Sleeping Beauty

It has been nearly 10 years since I began studying homeopathy. What began as a search for something that would help me to obtain better results with my patients has become an avocation and a passion. Entering into my exploration of homeopathy, I had no concept of how profound this medical art is, and no inkling of how much it would affect my practice and my way of thinking about medicine.

The shocking reality of homeopathy that struck home not long after I began my studies in earnest at the Hahnemann School in the fall of 2000 was that homeopaths were treating nearly everything I was treating with as good or better outcomes, less morbidity and at less expense. Whereas the best I could hope to acheive was palliation of my patient's symptoms, they were acheiving true cures. While I was treating people for years, if not decades, they were treating people for months and obtaining more dramatic results. All this was being accomplished at far less cost and with little or no adverse effects. This appeared to be true not only for psychiatric patients, whose concerns were initially of greatest interest to me, but also to patients with more general medical problems, many of which were of a serious nature. This was not just "complementary" medicine. This was a whole parallel medical universe, existing in silent neglect alongside the behemoth of the medical industrial complex.

In a flash, I perceived that if the allopathic world found any treatment even for any single disease, that was as effective, as inexpensive, and as safe, it would be a media bombshell, and would in fact revolutionize medical practice. Here then was my second great shock: the allopathic wold was aware of homeopathic treatment, but was utterly indifferent. Homeopathy had a bad "rep" in the allopathic world, so all the hooting and hollering about cures and safety and inexpensiveness were falling on deaf ears. In fact they had been falling on deaf ears for over 150 years, and so the amount of hooting and hollering had been reduced to almost nil. Homeopaths had many stories to tell about homeopathic research that was dismissed, criticized, neglected, ignored, or devalued because of the fact that it was obvious, prima facie, that the treatment was nonsensical.

Accepting the unreceptivity of the world to homeopathy has been something that has always been hard for me. Sometimes I can laugh at it, like the joke about the man looking for his keys under the lamp (even though he dropped them elsewhere) "because that is where the light is." At other times, the tragic consequences of homeopathy's relative disrepute pain me. I see people experiencing the consequences of unsuccessfully treated illnesses or dealing with the side effects of the treatments and I am pained by what seems to be unnecessary suffering. This pain is transduced into outrage when I see the medical industry bringing in massive fiduciary gains in spite of these (unnecessary) negative outcomes.

This brings me to my point -- that in these times of medical cost overruns, and with health reform in the limelight, homeopathy is uniquely poised to make a contribution. Noone, not the health insurance industry, nor the hospital industry, nor the medical profession, nor the pharmaceutical industry, nor the medical device industry wants to see its profits significantly cut into. And keeping the medical system substantially the same is the best way to ensure that none of the major industry financial concerns are negatively impacted. Unfortunately, it is also the best way to make sure that we do not change the exploding costs of health care. Here's the naked truth: the current system is just too expensive. Until this elephant-in-the-room is named, we will continue to pursue chimerical or band-aid solutions. The silent and neglected universe of homeopathy -- safe, effective, and miles less expensive -- lurks in the background. If it weren't called homeopathy, it would be called a miracle solution, a deus ex machina, a godsend. But because it is, it will likely remain in silent desuetude, a sleeping beauty waiting to be awoken, while the vines grow taller and the kingdom is engulfed.

The Boundaries of Homeopathy

In an effort to expand my repertoire of treatment options, I recently began training in a type of bodywork known as "Bowenwork." Developed in the 1950's through the 1970's by the late Tom Bowen, an Australian sports trainer, Bowenwork attained such success in Australia that by the 1980's it was spreading world-wide. It's applications have expanded far beyond it's author's original intents, largely by virtue of empirically demonstrated results, to include, in addition to general musculo-skeletal injuries or illnesses, respiratory problems, kidney problems, some mental and emotional disturbances, and a variety of other general systemic illnesses. It's adherents report success rates of 80-90%, with virtually no adverse effects and relatively few sessions (3-5 on average) to complete the majority of treatments.



Sometimes known as the "homeopathy of bodywork," Bowenwork also uses minimal dose methods (less is generally more effective), it embraces the notion of healing through energetic processes, and also, it seems to have the same absurdist mode of action -- i.e., it is completely inexplicable. Bowen workers twang and pluck muscles, tendons, ligaments, and other physical structures in the body much like guitar strings. This plucking process, which are referred to as "moves" are for the most part extremely gentle and pain-free, although why they should have any salubrious effects is in no way apparant. Certain moves may elicit some discomfort, but the presence of pain is generally considered to be an indication that the practitioner has not used proper technique. Like homeopathy, treatments must be given time to have an effect, and too rapid repetition of a treatment can be counterproductive. My interest in Bowenwork was actually stimulated by other homeopaths, who have written or spoken favorably about Bowenwork (including Jeremy Sherr).

