Angry Doctor

Thursday, November 03, 2005

Clues for the Clueless – Chapter 2

Chapter 2 – East is East…

… and West is West.

And I’m a western doctor. Yes, I know I am not a westerner but I practise western medicine (I know some refer to it as ‘modern medicine’ or ‘biomedicine’ or ‘allopathic medicine’, but we both know it as western medicine and for good reasons, so let’s just call a spade a spade).

So don’t come into my clinic asking if you are too ‘heaty’ or ‘have wind’. Those concepts are not part of my paradigm. I don’t mean to insult your system of beliefs, but I cannot really incorporate it in our clinical relationship in a meaningful manner.

Think about it.

Would you really be happier if I told you to go to a medical hall to get some herbs to boil instead of prescribing you little pills and syrups?

Would you really trust me if I told you you don’t need an X-ray but should go for acupuncture?

When it comes to traditional medicine, my advice is as good as that of a layman, because in the eyes of a traditional medical practitioner, that’s what I am!

I appreciate that fact, and I personally think it is unprofessional and unethical for me to discuss traditional medicine in our patient-doctor relationship.

By the same token, don’t come to me asking me to order an X-ray or blood test because your chiropractor thinks your spine is out of alignment, or your sinseh thinks your uric acid levels may be high. If you have a problem, consult me and I will give you my opinion and order the tests which I think are necessary. I am not an errand boy for them.

If you were more discerning you would ask yourself why if they thought the tests were necessary they would not order them themselves.

When you enter into a premises that practices western medicine, you in effect agree to buy into its paradigm, with all the good bits and the bad ones. To try to impose your system of belief on us is like going into McDonalds and asking for noodles. We may not be the best around, but that’s what we do.

So if you want a burger, place your order at the counter.

If you want noodles, I hear there’s a good place down the road…

24 Comments:

  • yah patients ask doctors trained in western medicine about what is their opinion of chinese medicine. the truth is we do not know.

    By Anonymous Anonymous, At November 03, 2005 8:41 pm  

  • there's a reason why patients turn to alternative medicine. not every patient is taught the ways of western medicine, and they have their own lay beliefs. i believe it will be beneficial to educate them on their aetiologies in very basic terms and let them see the rationality of western medicine. we must offer treatment that will not contradict their lay beliefs or they will find it hard to accept. well, at least this is what I am taught in COFM.


    medical student.

    By Anonymous Anonymous, At November 03, 2005 9:28 pm  

  • thank you for sounding exactly like my cofm professors. it warms the cockles of my heart to see that they're getting their message across. it really does.

    on a separate note, i HATE it when patients tell me which vein to poke for my bloods, or try to "educate" me on the proper method of setting a plug:P

    By Anonymous Distinguished Mediocrity, At November 03, 2005 9:53 pm  

  • "we must offer treatment that will not contradict their lay beliefs or they will find it hard to accept"

    Say a patient needs antibiotics but refuses to take it because he thinks it's 'heaty'. What do you do?

    Tell him he is correct and therefore does not need to take the antibiotics?

    Tell him the antibiotics is not 'heaty', in effect lying to him because in actual fact you do not know if the antibiotic is 'heaty' or not?

    If you think back to your pharmacology days you will remember 'heatiness' was not an attribute of drugs as you learnt them.

    I think it's time we be honest with ourselves and the patients instead of lying to them and thinking it's OK.

    By Blogger angry doc, At November 03, 2005 11:08 pm  

  • Say a patient needs antibiotics but refuses to take it because he thinks it's 'heaty'. What do you do?

    Tell him he is correct and therefore does not need to take the antibiotics?

    Tell him the antibiotics is not 'heaty', in effect lying to him because in actual fact you do not know if the antibiotic is 'heaty' or not?

    explain to him that no studies have proven antibiotics to be heaty.
    tell him he can drink barley (cooling what) if he thinks antibiotics is heaty.

    he can't drink so much barley water anyway. =P
    and it's ok to drink barley water.. maybe tell him add less sugar. =)

    med student who finished COFM last friday and going to sit for MB and IM tomorrow

    By Anonymous Anonymous, At November 04, 2005 12:02 am  

  • What happens when a patient only has viral infection but insists that he/she needs antibiotics?

