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Doctor and PatientA patient goes to a doctor’s office with the belief that the doctor knows something, or has the ability to do something, that will help the patient. It is the doctor’s obligation to have knowledge, or have access to knowledge, relevant to the patient’s situation, or the training to perform a procedure to evaluate or treat the patient.

It is therefore important for the doctor to be educated in what he purports to know, to offer recommendations based on a satisfactory knowledge base. It is also important that the basis of a physician’s recommendation is the well-being of the patient, not the physician’s self-interest.

These conditions are by no means straightforward. Many types of approaches are available for most conditions, while other conditions have few proven therapies. Still, patients will always look for answers, for some kind of help, because it is not in man’s make-up to sit and do nothing in the face of adversity.

The doctor must keep in mind that a given treatment may not help the patient, or may cause complications and make the patient worse, or that the real diagnosis lies elsewhere. The age, physical and mental status of the patient must also be considered in choosing a therapy. Cardiac bypass surgery may be a proper choice for a 50 year-old, hard-driving businessman, but excessively dangerous for an 85 year-old woman with severe arthritis and emphysema. Determining the best therapy may more involve the art than the science of medicine.

It is often difficult for the patient to navigate through the myriad of therapeutic options. It may be difficult, but I believe important, for the physician to have a minimally biased, functional knowledge of possible treatments, so that he does not omit what may be effective, or suggest something unlikely to help.

What, for example, is the obligation of a rheumatologist to recommend a trial of a vegan diet for rheumatoid arthritis, prior to prescribing immunosuppressive drugs, with their serious risks? We have several patients with rheumatoid arthritis who have responded to a vegan diet and its variations, who nevertheless had been told by their rheumatologists that dietary changes would not affect their disease.

What is the obligation of a cardiologist to prescribe, or at least to discuss, enhanced external counterpulsation, a non-invasive compressive therapy that creates new blood vessels in the heart and often relieves congestive heart failure when other measures fail? We see many patients who have not been informed of this therapy by their cardiologists.

Some common therapies are highly controversial, reviled in some quarters while routinely utilized in others. This would include vaccination, considered by some a cause of autism, while many pediatricians demand vaccination as a condition for continuing care. Psychiatric drugs including sedatives, antidepressants, and antipsychotics are frequently prescribed for the young, the very young, the aged and the demented, to great excess and at substantial risk to their health. Our practice tries to avoid or discontinue these drugs in favor of non-toxic therapies such as amino acids and lifestyle changes.

The choice of therapies often depends on the patient’s personal beliefs about the utility of drugs, surgery, lifestyle changes, and alternative approaches like acupuncture, massage, supplements, Pilates, prolotherapy, ozone therapy, hormone replacement and many others. It is not possible for a patient to be well-versed in all these options, or for any physician to be experienced in all of them. It would be better, however, for a physician to say “I don’t know” when asked about them, than to say “that’s hokum”, when he really has no knowledge about the subject. Some physicians offer the attitude that if they don’t know about something, then it isn’t worth knowing about and it doesn’t work. This is arrogance, unattractive to many patients, and certainly not in their best interest.

On the other hand, some alternative practitioners have the attitude that no drug is any good and surgery should be avoided at all costs. I believe that this also is a dangerous posture, established through bias and ignorance.

I utilize textbooks of both conventional and complementary therapy, and offer patients choices from both. I read several journals of alternative therapy, like the Townsend Letter, along with major allopathic journals, The New England Journal of Medicine, The Annals of Internal Medicine, Lancet, JAMA, and a few others. Though I can’t read through them all, I can read the review articles, selected areas of interest, and information about new drugs, supplements and techniques.

Patients need to be aware of their doctors’ training, knowledge, experience and attitudes, do their own careful research, and be willing to get a second opinion. Certainly, when given recommendations that clash with their understanding or preferences, they should look around to find if better options are available. Do not expect your physician to be all-knowing or all-powerful, and always ask questions. The practitioner who is too impatient to answer questions is not to be fully trusted. The best results come from cooperative interaction between doctor and patient. This may require additional office visits, phone calls, letters or e-mails. It always helps for physicians to have an excellent office staff, who know when to interrupt the physician with a question.

In medicine, as in other areas, the buyer should beware. Current therapies are far superior to those of even a few years ago, and diseases can be diagnosed and cured when once they could not. Yet risks abound for any treatment. Patients should do what they can to support their bodies and minds with a healthy lifestyle. This will help them withstand any needed medical intervention, and reduce the possibility of illness in the first place.

Allan Sosin, M.D.

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