One of the things that has struck me about Bowenwork as I have been learning it is how tightly regulated it is in comparison with homeopathy. Certified instructors are the only ones permitted to teach, and they must undergo additional training to be certified. To be certified as a Bowen Practitioner, one must pass a practicum, and demonstrate proficiency in business matters as well. In short, the Bowen establishment want the purity of the technique to be preserved and they also want people to be successful in their practices, so that Bowenwork achieves the success its founders felt it deserved.

By contrast, homeopaths have no mandatory certification process, and pretty much anyone can study or teach it. There is a certain amount of infighting within the homeopathic community about which approaches are legitimate (this infighting actually began in the late 19th century, with the so called "highs" and "lows", who fought over the legitimacy of the high potency remedies vs. low potencies), who is most qualified to practice homeopathy, and which homeopathic organizations should represent homeopathy to the public and the scientific community. There is the National Center for Homeopathy (open to anyone), The American Institute of Homeopathy (open to M.D.s, D.O.s, dentists and certain other qualified practitioners with medical backgrounds) and the North American Society of Homeopaths (organized and run by naturopaths). There are several types of certification, and practitioners may have anywhere from zero to three certificates, depending on their ambitiousness. The value of these certifications seems largely nominal, as the non-homeopathic world does not tend to regard homeopathy as legitimate, and being certified in an illegitimate practice confers little or no more respect. These certifications are valued by homeopaths as personal acheivements and to some extent by the rest of the homeopathic community, although they are not regarded as necessities.

While there there appears to me to be a tendency in the allopathic community to label all treatments as on the one hand "medical" or "evidence based" or "legitimate" and on the other hand as "alternative" or "complementary" or "of questionable legitimacy", the truth about the varieties of treatment is far more complex. Some conventional treatments are of little value, even though evidence may support their validity. Some evidence is simply not very high quality. Other treatments, though lacking in large randomized controlled trials, are buttressed by testimonials, dramatic case findings and other empirical evidence. It is important that we as homeopaths define our boundaries a little better. Some lay treatment practitioners are far better at what they do than many board certified physicians, or other licensed health professionals. I myself have had several sports injuries which were helped by non-medical professionals, one a sports trainer, and the other a naturopath. I had been evaluated by several experienced and well trained orthopedists, had x-rays, bone scans and MRI's done all to no avail. These non-medical professionals fixed up the problems, which had become quite chronic, in short order.

Yet, I know that if I had advanced osteoarthritis, a complex fracture, or other severe pathology, I would have been in better hands with the orthopedists. It's not a question of who is better, but who is better for what problem. Homeopaths with medical backgrounds have an advantage in treating complex medical illness where there are medication issues to deal with in conjunction with the homeopathic treatment. This is not to say that those without medical backgrounds are unable to treat people with such illnesses. Rather, I wish to make the point only that overall, in such cases, those with a medical background are more likely to be well equipped to handle severe pathology, managing the allopathic and homeopathic treatments together. Those without a medical background may do fine treating these cases in some circumstances, but overall, they will more often be in their comfort zones in cases where such severe pathology and pre-existing medical treatment is not a significant issue. You don't need 12 letters after your name to prescribe Arnica for a bump or bruise. Conversely, having the 12 letters does not necessarily mean that your results will be better in the treatment of chronic illness, where constitutional remedies are likely to be most effective.

Homeopaths need to define the scope of their work better, and within the homeopathic community those of us with different backgrounds should define the scope of our work vis-a-vis other homeopaths better. Certification would be more useful if it gave some indication of where our strengths and weaknesses as healers lie, rather than simply some more letters of unknown significance to tack on after our names in the vain hope of impressing ourselves or others. The same would be true for physicians and other practitioners of alternative medicine. Being board certified in a medical specialty, from my experience, means being a good test-taker. There has been no evidence that I know of that being board certified is correlated with better care or more satisfied patients. Yet people often act as if this is the case. What foolishness!

Make 'Em Pay

The newspapers are publishing articles about Obama's sagging popularity, due in large measure to decreasing support for his health reform plan. Skipping over the fact that Obama doesn't actually have a health plan (he has just issued guidelines to Congress for the types of changes he would like to see), it seems to me that few have credited Obama for actually having the courage to take on a problem that he surely must understand is a hornet's nest of conflicting interest groups. His efforts to make insurance plans more fair and to cover more people is laudatory, but the problem he and the Congress have not shown signs of being able to successfully address (other than to raise taxes on the wealthy) is how to hold down the growth of the health system. All the players are for reform, as long as nothing is taken off their own plate.

Surely, if doctors were asked to line up to have their salaries reduced in order to save the government from going bankrupt, this would be the shortest line imaginable. Noone would show up. The insurance companies, who are already feeling great pressure to keep up their returns to please their shareholders are not going to be lining up to cut back their rates either. The pharmaceutical companies are not producing any new low priced drugs to help people get off their more expensive treatments. "New" and "low-priced" are oxymoronic in the pharmaceutical business. And hospitals and health care corporations are not fighting for the opportunity to give back their excess riches for the good of the community. They are too busy trying to stave off bankruptcy because of their own ever-increasing payouts.

