Integrative / alternative medicine

[VA Hopeful Dr]

A lot of medicine that we do is not particularly evidenced based, and is essentially alternative medicine, as you suggested above.

Joint injections, trigger points, vertebral fusions, ESIs in a lot of cases, opioids for chronic pain, tramadol for anything, docusate, sliding scale insulin, nebs instead of inhalers, etc. etc. A lot of the specific things physical therapists do are not evidence based, and some of it is exactly the same as what chiropractors and osteopathic providers are doing.

Choosing Wisely: Things We Do For No Reason has some good reads. We all have used alternative medicine, and most of us will use alternative medicine on Monday. Many are surprised that some common practices are almost completely tradition and not based on much evidence at all.

Much as I see integrative medicine as just part of what we already learned about already in family medicine residency, It also seems strange to me for us to look down on acupuncture or chiropractic when we are often working on the same evidence level.

For example, if you are prescribing tramadol then you are doing something with comparable evidence to acupuncture, and you are doing alternative medicine. This is important to think about because many of our treatments in mainstream medicine have more risk (like an opioid or an invasive procedure/surgery) than many alternative medicine options (like chiropractic or yoga) and do not have a clearly demonstrated higher benefit.

We should be aware of the perverse incentives that exist in our medical system as well. For example, I think we can all agree that there's no way there would be so many spinal surgeries if they didn't make so much money, and the data vs usual care is about the same at 24 months in many scenarios.

It's something uncomfortable to grapple with, but it is important to be academically honest about the whole situation so we can provide the best care.

I think you underestimate either the data that's out there or the specific populations for some of that stuff.

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[AFMD]

I think you underestimate either the data that's out there or the specific populations for some of that stuff.

Possibly, of course. I'm curious, are you talking about things that many evidence-based clinicians agree we do traditionally in mainstream medicine without much evidence, or are you talking about alternative medicine?

 

[VA Hopeful Dr]

Possibly, of course. I'm curious, are you talking about things that many evidence-based clinicians agree we do traditionally in mainstream medicine without much evidence, or are you talking about alternative medicine?

I think you're underestimating either the evidence for what us regular physicians do or applying it too broadly when the evidence supports more narrow areas.

Beyond that, some of what we do is motivated by a combination of lack of harm and patient preference. For instance, we all know (or should) that inhalers work as well as nebulizers for everyone over the age of 2-3 years old. But I have patients that INSIST on a nebulizer. Nebulized meds aren't harmful compared to inhaler-delivered meds and its not worth the fight for me to deny it. I'll try and educate but if they still insist I'm going to write for those nebs.

Don't even get me started on sliding scale insulin. I absolutely hate it.

 

[deleted87716]

Don't even get me started on sliding scale insulin. I absolutely hate it.

I refuse to do it, and immediately lose respect for any physicians who have done it when I inherit their patients.

 

[VA Hopeful Dr]

I refuse to do it, and immediately lose respect for any physicians who have done it when I inherit their patients.

Same

 

[FamilymedMD]

Much as I see integrative medicine as just part of what we already learned about already in family medicine residency, It also seems strange to me for us to look down on acupuncture or chiropractic when we are often working on the same evidence level.

We should look down on acupuncture , chiropractic as well as tramadol, surgeries without evidence, etc. etc.

 

[AFMD]

We should look down on acupuncture , chiropractic as well as tramadol, surgeries without evidence, etc. etc.

I imagine most of us don't make moral value judgements, but simply use the best tool or tools available for the current problem.

 

[Atlas Shrugged]

If you aren’t making value judgements base on sound ethics you’re failing as a doctor. Allowing patients to engage with charlatans is not good medicine.

 

[Proudfather94]

The only instances I could see utilizing them is if a patient explicitly asks for something (e.g. acupuncture, nutritional, or OMT). Even then, I'd have a discussion about pros (typically minimal) and cons (usually cost among others) and only give them the info of the provider if they still insisted. It does help to know who are actually good at what they do, i.e. they don't try to sell "extra" stuff from their shops and don't try to supplant actual medicine, always telling pts to refer back to me with new complaints.

As far as things like "functional medicine", low T clinics, homeopathy, etc. As far as I'm concerned there are no patients that are appropriate to refer, because I've yet to meet one that didn't do things irresponsibly or misled patients for very clear monetary gain.

Hey can I ask you what is wrong with low T clinics? I'm pretty into the fitness industry and see that responsible ones help those who want to maintain their muscle mass as they age or help those who have abused anabolic steroids. I can understand how one could give more than what's the normal range naturally but does that happen at so many of them that they're seen as scummy practices?

