Ask the Expert

What You Can Do When Your Doctor Says “There’s NO Evidence for That”

By August 22, 2018 No Comments

Has this happened to you or a loved one? You’ve just been diagnosed with a health condition and you have tried some of the treatments recommended by your doctor. However, none of these have helped. You have then done some research to discover other options that are not part of the mainstream information found on reputable sources and are not part of what your doctor is telling you. You mention these potential options to your doctor and they just look at you with an expression of scorn on their face and state, “There’s NO evidence for THAT.

Many patients feel dismissed by their doctors in these situations, and justifiably so. Many doctors only feel comfortable using accepted treatments that have ample evidence behind them. However, the truth is that not a lot of medicine can be practised in a perfectly evidence-based manner. Research takes time and we simply haven’t done all the right trials, so there is a vacuum of knowledge. The standards of evidence-based medicine are also set so high that a lot of research that has been done is inadequate. There simply are insufficient well-done clinical trials that look at the most meaningful clinical endpoints, such as improving overall mortality or reducing specific harmful outcomes, like a stroke. Many treatments are also almost impossible to study satisfactorily, such as those that involve specific nutritional supplements. Clinical trials that look at micronutrients, for instance, are almost all invalid because they focus on single nutrients and ignore the fact that there is a synergy among all of the antioxidant vitamins, minerals, and phytochemicals that we take in to help our bodies work optimally.

We also have to remember that many of the well-done clinical trials that “pass the test” are expensive to run. They are done for many pharmaceuticals because the trials themselves are funded by the pharmaceutical industry that manufactures the drug and whose main objective is to make money. That is fine if their drug greatly benefits people. However, it makes it difficult to get adequate funding for well-done clinical trials examining treatments that may be less lucrative. The infiltration of modern medicine by the pharmaceutical industry from medical school all the way up to the lecture halls of academic medical centres is very real and it is a problem that we as physicians need to be wary of and distance ourselves from as much as possible. We need to be vigilant so that we draw our conclusions from just the science and not the glossy pharma marketing campaigns.

Consider motivations on both sides of the issue

Many of these facts are emphasized by health care practitioners that want to offer non-mainstream approaches to their patients. They definitely have a point. Unfortunately, I find that these very well-made observations are then used to inappropriately justify their use of treatments that lack quality evidence of any kind. It is not logical to suggest that just because their treatments are not adequately studied by an unfair system, that they should not have to provide some objective evidence about it. If quality evidence doesn’t exist then they should be transparent about that. If they are treating your problem based on their own theory about your disease then they should tell you. Such practitioners often do not fully explain the potential risks of their treatments. They may want you to believe it will work and don’t want to admit that there are things that could go wrong. In essence, you are in uncharted territory with them, but that is never adequately explained to you. It’s marketed as a quick fix or a miraculous cure.

I see a lot of such practitioners claiming that their treatments are based on their superior understanding of the root cause of a complex illness like cancer that no one else has, even medical experts who have studied these diseases for their whole careers. That statement should raise alarm bells. For physicians, the consent process is clear as outlined in Policy Statement #3-11 on Complementary/Alternative Medicine (CAM) from the College of Physicians and Surgeons of Ontario. It states that “physicians must always provide patients with accurate and objective information about the available therapeutic options. Physicians must never inflate or exaggerate the potential therapeutic outcome that can be achieved, misrepresent or malign the proven benefits of conventional or CAM treatment or make claims regarding therapeutic efficacy that are not substantiated by evidence.”

It is also important to note that just as with the pharmaceutical industry, many of these individuals profit directly from their suggestions. I find it odd that many of these people who criticize Big Pharma on the one hand for “controlling medicine” then run a whole self-serving industry for their own profit, complete with their own in-house compounding pharmacy, intravenous vitamin drip suite, multiple book deals, and online supplement store. How can you be objective about anything if you profit so directly from what you prescribe? Patients need to beware of practitioners with such ulterior motives. Conventional doctors definitely have our own conflict of interest issues, but our profession does have guidelines. The Canadian Medical Association states in their policy “Guidelines for Physicians in Interactions with Industry” that physicians “must avoid any self interest in their prescribing and referral practices,” and “Physicians should not dispense pharmaceuticals or other products unless they can demonstrate that these cannot be provided by an appropriate other party, and then only on a cost recovery basis.”

