Differences between CAM practice and primary care practice

ResearchBlogging.orgIf there is one aspect of “complementary and alternative” medicine (CAM) that can puzzle advocates of science-based medicine, it’s why, given how nonsensical much of it is given that some of it actually goes against the laws of physics (think homeopathy or distance healing), CAM is so popular. Obviously one reason is that there are conditions for which SBM does not have any “magic bullet” treatments. Diabetes, heart disease, other chronic illnesses, SBM can manage them quite well, but it can’t cure them. Then there are conditions that science doesn’t understand very well, conditions like, for example, fibromyalgia. It would be less than honest of me (or any other supporter of SBM) not to acknowledge that SBM sometimes has little to offer some patients. Of course, there’s no evidence that CAM has anything therapeutic or concrete to offer these patients either, although certainly CAMsters would like you and their other marks to believe that they do.

Actually, that may not be entirely accurate. There does appear to be something that CAMsters offer patients that we practitioners of SBM appear to have a problem providing. It’s unfortunate that this is true, but it does appear to be, and what it is should be fairly easy to guess. Basically, it’s time. Anecdotally, most of us who pay attention to the issue of CAM and the infiltration of pseudoscience into medicine have suspected this, but there hasn’t been a lot of data one way or the other to determine whether this is indeed the case and, if so, what the difference is. Last week, however, Dr. RW pointed me to a study that takes a stab at answering that very question. Published by a Dutch group, the study examined the practices of conventional physicians and CAM practitioners in terms of diagnoses seen and time spent with patients. The CAM practitioners included physicians practicing homeopathy, acupuncture, and naturopathy. A total of 5919 visits in 1839 patients were studied for diagnoses and time spent with each patient. These data were then compared with data from general practitioners (GPs) participating in the second Dutch national study in general practice (DNSGP-2). One result of this study was not surprising:

Comparisons of visit length in CM practices and mainstream GP revealed major differences. General practitioners usually invested between 1-15 minutes, whereas CM physicians used at least 30 minutes for repeat visits and even twice as much for intakes. One of patients’ reasons for consulting a CM physician is in line with these findings, i.e. the wish to get ample time to talk with the physician [42]. Other studies on visit length have indicated that in mainstream GPs shorter visits were related to discussions about only one or two health issues, whereas in CM more issues were discussed and a higher number of advices were given [28]. Visit length is also found to be positively related to patient satisfaction [24,26,27].

In other words, on average CAM practitioners spent at least twice as much time with patients as GPs, particularly for the first visit. Although the Dutch have universal health care, it would appear that the time pressures on GPs are the same there as they are here in the U.S., and, if this study is accurate, GPs there focus on key health concerns rather than a wide-ranging discussion. Here in the U.S., ever-declining reimbursement for primary care visits have led to increasing time pressure on doctors to see more patients in a day. This situation is not conducive to physicians spending a lot of time with each patient. Even as a specialist, in my own practice I can spend quite a bit of time with new patients, but that’s only because I am lucky enough to work in a large academic cancer center with a large support staff. That’s one reason why I like working in a large cancer center, aside from the opportunity for academic pursuits and lab research. If I were in private practice, I doubt I could afford to spend that much time with new patients.

One aspect of this study that Dr. RW didn’t mention is its other part, namely the comparison of diagnoses arrived at by the CAMsters versus the GPs. Table 3 in the paper tells the tale. Earlier studies have found that CAMsters tend to see more of specific types of problems, such as chronic disease, anxiety, depression and poor physical fitness. Findings of this study were described thusly:

The primary diagnoses indicate that CM patients visited CM practitioners for general complaints (as coded in the ICPC) more often than patients in general practice (Table 3), especially for fatigue. More specifically, in homeopathy practices 77% of these general complaints concerned fatigue, in acupuncture practices this percentage was 68%, and in naturopathy practices 45%. In homeopathy and acupuncture practices allergic reactions came as second most frequently diagnosed general complaint, in 12% and 11% of the general complaints, respectively. In naturopathy practices, infections were the second most frequently diagnosed general complaints (12%). Also, psychological problems were diagnosed more often in CM practices than in GP practices, in acupuncture and homeopathy practices about three times more often than in GP practices. The incidence of problems with the nervous system was also found to be higher in CM practices than in GP practices, whereas problems in the cardiovascular system were more often diagnosed in GP practices. Differences in diagnoses between three types of CM practices gave an idea of the specific expertise of each CM specialty. We found that the diagnoses of problems with the musculoskeletal system were highest in acupuncture practices and those of skin problems diagnoses were highest in homeopathic practices. Naturopathic physicians diagnosed more often gastrointestinal problems, compared to GPs as well as the other two CM specialties