 

[VA Hopeful Dr]

Hey can I ask you what is wrong with low T clinics? I'm pretty into the fitness industry and see that responsible ones help those who want to maintain their muscle mass as they age or help those who have abused anabolic steroids. I can understand how one could give more than what's the normal range naturally but does that happen at so many of them that they're seen as scummy practices?

Most of us treat hypogonadism in our practices, but we follow Endocrine Society guidelines when we do.

Clinics that specifically talk about treating "low T" are, in my experience, much more likely to not follow those guidelines.

 

[Proudfather94]

Most of us treat hypogonadism in our practices, but we follow Endocrine Society guidelines when we do.

Clinics that specifically talk about treating "low T" are, in my experience, much more likely to not follow those guidelines.

Oh I see why refer them if you can do it yourself. I have heard some of the worst ones will just give anabolics to them instead of a normal dose of testosterone. At that point they're a steroid dealer that needs to get their license yanked.

 

[Dr G Oogle]

Acupuncture has reasonable evidence for overactive bladder and some for fecal incontinence, especially compared to meds. And is similar in needle placement on the foot to posterior tibial nerve stimulation.

The role of acupuncture in managing overactive bladder; a review of the literature - PubMed

Despite their limitations, existing studies serve as a promising foundation for suggesting a role for acupuncture as an alternative therapy for OAB. Further well-designed studies are required to investigate optimal technique and their outcomes.

pubmed.ncbi.nlm.nih.gov

The regimen I use is 6-12 weekly sessions and 1-3 month maintenance.

 

[hallowmann]

Oh I see why refer them if you can do it yourself. I have heard some of the worst ones will just give anabolics to them instead of a normal dose of testosterone. At that point they're a steroid dealer that needs to get their license yanked.

There are tons of places that function exactly like anabolic steroid dealers regardless of the consequences and side effects. Places that just treat hormone deficiencies are called primary care doctor's offices and endocrinology clinics.

Virtually all low T clinics I've seen treat everyone with mild depression, fatigue, OSA, overweight/obese BMI, etc. with testosterone, because obviously that must be the issue of why they feel bad.

 

[deleted87716]

There are tons of places that function exactly like anabolic steroid dealers regardless of the consequences and side effects. Places that just treat hormone deficiencies are called primary care doctor's offices and endocrinology clinics.

Virtually all low T clinics I've seen treat everyone with mild depression, fatigue, OSA, overweight/obese BMI, etc. with testosterone, because obviously that must be the issue of why they feel bad.

When your only tool is a hammer...(etc.)

 

[Proudfather94]

There are tons of places that function exactly like anabolic steroid dealers regardless of the consequences and side effects. Places that just treat hormone deficiencies are called primary care doctor's offices and endocrinology clinics.

Virtually all low T clinics I've seen treat everyone with mild depression, fatigue, OSA, overweight/obese BMI, etc. with testosterone, because obviously that must be the issue of why they feel bad.

That's incredibly unethical and predatory. I know there are alot of people who abused anabolic in the past and want to go on hrt so that they can live a normal life. Tempting them with anabolics and too much testosterone could be what causes them to relapse and have a heart attack.

 

[shezadeh]

The herbal stuff...obviously can be pretty hit or miss (mostly miss IMO). I feel like most of the herbal stuff that works has been utilized as actual medicines by now, and the stuff that's out there of course is not really regulated by the FDA in terms of proving safety and efficacy.

I do think some of the herbal stuff has evidence behind it. Pharmacogosy as a field does exist. Cranberries for UTIs (plenty of research on this one). Turmeric has some evidence for inflammation. The issue is that each company will have different manufacturing methods, etc, so it is indeed a hit or miss.

 

[VA Hopeful Dr]

I do think some of the herbal stuff has evidence behind it. Pharmacogosy as a field does exist. Cranberries for UTIs (plenty of research on this one). Turmeric has some evidence for inflammation. The issue is that each company will have different manufacturing methods, etc, so it is indeed a hit or miss.

Yeah, research that says it doesn't do anything:

Cranberries for preventing urinary tract infections

www.cochrane.org

 

[shezadeh]

Yeah, research that says it doesn't do anything:

Cranberries for preventing urinary tract infections

www.cochrane.org

I read about some research at a university (in the medicinal chemistry department) regarding Cranberries. I will try to find the link. I think they were able to find some evidence in vitro, but that may have limited clinical impact (lots of things have an impact in vitro but are not used clinically)

Regardless, while this may not have been the best example, I did mention that the field of Pharmacognosy exists to investigate these things. The biggest issue I see is that even if we find something that is effective, every brand will have (possibly significant) variations in their manufacturing methods.