How patients should approach alternative medicine

So what are we to do as patients? Only ever undergo treatments that have the “right” kind of evidence behind them and completely ignore everything else? What if we find out that we have cancer and our life is on the line, would we be willing to ignore potential treatments that have not been adequately studied? There is no time to wait for the right trials to occur in these situations. What if we are suffering day after day from symptoms that are so debilitating that they make our quality of life so poor that we are feeling completely hopeless? What if we know that a certain disease runs in our family and results in death at an early age? Will we just continue to stick with mainstream, universally accepted approaches that have passed the evidence test?

First of all, it would be most unfortunate if a health practitioner took advantage of someone who found themselves in one of the above scenarios. These people are especially vulnerable, are looking for hope and need to be approached in the most caring manner that puts their best interests front and centre.

Here is my approach to seeking medical treatment that lacks strong evidence:

  • Discuss with your current treating medical doctor. If you are being dismissed then clearly that individual is not comfortable advising you on proceeding with that treatment option. They may be correct about this, and just are not communicating it well, so listen carefully to the reasons why they are advising against it. Be open-minded, just like you are asking them to be open-minded. Realize that sometimes it is human nature to want to try anything to help when we are in a vulnerable state but we should not let that put ourselves at unnecessary risk. If you still wish to proceed, realize at this point you will need to find a different practitioner to help you, but I would encourage you to be cautious.
  • Look for a practitioner who is regulated by a licensing body, such as the College of Naturopaths of Ontario. This will ensure that the person you are seeking advice from has received an adequate level of training in their profession. If they are regulated they will also have certain consent and conflict of interest policies that they will have to adhere to.
  • Ask the practitioner if they have any conflicts of interest in suggesting that treatment. In other words, do they sell the medication themselves or do they work with the natural health company that makes it? Knowing this will give you a better idea of how to interpret what they are telling you. That’s also good advice to ask anyone who treats you, by the way.
  • Ask the practitioner about the evidence that they have in favour of the treatment. Beware of the use of anecdotal evidence — in other words, if their evidence that the treatment is effective is based entirely on personal stories. Personal stories are very powerful and that is why many practitioners use them to justify treatments. As far as science is concerned, however, anecdotal evidence is considered weak evidence. Ask for specific objective evidence such as any small trials that may give a percentage of who benefits and how they benefit. In this way you hear both the positive and the negative, not just the great outcomes.
  • Get the best unbiased information available about the risks of the proposed treatment. Discuss in detail with the practitioner: you want to know what evidence there is about its efficacy and also about the potential risks. You need to know about interactions with your current medications. Cost is also a big issue. One should not rely solely on the prescribing practitioner. Look to other unbiased sources of information like Health Canada or the National Center for Complementary and Integrative Health. McGill’s Office for Science and Society is also a good resource for information on the science behind many supplements. Avoid any sources of information that sell the treatment themselves. Avoid social media, random websites from Google searches, or blogs from self-reported health experts. Invariably such information sources are in fact advertisements leading to their own products being peddled.
  • Finally, have an open discussion of the pros and cons of proceeding with the treatment with the practitioner. You should feel comfortable that you know all of the facts that are available and can now make your own personal decision that is right for you.
  • Ensure that if you proceed with treatment that you inform everyone in your health team what you are doing. They may not agree with your choice, but they should know what you are doing, so they can advise on possible interactions with their own treatment and monitor you accordingly.

The bottom line is that when you are seeking medical care outside of a strong evidence base you need to find a provider with a strong sense of ethics. You need full transparency. This can be difficult to find, but it can be found with the right approach.

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