Nor are people volunteering for less care. They are often being pushed into getting less because of the inability to afford the care that is presently available to them. And they are not happy about it. Noone is bragging about how much they are helping our society to manage its budgetary problems. No, if it is talked about, it is in the form of a complaint about not taking their medications so they can eat or pay their rent.

Here lies the problem: everyone wants less, but no one is willing to accept less for him or herself. I think it was Emerson who once said something like, "Every man will change the world, but no man will change himself." If I were Obama, I'd realize this and make 'em all pay. No one wants to suffer, but if we all partake in the suffering more or less equally, at least it's fair.

Uninformed consent

In a recent New York Times piece (July 30, 2009: Treating Patients as Partners, by Way of Informed Consent) Pauline Chen discusses the trends towards involving patients in their own care. Comments on her blog range from those who think patients are too stupid to sign off on any medical treatment to those who supported the idea that patients should be given even better explanations of their health care treatments than they presently do. The unstated issue in informed consent is that patients are being asked to take responsibility for taking risks to their health without a full understanding of what these risks mean. In fact, it is not clear to me that doctors themselves fully understand the meaning of the risks they are asking their patients to take.

Some of my colleagues tell me that in discussing the risks of a treatment with people it's important not to frighten them, or it's important to put the risk in perspective for them. What this means to me is that we as doctors must present the risk from our own perspectives as physicians rather than objectively. It starts from the premise that the patient should consent to the treatment, because we as physicians have decided (beforehand) that the benefits that might accrue from the treatment outweigh the risks. But this is a biased position. Risk assessment is very much in the eye of the beholder. Some people are petrified to drink tapwater out of fear they might be poisoned and others smoke, use drugs and all manner of foods and substances, or lie out in the sun all day because they believe that their own personal risk is low for these behaviors. In some cases they will be right and in other cases, wrong. But doctors know who is right and who is wrong no better than patients do. They only know statistics, and statistics do not usually account for individual risk, only for group risk.

Moreover, doctors are for the most part familiar only with medically oriented treatments, and not with alternative medical treatments. When your doctor tells you to take a proton pump inhibitor for GERD, does the doctor know what the botanical treatments, acupuncture or homeopathic treatments have to offer? Is the doctor familiar with the risks and benefits of these and how they compare with proton pump inhibitors? Of course not! These are not made a part of physician training for the most part in the United States (but not necessarily in foreign medical schools). So when the "alternatives" to proton pump inhibitors are discussed, they are usually dismissed summarily, without a full appreciation of what is being dismissed. It is usually assumed by physicians that only treatments that are endorsed by the conventional medical establish have any merit, because if there were others that deserved attention, they would have learned about them in their training. There is not a shred of truth to this assumption, but it is firmly embedded in most doctors' thinking.

The literature on drugs that is distributed for patients and the advertising that is seen on television continues to tilt peoples' perspectives in the direction of choosing drugs for yourself or your family. The on-line information resource known as "Adult-Pals: Adult Patient Advisory Leaflet System (see online.lexi-com) describes the side effects of Lithium Carbonate as "feeling lightheaded, sleepy, having blurred vision, or a change in thinking clearly...shakiness, headache, nausea or vomiting...frequent urination." No mention is made of the more serious medical consequences of chronic Lithium use: thyroid failure, and kidney disease. Many of the more disturbing side effects such as weight gain, dry mouth, and diarrhea are omitted. For Risperidone, the side effects are given as "feeling lightheaded, sleepy, having blurred vision, or a change in thinking clearly..feeling dizzy, high blood sugar (usually reverses when stopped), weight gain, change in sexual ability or desire (this is usally reversible), drooling, inability to sleep." There is no mention of the more serious consequences of taking the drug such as tardive dsykinesia (an irreversible neurologic condition characterized by disfiguring involuntary motions), dystonias, neuroleptic malignant syndrome, or metabolic syndrome. In fact, the "information" discourages people from looking at the diabetes and sexual dysfunction as permanent (They describe these side effects as "reversible.") even though Risperdal is almost always prescribed for long term use. The only reason it is not taken indefinitely by patients is that it doesn't work that well or it can not be tolerated for long periods of time by some patients because of the serious negative effects on their health.

While not everyone may want to partake in the decision-making process that most medical treatment requires, leaving all the decisions up to the physicians is a cop-out which permits the more paternalistic side of physicians to flourish more than it ought to. Sorry, to those of you who want to leave all the thinking up to the good doctor, but the good doctor needs you to be a part of your own treatment (excepting in cases of emergency of course, when time does not permit this to happen). Unfortunately, even for those who wish to be part of the decision-making process, all the information needed to make an informed choice is rarely on the table.