    We know very well that he/she doesn't have the brain cells to understand or accept the fact that viral infections are self limiting and antibiotics play no role.

    But if you don't give it to them, the doctor down the road will. And you'll then be known as the "incompetent doctor who couldn't even cure my flu".

    And if you're practising privately, soon you'll realise all your patients had gone to the GOOD doctor who has a charming smile and unlimited supply of antibiotics.

    Life is hard when one tries to be professional and ethical. It's even harder in asian countries where medications have been wrongly overused.

    -Neither a MD nor a medicine student-

    By Blogger MisSmall, At November 04, 2005 12:28 am  

  • "explain to him that no studies have proven antibiotics to be heaty.
    tell him he can drink barley (cooling what) if he thinks antibiotics is heaty."

    Is institutionalised lying what they are teaching in COFM?

    The first part is half a lie because (as far as I know; I may be wrong here) no studies have be conducted on the concept of 'heatiness'.

    The second part is advising a patient on an area where you are not qualified to. You don't KNOW that barley is cooling. No part of your medical education taught you it is. If you tell the patient barley is cooling, you are just passing along hearsay. I don't think that's appropriate advice to give at a professional level.

    By Blogger angry doc, At November 04, 2005 9:17 am  

  • To angry doc,

    regarding heaty and cooling, it is actually very simple to overcome this problem.

    Read some books about Yin (cooling) and Yang (heaty). You will find some parrallel to Acid (heaty) and alkaline (cooling) balance. Or in essence protons and positive charges (heaty) and cooling (electrons and negative charges).

    There are also some links to K:Na ratios. The higher the ratio the more Yin. The lower the ratio the more Yang. Same with Ca/P ratios. The higher the ratios, the more Yin the lower the ratios the more Yang.

    My point here is not that WE should become experts in this heaty and cooling , Yin and Yang, Acid and Alkaline business, but that we should at least know a BIT about it to have conversations with our patients when they bring it up. Honestly the patients don't expect us to be experts but they will feel comforted if the doctor tries to explain it to them.

    Sometimes the patients themselves know nothing about what is heat or cooling etc. But if you explain to them a bit eg why protein being amino acids is heaty, while high potassium vegetables are cooling, they get impressed. They are "cheemed" out. Then you gain some credibility and reputation in their eyes as not being the doctor who knows nothing about heaty and cooling, but the doctor who knows.

    Face it you're not going to prescribe herbs based on whether they are heaty or cooling and thus beneficial to their condition. Patients ask a question, we try our best to answer it logically.

    After all that's what the TCMs do right? When asked about western med, they also answer to the best of their ability and then link it to their prinicples of healing. They don't go "I dunno anything about it don't ask me."

    If we want to fight the battle, we have to be smart. No way can we win by going the moral high ground. That is my experience to share with you.

    By Anonymous Dr Oz bloke, At November 04, 2005 9:54 am  

  • Perhaps, rather than adopting an 'us' (allopathic) and 'them' (non-allopathic) mentality, one might consider practising medicine - not in isolation - but trying to understand that sometimes, it is not just about the ailment (and the treatment) itself, but your patient as a person. And perhaps, actually having some kind of understanding of 'alternative medicine' might help you to understand and better address your patient's concerns
    (not as in referring your patient to a TCM physician).

    After all, keep your friends close, but your 'enemies' even closer.

    ~ xena

    By Anonymous Anonymous, At November 04, 2005 1:06 pm  

  • Dear Angry Doc,

    What about the concept of Integrative medicine or integrative therapy that is so popular in the west?

    Conventional medical doctors in the west has long started to integrate and learn abt alternative treatments and incorporate them into their practise. And it seems to be the trend. Studies has also shown that these approach is beneficial and effective in many ways.

