A rant against naturopathic medicine (in the treatment of cancer)

I started off my day today with a very sad case. A patient in their 60s was admitted to our service with stage IV cancer that had spread throughout their body. It would appear from their labwork that the organs in their body were starting to shut down. The patient is young and got a really crappy diagnosis, and they made some poor decisions when it came to choosing treatment, and now they are dying.

The patient was diagnosed not too long ago and started chemotherapy less than a month after the diagnosis. Then they heard about a naturopathic "doctor" who was doing colonic hydrotherapy here in Nanaimo and treating patients with cancer. When they saw this practitioner, he promised to treat them but stated he preferred his patients to NOT be on chemotherapy. With hope in their eyes, my patient quit the chemotherapy and went ahead with an unproven and RISKY treatment, advocated by a naturopath.

My problem with this scenario is many-fold.

When we, as medical practitioners, are trying to decide on a therapy for our patients we use the best available evidence to guide our rationale. We use the studies, to the best of our abilities, to give the patient the best information possible to help them make the best decision possible. For example, if I believe a patient needs a blood transfusion we go over the benefits and risks of having this procedure. If they want to know the risk of acquiring HIV or Hepatitis C from the transfusion, I can quote those numbers. After we're done talking, the patient chooses to sign a waiver of consent saying they understand the risk vs. benefit of the procedure and that they would like to go ahead or waive having it done. Same goes for surgery. And if I start a patient on a new medication we go through benefits and risks of this medication and they decide if they want to take it or not. Never would I tell my patient "I'll only give you this medication if you promise to stop ALL of your other medications, even if they are life-sustaining drugs".

The problem with procedures like colonic hydrotherapy is that there are NO GOOD STUDIES to lead into a discussion of cost vs. benefit for having the treatment done. There are no randomized control trials, there aren't even trials testing the colonic hydrotherapy vs. chemotherapy, or vs. surgical treatment. So very vulnerable people who may or may not have the education to make decisions about these kinds of procedures are paying money up the wazoo for a procedure that is risky at best. And we have nothing to prove that there is ANY benefit to the patient. How can I get consent from a patient when there are no studies? How can they know the cost vs. benefit analysis when it's never been done (and likely will never be done for obvious reasons).

To add insult to injury my patient recently started having falls. And the family was merely told that she was "attention seeking".

If I, as a medical practitioner, had done any of the above I WOULD HAVE MY LICENSE REVOKED. I would like be sued for negligence and I would certainly not be asked to work in the hospital, and likely BC, ever again.

Going back to my case, I discussed the prognosis with my patient's twenty-something year old daughter as she bounced her 4 month year old son. The daughter had tears in her eyes as I explained that we would do everything possible to stabilize her parent so that we could get them back on chemotherapy and potentially gain them a few more months of life. She asked me how the naturopathic doctor could be allowed to practice. I wish I could give her a better answer. I just don't know.

Our Incredible Minds

I've found myself reflecting on dementia lately. This is likely at least in part due to the fact that about half my patients suffer to some degree from this sad, incurable disease. And I suppose in the back of my mind I worry about what it might be like to have *my* family member suffering with a similar illness. Note to self: must get them doing those crossword puzzles!

But often my demented patients make me smile, or even laugh out loud. Because dementia removes all filters and these people are who they are. And more often than not they remind me of children and they very often need the care and attention of a child.

I was evaluating a woman for admission to hospital and she was cold. I often hold a person's hand while I examine them so that we have that personal touch while I'm somewhat intrusive. Well this woman was cold and she could feel the heat from my sweatshirt and before I could stop her she had stuffed one frigid hand up my shirtsleeve and was trying to get the other one up that same sleeve. I burst out laughing, as this was something I used to do as a child with my parents. She had these piercing blue eyes in a wrinkly old face and she happily looked up at me with warming hands.

And another patient who had been so rude with me on admission to hospital. He had all the answers and he'd be damned if "some woman" was going to try and convince him otherwise. Never mind that "some woman" was his freakin' doctor. A few days later I saw him and he was just about ready to go home and now he was scared about the upcoming change. He wiped away tears with a shaky hand. After we had conversed he shouted after me as I walked away "I love you dear!"

When a different patient walks into my office looking for the escaped cat from the movie set, I don't blink an eye. I get up and drape my arm through hers and move back out into the hallway. I had heard a rumour that this pesky cat had been irritating the nurses and we set out on the hunt to capture the cat until the patient is properly redirected and in safe hands.

