex effect that stress and dissatisfaction have on our health; we now know through research that stress and mood affect learning and memory, gene expression, aging, sleep and weight gain. Is unreasonable to believe that positive emotion could have a contrary, protective effect on our physical health? We have the research to back up the effect of emotions on our physical bodies, but it remains difficult for physicians to monitor the often immeasurable changes that are occurring in our patients when they feel supported and cared for. And thus, they are often discounted.
We cannot quantify the placebo effect in being told that a substance, dietary intervention, or lifestyle change will help one feel better; however, I don’t think it makes these interventions any less powerful. I think this is mostly accomplished in naturopathic medicine through listening to our patients tell their stories, and helping them feel truly heard. If listening, counseling, modifying diet, and lifestyle change keep the patient off of long-term medications, decrease pain, and help patients enjoy their lives in a more fulfilling way, then I will continue to support what other practitioners are calling the “placebo effect.” Just because an intervention is not drug- or surgery-based does not mean it is invalid or inappropriate. It means that there are mechanisms – genetic, neurological, and hormonal – that we don’t yet understand in research, and that we must employ common sense and a caring heart in order to see people truly heal.
Though the effect of emotion on health is not well understood in double-blind, placebo-controlled studies (mostly because research is very driven by the profits anticipated from results), it is common sense that feeling good emotionally helps us feel better physically. If a patient feels better on a meditation program, energetic medicine, exercise regimen, supplement, or diet that I am unfamiliar with, I do the following: 1) inform the patient that I don’t know much about the therapy, 2) research the intervention to make sure there is no imminent harm in continuing the therapy (based on their medical history and labs) and 3) continue the therapy. How could I be so arrogant to assume that because I don’t utilize a certain tool, it doesn’t work? Or that it does not help the patient feel better? I can’t. Despite what we have been led to believe, doctors are people not gods. We do our best, and that’s all we can do. I find that honesty is the best policy with patients, whether that means that I become the expert, the learner, refer to another practitioner, or work through the issue with my patient as part of an interdisciplinary team.
The Power of the Patient
I am thankful that I don’t base every decision I make on research. In the presence of the dominant medical profession, I would love to state otherwise. But having gone through countless classes on research interpretation and statistics, I can’t help but be aware of the limitations, bias, and media hype surrounding certain research articles. And I can’t help but notice that many doctors practice based on research headlines rather than on the studies themselves. I encourage my patients and readers to read the research on dietary approaches and supplements. I do this both because I consider my role as doctor and teacher, and because I have seen the role empowerment can play in patient health. If you would like to learn about research and use of probiotics, please read my Practical Guide to Probiotics. If you’d like to learn more about food intolerance, allergy, sensitivity (especially to gluten but foods as well) and various ways to test for these conditions read my Gluten-Related Conditions and Lab Testing article.
I am thankful that I have been shown the value of non-quantifiable interventions. Many of you don’t know that before I chose to become a naturopathic doctor, I worked in a field called Recreational Therapy. This field is focused on using play and recreation as a healing tool, employing both objective and subjective assessments and treatment plans to improve quality of life. I worked in retirement homes and children’s hospitals, with both the young and old, often losing their lives surrounded by the most advanced in modern medicine. At first, this made me feel utterly powerless. But ultimately it led me to realize the importance of quality of life, in conjunction with prevention of death. I saw children’s pain scales decrease for multiple days after I led them in a guided meditation, post-spinal surgery. I played music for the elderly as they were dying from brain tumors, and watched smiles spread across their faces. I experienced people’s lives up unto the point where modern medicine had nothing left to offer, and what is really important became evident. Through this process I became very open-minded to the effects of the unquantifiable, the mundane, and the ordinary moments that could be created but not properly researched in a double-blind, placebo-controlled study.
I am thankful that I was taught both sides of medical knowledge, both the old and the new. Being the “underdog” medical profession at this time, we are, by default, responsible for knowing how conventional medicine practitioners practice. We speak the language, use the labs, and call upon the power of medications when necessary and based on the individual needs of each patient. And I am thankful to have learned this information and call upon it every day. But we have to remember that conventional medicine as we know it today is only about 75 years old, which is microscopic (pun intended) compared to the duration of time we spent using home and herbal remedies to survive. I will be the first to attest that modern medicine has afforded us many life-saving opportunities: STAT laboratory results, surgeries, medicines that can kill many of the most harmful of bacteria in the blood. But the truth is that people still die, as they are meant to. There is no medicine, surgery, herb, or supplement that can make someone invincible, so we have to balance wanting to prevent death and quality of life.
The Bottom Line: A Note to Health Care Professionals
As practitioners who chose to help people for our life’s work, let us remain cognizant of the fact that science is not infallible. Scientists thought the earth was flat, that infection came from the ether, and that light was not affected by gravity. Laboratory medicine guidelines change yearly to monitor both acute and chronic disease, so quickly it’s often hard to keep up. The very nature of research is that we need to isolate one variable or intervention in order to get unbiased results, which inevitably diminishes our ability to extrapolate these results to a broad population.
Does this mean that we should shun all research? Absolutely not. Does this mean that medicine is futile? No. It means that we must support one another, refer to and consult with one another, educate each other on the most up-to-date practices and protocols, and always keep the individuality of the patient in mind. We need to find common ground in our focus on the health and happiness of our collective patients. And we cannot underestimate the power of the patient in healing disease. Patients’ minds and emotions are an immensely important part of their health outcomes, so let us value – rather than diminish – patient education and empowerment.