    Is East really just East? And west really just west?

    What I observe is that in Asia, and in Singapore, we are always 20 years late in terms of embracing new medical approaches.

    To be so adament about drawing a clear line in terms of your practice may not be the best approach.

    That's just my two cents worth..

    By Anonymous Anonymous, At November 04, 2005 2:22 pm  

  • Yes I would agree with Xena that we should practise "healing" and not just medicine.

    Complementary medicine is ther term best used to describe the "alternatives".

    What is true though is that medical students enter medical school thinking all the mysteries of life and the human body would be revealed. But after graduating we find that many questions are still unanswered.

    To have to study a totally new concept of healing and all seems rather "wasteful" to many western doctors out there.

    Another thing is that western medicine has taught doctors that if they do not understand or know what the patient is taking in the form of vitamins, supplements or herbs, then western doctors should not say anything good about it.

    If a patient asked me whether it was good for her to take supplement XYZ and I knew nothing about it, what would be my first instinctive response? "Better don't take it" Correct?

    That's the problem with so many doctors today. The field of medicine and healing is growing so fast. In many instances we cannot keep up. On the other hand doctors do not like telling patients they do not know anything.

    I have seen many patients go to many doctors asking them if they should take multivitamins. And the doctors tell them "better don't take". All kinds of reasons have been given eg "wait get kidney stones".

    The problem really is that doctors know nothing about vitamins, supplements or herbs. Especially so in Singapore. Which is why they blanket reject the use of all of them.

    We have begun to see studies from very reputable journals on the importance of nutrition, vitamins, certain supplements that assist in the healing of our patients. Just because we do not know, or are reluctant to know more about them, does not mean we should advise patients against them.

    In fact as doctors we have a crucial role in the industry as we are the best placed to advise patients what vitamins or supplements they require, do not require, and what would be more helpful and less helpful for their particular conditions. We can serve to check on unscrupulous sales people who my be out to make a quick sale with no benefit to te customers.

    But to do that we must first acknowledge that we do not know. Then we can say let us get to know.

    By Anonymous Dr Oz Bloke, At November 04, 2005 2:53 pm  

  • Oz Bloke,

    "Read some books about Yin (cooling) and Yang (heaty).”

    I guess the question is what books to read.

    ”My point here is not that WE should become experts in this heaty and cooling , Yin and Yang, Acid and Alkaline business, but that we should at least know a BIT about it to have conversations with our patients when they bring it up.”

    My point is we should NOT discuss this in the professional context, because we are NOT trained in it. Reading ‘some books’ is not going to make us qualified to do so. Imagine if some sinseh read some western medical text and presumed to give advice on your treatment?

    “Patients ask a question, we try our best to answer it logically.”

    And I think sometimes an honest “I don’t know, I am not trained in this field” is the answer to give.

    ”After all that's what the TCMs do right? When asked about western med, they also answer to the best of their ability and then link it to their prinicples of healing. They don't go "I dunno anything about it don't ask me." “

    Like I said I don’t find that a satisfactory state of affairs.

    ”If we want to fight the battle, we have to be smart. No way can we win by going the moral high ground. That is my experience to share with you.”

    It depends on what you mean by winning, doesn’t it?

    “But to do that we must first acknowledge that we do not know. Then we can say let us get to know.”

    Wise words. I am not for integration, but then I am not against it either if someone is competently trained in more than one discipline and have no problem practising in that manner. I am just against a half-assed approach.

    By Blogger angry doc, At November 04, 2005 4:53 pm  

  • Anon,

    You are right that we are often behind, but that also means our patients are less often guniea pigs. :)

    (But then, Vioxx.)

    Integration will come and has already come; many of the medicines we prescribe today are herbal 'folk' cures. Along the way we also drop things like blood-letting and phrenology. Medicine evolves.

    One of the things that must first take place is a common language. The location of 'Qi' was not taught to me during my anatomy lectures.