And all I can think is, our incredible minds.

How can I help you when I don't even like you?

How do you provide good medical care to someone you don't like? For example the man who smiles at you but calls the nurse a "lazy bitch"...Or the woman who interrupts you with "now you listen to me missy"...Or my worse case yet, the retired and demented sex offender.

How do we normally deal with people we dislike? It's an interesting question and I'm sure you can think of a couple of different ways that you've coped with this problem. Do you avoid the person? Do you ignore them? Do you politely get through the encounter while discrediting in your mind, all that's been said? Do you confront them? Do you let them walk all over you? Do you try and find a medium or a balance that leaves both parties satisfied?

I need to provide equally good medicine to all my patients. I believe I've used all the above techniques at some point to deal with an unpleasant situation, with varying levels of success. And of course what works for some patients may not work for others. But somehow we, as physicians, must learn to push aside our dislikes to evaluate critically what is wrong with the patient and to give them the best possible care, regardless of the negative emotions the person might elicit from us.

I think of all of this today because one of my "toughies", a person I would mentally have to prepare myself for before each and every visit, stopped me today in the hallway. The first time we interacted I was doing a colleague a favour by seeing her. This patient dictated exactly how the encounter was going to go, which made it unpleasant for both of us. She was rude and manipulative, and in retrospect, probably deeply afraid of the coming months. I left the room that day shaking with anger. But I'd also learned some tools on how to work with her in the future. Our next encounter went more smoothly. Near the end I was starting to get wound up so I called it a day. And from that day forward we had established our boundaries. And she opened up to me about her life, her children, her successes and her failures.

She was diagnosed young with ovarian cancer and it is killing her. Today when I saw her her appearance shocked me. By the flash of a younger self, who was startlingly beautiful. By the fact that she is so very obviously now dying. And even more so by my hand on her shoulder and her bringing her hand up to cover mine and to then pull me into a strong hug and a whisper in my ear "I love you".

Having just rediscovered this blog site I'm realizing that my hiatus went from a couple years to nearly half a decade, but here I am, fully graduated and working and thinking of sharing some of the amazing stories I'm so fortunate to witness on a daily basis. Bare with me. Sometimes I leave an encounter with a smile, other times with tears. But each story bares witness to someone's life...so some postings may be happy, others sad, others might share an anecdote or a lesson a patient has taught me. So...let us begin :)

Disclaimer: Confidentiality will be maintained throughout these postings.

I was driving to my Spanish lesson today and thinking about one of the sadder cases I've seen in the past several months working in hospital. My patient is just under twenty and was hit by a car on a freeway. The circumstances of the accident (what we call a peds struck) is shady at best. The poor girl was left with a very traumatic brain injury, a dislocated neck, a broken hip just to give a brief overview. After months in the hospital she was transferred to our facility. I met her today and only one eye can focus on me. She cannot talk, she doesn't have control of her body any more. But that one eye can focus on me, and I like to believe that she could understand me when I spoke, when I touched her arm. She's still quite sick, and unfortunately it may be the result of her brain injury. Which means there's not much we can do other than to try and make her comfortable. There is more to her story, which makes it even sadder, but we'll leave it at this, as the point of my story is different.

I was working with this girl, who shares a room with 3 other people. Another of my patients joined me and put a hand on the head of the girl and told me that they had got to know one another a little over the last several weeks. She could tell me what was wrong, and what she had noticed in the night. She spoke with me as though it was her own daughter in the wheelchair, not a stranger. She asked that I look after her and try and solve the problem that was causing discomfort. All the time she kept her hand on the girls head, stroking what remained of her hair, and talking as though the girl understood.

At the time it didn't strike me, but as I was driving to my lesson today tears came to my eyes. How incredible is it that someone who is a complete stranger, who has never exchanged actual words with this young girl, can stand up and advocate for her health and well being? Most people would be frightened to see her with her tube feeds in her wheelchair, but this patient, who was sick herself, could see past all of that and see the girl who needed someone to stand up for her.

Let's talk medicine.

My experience in the hospital really has been very great so far. As I think I may have mentionned before, what I was hoping to gain from working here more than anything, was how to work with less. And boy am I learning quickly! We are in a teaching hospital here, and we have an xray and an ultrasound machine. That's it for imaging folks! I never realized how GREAT a CT scan was, let alone MRIs! And bloodwork is severly limited as well...sometime we cannot even get a CBC. So it really feels like you're working in the dark sometimes, which can be scary. But the docs do what they can with what they have and what they know, and generally the patients do well, which is comforting, and something to learn from as well.