I was actually surprised that infections were so frequently diagnosed in naturopathy practices. On the other hand, given the number of dubious and outright bogus diagnoses in naturopathy, there’s no way of knowing what kind of infections were being diagnosed. For all we know, these naturopaths could be diagnosing one of the favorite alt-med catch-all diagnoses, chronic fungal infections. Be that as it may, the difference in diagnosis patterns is important. The preponderance of musculoskeletal complaints and, in particular, complaints of fatigue suggest that patients seek out CAM for complaints for which SBM doesn’t always have good responses. Alternatively, this could be yet another study implying that CAM patients seek out CAM for what we call the disease of living; i.e., the fatigue and little aches and pains that we all experience as we get older. Another favorite of the CAM practitioners are allergies. Unfortunately, it wasn’t clear from this paper if these “allergies” were mainly food allergies akin to the type of “allergies” diagnosed, for example, by DAN! practitioners in autistic children. After all, if there’s one thing I’ve learned from blogging about alt-med for over five years, it’s that, in alt-med, if it isn’t an “allergy,” it’s a “food allergy” or a “chronic fungal infection” or, of course, the dreaded “toxins.”

Unfortunately, the authors appear not to “get it.” Although they do mention that the Royal Dutch Medical Association (RDMA) emphasizes that it is the physician’s duty to emphasize the importance of mainstream, evidence-based treatments at all times and that it emphasizes that CAM exists “outside the world of mainstream medicine” (would that medical societies here in the U.S. would take such a strong position with respect to CAM!), they seem untroubled by the infiltration of woo into Dutch medical practice and appear to have done this study at the behest of the Netherlands association for homeopathic physicians (VHAN). Worse, they describe homeopathy, traditional chinese medicine, and naturopathy pretty much the way that woo-meisters describe them, complete with references to “energy” and “energy flows” being restored.

Overall, this study basically confirms what most of us have already suspected, namely that CAM practitioners spend a lot more time with their patients than science-based practitioners do, but they come up with a distinctly different set of diagnoses, mainly general diagnoses related to fatigue and musculoskeletal. Putting the two together, I fear that the cost of that extra time spent by CAM practitioners is a whole lot of dubious diagnoses. Sure, this study doesn’t show that; it can’t. But taking into account just what acupuncture, naturopathy, and homeopathy are, how could it be any different? The very basis of these specialties consists of prescientific conceptions of disease akin to miasmas or imbalances in the four humors or, in essence, vitalism, complete with references to “life forces” (qi or “energy”).

This study suggests another thing to me. People with chonic complaints want very much to know what’s wrong with them. Being told that a diagnosis can’t be easily derived from their symptoms and findings (or that there is no known diagnosis for them) is profoundly dissatisfying. Enter the homeopath, the acupunturist, or the naturopath. They are virtually always able to give a patient a diagnosis–or often several diagnoses–virtually all of them bogus, such as “imbalances in energy flow,” chronic allergies (unsupported by science-based diagnostic tests indicative of allergies), food allergies, or chronic fungal infections. At the same time, they spend a lot more time with patients. It’s a combination that’s hard to beat for a certain class of patient, and even hard-nosed skeptical patients can be taken in by someone willing to take a lot of time and provide answers that SBM has trouble giving. It doesn’t matter if those answers have no basis in science or are based on quackery; it can be very seductive, and many are seduced.

I often wonder what would happen if practitioners of SBM spent as much time with their patients as CAM practitioners do. I can’t help but wonder if it would take away one aspect of CAM that is, to the average patient, very appealing compared to SBM.

REFERENCE

Heiligers, P., de Groot, J., Koster, D., & van Dulmen, S. (2010). Diagnoses and visit length in complementary and mainstream medicine BMC Complementary and Alternative Medicine, 10 (1) DOI: 10.1186/1472-6882-10-3