    Question is whether the fact that one day the two disciplines will be integrated is an excuse for us now to dispense advice to patients on something which we have no formal or professional knowledge on. Just because it's being done in the west and because it's the trend doesn't automatically make the next doctor you visit qualified to talk about ying and yang.

    By Blogger angry doc, At November 04, 2005 5:00 pm  

  • If you were to refer to the cover of the Infectious Disease 'Bible' THE SANFORD GUIDE TO ANTIMICROBIAL THERAPY, you will find the words 'heatiness illness' in Chinese characters...

    By Anonymous dryvlee, At November 05, 2005 12:07 am  

  • dryvlee, you and I both know that refers to 'febrile illness' and not 'heatiness illness'...

    By Blogger angry doc, At November 05, 2005 12:42 am  

  • Agreed but its very convincing to patients when they keep insisting that their acute pustular tonsillitis is due to heatiness from fried chicken.

    By Anonymous dryvlee, At November 05, 2005 11:11 am  

  • Generally I don't find it a profitable exercise to discuss something with a person who thinks that eating fried chicken can cuase him an illness, but goes ahead and eats fried chicken anyway...

    By Blogger angry doc, At November 05, 2005 11:20 am  

  • Human behaviour is like that isn't it? Going for thrills and challenges; taking risks and thinking they are better than the rest of fellow humans..

    By Anonymous dryvlee, At November 07, 2005 9:30 am  

  • does all the advice you dispense be documented before it can be considered professional? I think with you experiences your judgment on the situation would be professional enough. It doesn't necessarily have to be evidence based medicine. It could be experience based.
    For the heatiness or cooling thing it is just a common chinese form of expressing certain set of symptoms. I am sure with your careful probing you would be able to identify the areas that the patients is concerned and then address the issue. TCM is more holistic. They combine a few medications to reduce/conteract the side effects of the different ingredient. In western medicine they usually give only 1 type of medicine to solve the problem but you do see them giving 2 types of medicine sometimes just to counteract the side effects. Like chemotheraphy and anti emetics and at the same time giving some some supplements to prevent extensive destruction of good cells. The only difference is instead of drinking one concoction you will be popping a cocktail of pills.

    By Anonymous Anonymous, At November 10, 2005 12:34 am  

  • OK, I have to ask: how is TCM more holistic?

    By Blogger angry doc, At November 10, 2005 8:36 am  

  • I am no expert in TCM but their philosophy is usually to restore a balance if I am not wrong. Western medicine just go directly to treat the symptoms instead of restoring the balance. Well that is just my opinion.

    By Anonymous Anonymous, At November 11, 2005 6:56 pm  

  • It seems to me it's just a case of 'names' then.

    You don't feel well, you seek medical attention. The western doctor tells you it's a virus and gives you something to control the symptoms. The sinseh tells you it's because there is too much heat and gives you something cooling.

    You take the stuff, and feel better.

    The western doctor says it's because the body's immune system has taken care of the virus, the sinseh says the balance is restored.

    By Blogger angry doc, At November 11, 2005 7:17 pm  

  • Hello,

    "My point is we should NOT discuss this in the professional context, because we are NOT trained in it. Reading ‘some books’ is not going to make us qualified to do so. "

    I agree with you that reading some books does not make one qualified but I am sure most of your knowledge are gleaned from books such as the medical bibles and personal experiences and not just from your COFM professors.

    As for "we should NOT discuss this in the professional context", what about the personal context? A patient doesn't see a doctor for his professional opinion but also for his friendly and approachable demeanor. Good bedside manners count. If it is just a professional opinion, I can see literally any Dr. Tom, Dick or Harry. Patients just need a friendly ear from a doctor. The point in medicine I see is not just to diagnose illness and dispense medicine but attend to the psychological well being of a doctor's patients.

    But hey, stick to your western medicine if that is what you do best.

    As for distinguished mediocrity, don't laugh when I tell you that there are doctors out there who have trouble finding the vein.

    Cheers all you good doctors and have a great day.

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