We see tons of osteomyelitis here. It's incredible. For a long time I couldn't figure out why we were seeing SO much of it. Then it was explained to me that a lot of the kids we were seeing were malnourished, and thus predisposed to infection, which unfortunately seems to seed in their bones. We saw one boy who's hip had been dislocated for weeks, without anyone having noticed (even though he was in the hospital setting!) and the other hip had been completely eaten away by his infection. When this case was presented in the morning it was hardly even discussed. There is nothing we can do for this boy in Rwanda. He is about 12 years old and need to have both hips completely cleaned out, needs systemic antibiotics and needs bilateral hip replacement. That was depressing.

I'll write about one more depressing case then I'll try and come up with a positive one to end the story with, ok??

We had a child come in last week with an acute abdomen. He was about 1.5 years old and was pretty much comatose on arrival. We realized very quickly that he had an ileus (absolutely silent distended abdomen-so scary) and when we were placing lines (in his scalp) he didn't budge (also a very scary sign in a young child). Afterwards we discussed his case and we figured that he was already in heart and lung failure and that his kidneys had shut down. He had had a history of diarrhea for about a week and had been vomiting prior to presentation as well. What happened was that his electrolytes were completely out of whack and his bowel stopped working, which basically poisoned his blood and eventually killed him. When we were doing CPR on this tiny body it just felt wrong. They tried surgery but honestly, I think no matter what we would have done for him, he had presented too late. Like many of our patients, unfortunately.

So happy time! A lot of the kids who come to hospital present us with happy times! They may be around for awhile (with burns or osteomyelitis) but that means we get shrieks and smiles and giggles, especially as the white girl! One child had a seizure and fell into a fire (from what I understood) and though he'll be permanently disfigured, some plastic surgeons worked on him last week and he can now close his eyes again. And though he lost both his hands to amputations, he has prostheses available to him. And he always comes running to place his stumps in my hands and to receive a hug...which is just great! The kids in the hospital do not treat him any differently and we can only hope that these friendships will help him through what will certainly be a challenging life.

I will stop by saying thank you to everyone for their support and positive wishes over these past several months! I got my first choice for residency programs, and will be starting family medicine on July 1rst in the Greater Vancouver program run through UBC. I am so incredibly excited, but am trying not to let that affect my last several days here in Butare. I've got a great weekend planned and can't wait to tell you all about it, next week! Big hugs!!

I am having such a fabulous weekend - which is exactly what I needed considering we are now less than 36 hours away from determining where I shall be training these next couple of years!

I started my adventure Friday when I met a Rwandan friend at the bus station and rode into Kigali. There the German medical student I was traveling with and I each hopped on the back of a motorcycle taxi to make our way to a suburb to meet friends. Reminiscent of my Cambodian days, I had a backpack on, the girls' wheelie suitcase balanced on my lap, and my phone rang (which I of course had to answer!) Still got it!

We met the American that I had met in the airport three weeks ago (the coach for the National Rwandan Cycling Team) at this lovely, expat restaurant. A little bit of culture shock, I have to admit, but the latte I had was just out of this world! Shortly after arriving the German girl got a lift to Ruhengeri with the American's new mechanic, and I got on the back of the American's motorcycle and we rode the 1.5 hours through the rolling mountains to Ruhengeri. It was such an amazing experience - exhilarating and quite the adventure. We got stopped twice by the police...one time to tell us to slow down, but really they just wanted to stop us and find out what two muzungus were doing on a motorcycle in Rwanda! Once in Ruhengeri, I decided to join Jock (the American) on his venture to Gisenyi, where he was meeting with possible donors. We drove to the border with the Democratic Republic of the Congo and stopped in a fancy hotel where we met with the investors. There I met many many Canadian-Rwandans, one of whom lives about a 2 minute walk from my apartment in Toronto! What a small world - and hopefully my schmoozing helped the team out a little :) We drove back to Ruhengeri in the rain - which was really quite beautiful, with lightening in the distance over Goma. And you could see the active volcano as well, glowing red in the mist across the border.