 

[VA Hopeful Dr]

I read about some research at a university (in the medicinal chemistry department) regarding Cranberries. I will try to find the link. I think they were able to find some evidence in vitro, but that may have limited clinical impact (lots of things have an impact in vitro but are not used clinically)

Regardless, while this may not have been the best example, I did mention that the field of Pharmacognosy exists to investigate these things. The biggest issue I see is that even if we find something that is effective, every brand will have (possibly significant) variations in their manufacturing methods.

Oh yeah, there's great evidence that cranberry juice inhibits e coli in vitro (I think it prevents it from attaching to bladder calls if I remember right).

But that's in vitro.

This is applicable:

 

[sloh]

Turmeric is also bogus.

 

[Atlas Shrugged]

I do think some of the herbal stuff has evidence behind it. Pharmacogosy as a field does exist. Cranberries for UTIs (plenty of research on this one). Turmeric has some evidence for inflammation. The issue is that each company will have different manufacturing methods, etc, so it is indeed a hit or miss.

How do I dislike this?

 

[hallowmann]

Turmeric is also bogus.

I mean there are plenty of correlation studies with populations who eat high turmeric foods, but just absolutely 0 evidence that taking "turmeric supplements" does anything. I still put it on a lot of my food... because I like the way it looks and tastes...

 

[shezadeh]

I mean there are plenty of correlation studies with populations who eat high turmeric foods, but just absolutely 0 evidence that taking "turmeric supplements" does anything. I still put it on a lot of my food... because I like the way it looks and tastes...

Fair enough.

 

[scharnhorst]

Very close relative just forwarded me a metabolic profile of his kid ordered by their naturopathic doctor
After I was done cussing and venting I had to grapple with what to do with a low selenium, high lysozymes and yeast in poop
Any evidence based suggestions?

 

[VA Hopeful Dr]

Very close relative just forwarded me a metabolic profile of his kid ordered by their naturopathic doctor
After I was done cussing and venting I had to grapple with what to do with a low selenium, high lysozymes and yeast in poop
Any evidence based suggestions?

Ignore them. There are no evidence-based suggestions because those are not evidence-based tests outside of very specific and very rare conditions.

 

[scharnhorst]

Ignore them. There are no evidence-based suggestions because those are not evidence-based tests outside of very specific and very rare conditions.

I know ( was trying to be sarcastic sorry) but how to explain this to people many of whom think any lab abnormality must correlate with a disease process. And they link any symptom real or imagined to a lab abnormality

 

[VA Hopeful Dr]

I know ( was trying to be sarcastic sorry) but how to explain this to people many of whom think any lab abnormality must correlate with a disease process. And they link any symptom real or imagined to a lab abnormality

I usually say something like "there is no research that addresses the results of weird tests like this outside of super rare generic conditions which you don't have, I have no idea why anyone would order this test for you in the first place so I wouldn't worry about it".

Depending on your relationship that last part can be changed to "I think the person that ordered those tests is hoping to sell you on needing expensive and unnecessary supplements".

 

[sloh]

I usually say something like "there is no research that addresses the results of weird tests like this outside of super rare generic conditions which you don't have, I have no idea why anyone would order this test for you in the first place so I wouldn't worry about it".

Depending on your relationship that last part can be changed to "I think the person that ordered those tests is hoping to see you on needing expensive and unnecessary supplements".

Tends to get the point across more effectively

 

[scharnhorst]

I usually say something like "there is no research that addresses the results of weird tests like this outside of super rare generic conditions which you don't have, I have no idea why anyone would order this test for you in the first place so I wouldn't worry about it".

Depending on your relationship that last part can be changed to "I think the person that ordered those tests is hoping to see you on needing expensive and unnecessary supplements".

Yeah so the naturopathic providers complain about big pharma yet happily advance the agenda of supplements mafia ?

 

[PikminOC]

Yeah so the naturopathic providers complain about big pharma yet happily advance the agenda of supplements mafia ?

And they sell them with a hefty markup so that's ancillary income.

 

[VA Hopeful Dr]

Yeah so the naturopathic providers complain about big pharma yet happily advance the agenda of supplements mafia ?

Yep. Because they can sell supplements in their offices but can't do that with prescription meds.

 

[scharnhorst]

Yep. Because they can sell supplements in their offices but can't do that with prescription meds.

Do people really buy these overpriced placebos? I mean it’s one thing if it’s at the dollar tree but these are Cadillac versions

 

[VA Hopeful Dr]

Do people really buy these overpriced placebos? I mean it’s one thing if it’s at the dollar tree but these are Cadillac versions

If they didn't, the naturopaths wouldn't all sell them.

 

[door_to_balloon_knot]

Do people really buy these overpriced placebos? I mean it’s one thing if it’s at the dollar tree but these are Cadillac versions

Think of the average American and picture them standing in front of you.

Have the image?

Now remember half the population is dumber than that person statistically.