The next morning I woke up early, hopped on the back of the motorcycle and made my way to Kinigi where I met up with a group to go trekking for gorillas. This is a ridiculously expensive venture, but I've heard the cost is going to double in the next year - so I took the opportunity to get out and see these lovely animals. And I did it by the cheapest means possible, which I am pretty proud of! We hiked for about 1.5-2 hours up the side of a volcano that borders with the DRC and then bushwacked our way down a slope until we were meters away from the animals. At one point, one of the guys was yelling my name, but I wasn't paying attention until I felt something brush against my leg - a gorilla! haha! Our group was the Amohoro (Peace) group and consisted of 16 individuals. Two fluffy little babies, a ton of teenagers and one silverback. We bushwacked with the group for about one hour before we decided to take a different trail back to the vehicles. This required more bushwacking and was like no hiking experience I've ever had! Aside from a whiny mother-daughter duo from Europe/UN, we had a great great time, and watching them literally summersault over one another as they fell down a portion of the hill kind of made up for their poor company!

I was going to hike another volcano today, but everything is so muddy in the rainy season, and the views would have been similar to what I saw yesterday, so I decided to save myself the hefty hiking fees. Instead I'm going to borrow a mountainbike from Jock and a small group of us are going to try and bike a 40 km route to where we should get a lookout over two lakes up closer to the Ugandan border. The weather looks great so hopefully it will hold out!

I've been thoroughly spoiled these last couple of days. I have this gynormous bed, access to a HOT shower and dynamic wonderful people who are doing some pretty great work in this part of the world. Last night we had a big dinner and we had an 18 year old kid from America over who is teaching 5 year old children in the local school (no teaching education, thought he was coming here to assist!) we also had two CEOs for different African NGOs over...as well as Jock, who is running at least two to three NGOs that I am aware of, Suzanne who is building a prayer shelter for a school and has just finished building a library for another school, myself and another medical student and the brand new American mechanic for the National Rwandan Cycling Team.

I could not ask for a better life.

The Weekend (continued from below)

This memorial was created in the location of an old school, where 50,000 people had come for shelter when the killings had begun. The killers came and tried to kill people but the 50,000 were strong enough to keep them at bay. Then the interahamwe came with grenades and machetes and they managed to kill nearly everyone at this site. 48,000 people were buried in mass graves, and 2,000 bodies were placed on display, to remind people that there was a genocide in Rwanda and that it should never be allowed to happen again. What I didn't realize was that the bodies had been preserved - so in each of the 20 rooms we had to walk into, you were greeted with a stench as well as the atrocity of seeing bodies in very unnatural positions. David had visited this site before, and still walked with me from room to room, though we didn't say a word throughout the whole visit. The French, when they eventually came, used this as one of their homebase sites, and had unknowingly built a volleyball court over a mass grave. I have to say that I was a little disappointed that I was the only tourist at this site. If you go to any of the Jewish death camps in Germany or Poland you'll find busloads of tourists paying their respects. But here it was just David and myself, and the survivor who took us on our tour.

After finishing at the site (and leaving a 2000 Rfr donation - food was going to be tight!) David and I slowly walked back to Gikongoro. While walking he talked to me a little about his own experience and together we tried to understand, as a younger generation, how people could hate so strongly as to conduct mass murder. It truly is incomprehensible.

The rest of the day was very pleasant. I couldn't go out dancing with David because I had so little money (and nowhere to stay post-midnight!) but he invited me to his place for dinner (score!) and we spent the evening chatting, comparing cultures and looking at photographs.

Sunday I made my way into Kigali where I secured a gorilla trekking permit for this coming weekend (woot!) Getting this permit was a pain in the ass and is a story in itself. Then I walked to the official Genocide Memorial Museum (to complete the Genocide weekend!) where 250,000 bodies have been buried. This Memorial was very well put together and I was happy to see that there were more tourists visiting it. I spent two hours walking around and reading and found it interesting in that there was very little information surrounding the events that led up to the Genocide, but there was tons of info about when and how the victims were killed. Is this because we just don't have the details? It was pretty striking.

Oh and just to keep the food story going...that morning I had leftover popcorn and water for breakfast. I then ate a chocolate bar that I had bought a week ago for lunch - but it was so disgusting! The chocolate had turned white and powdery, but I needed to eat something! Then, happily, I was able to find some guys on the street who gave me an excellent exchange rate (better than the bank!) and I then headed directly to a restaurant where I got myself the requisite plate of carbs :) The things we take for granted! haha!

Ok. I should probably get back to the research I came here to do. One of the interns has asked me to teach him about abnormal heart sounds and I need to refresh myself so as to avoid confusing them, and myself!