Dr Reg Perkin, Executive Director of the College for more than 10 ... Toronto. B;riefing;. Bn'di-ig. Palfiative care training expanded. The College of Family Phys-.
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Hope against truth medicine Complementarg and palliative care LOUISA BL\IR
Patients who are dying are particularly vulnerable to the ministrations of complementary medical practitioners. Family physicians are often confronted with patients who have just come from a therapist down the road who has told them that they can be cured of cancer.
Robert Buckman is a cancer specialist and an Associate Professor at the University of Toronto. He is also a familiar face on medical television shows in Canada, Britain, and the United States. His books include How to Break Bad News and Magic and Medicine. "Complementary medical practitioners are not bound to give a total picture of the truth," he said at the Ontario College's Annual Scientific Assembly in November. "But medical doctors are not allowed to lie. If [patients] with oat cell cancer of the lung [come] to me, I am duty bound to tell them that, statistically speaking, 15% of sufferers will be alive in 2 years. A complementary medical practitioner may simply respond to the patient's desperation to get better by saying, 'If you want to enough, I'm sure you will!' or 'I've seen it happen."' How do you support your patients without misleading them? How do you cope with their faith in complementary practices about which you are privately skeptical? -4-
FOR PRESCRIBING INFORMATION SEE PAGE 511
Dr Reg Perkin, Executive Director of the College for more than 10 years, said goodbye to College staff in Mississauga, Ont, at the end of February: Perkin'sfive-part retrospective on his time at the College ran in "Progress JNotes"from October 1995 to February 1996. The key says Buckman, is trust. patient's medical condition and Many doctors have a relationship acknowledging the patient's emoof trust with their patients. But tions are both essential, he says. defining, analyzing, and teaching The third element, regard, is a the trust relationship is far more quality Buckman hesitates to define difficult. Buckman has identified as simply love (which few doctors three elements that are required for wvould be able to say they felt for trust between patient and doctor: every last one of their patients) but truth, acknowledgment, and rather calls an "unconditional posiregard. Telling the truth about the tive regard." 42 MARCH MARS 1996 -:*
Canadian Famil)y Phlsionian LeWfedecin
dejafinle (anadien1
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NEWS +* ACTUALITES
"It's not an emotion; it's a behaviour. It's an intellectual act; you don't have to feel love," he says. Regard can acknowledge and legitimize the patient's emotions without endorsing them. "You don't have to feel the same way as the patient. You don't have to believe in the same things or vote the same way." Buckman challenges a notion that goes almost unquestioned in the culture of complementary medicine: that is, that illness has a lesson for the sufferer built into it, or an intrinsic meaning, such as the idea that breast cancer afflicts only women for whom it is a solution to some personal problem or an escape for unresolved anger. This theory is unproven, and only continues an age-old tradition of blaming the patient, such as punishing lepers by locking them up, or the belief in Victorian England that Down's syndrome was caused by the parents' being drunk when the child was conceived. Buckman writes that this attraction to an intrinsic meaning of illness is understandable, as "a persuasive explanation offers hope of some kind of cure, whereas if the doctor doesn't know why something struck you and not your next-door neighbour, how can you believe in his ability to treat?" In his book Magic and Medicine, Buckman tells of a woman with cancer of the ovary being treated at the Bristol Cancer Help Centre (a famous institute of complementary medicine in Britain), who was told that ovarian cancer meant that she was probably denying her own creativity. After her death, her husband wrote, "It is unnecessarily cruel to tell people they may be dying because they have failed to live, -*-
FOR PRESCRIBING INFORMATION SEE PAGE 403
love, work, relax, or eat properly, whatever 'properly' means. We might be able to do these things better, but what right does anyone have to say that these factors might kill us? Where's the evidence?" Illness itself has no meaning; it is a random vicissitude, says Buckman, but it is a challenge, and as such it can bring an extrinsic meaning. "Your life itself has meaning, which is most realistically defined in human relationships.... No one can take away from you how you respond to illness." Buckman does not endorse the complementary medicines that his patients often would like him to. He has done extensive research on claims for complementary medicines in Canada, Britain, and the United States, and has found that there is adequate clinical evidence for only a handful: homeopathy for hay fever, chiropractic for low back pain, acupuncture for pain relief, and a Chinese herbal tea for childhood eczema. "There's no data at all for most complementary medicines," he says, and challenges practitioners to conduct more rigorous clinical trials and to regulate themselves. But he does not criticize his patients for seeing complementary practitioners. When patients come to him purely for endorsement of some complementary intervention, he tells them, "I'm glad for you, if it makes you feel better." He also recommends trying therapies in succession rather than simultaneously; for example, if a patient wants to try Essiac for cancer, he would suggest a trial period followed by chemotherapy. "Most important is to say to them that you'll be there for them," he says, "and that they can come back. And they do."
B;riefing; Bn'di-ig Palfiative care training expanded Family Physicians of Canada is proposmg an optional third year of family
The College of
mned'icine
training care.
residency
specifically in palliative
"Most of the needs of patients for [relief of pain,] anxiety, cdepression, anda fear are met by family physicians im the community as well as; dealing, with the grie reaction of survivors, says
Dr; ic'hard MacLachlan, Halifax family physician who a
prepared sion
the College's submis-
for
the
S4ienatLe
special
Committee hearings on euthanasia
and
tion
to
assi'sted
suicide. In addi-
improving education, tne
College supports enacting the recommendations released by the speca Senate Committee.
Statement on banking human milk
The
Canadian Paediatric Society
has issued a statement reaffirm-
ing that breastfeeding for fullanid expressed
inifants
term
fortified milk from preterm
infants' mothers are the preferred choices for infant feeding. examfininyte
After
shortcomings
of
benefits and
using banKed
human milk, the Society advocates
strict
screenig
requirements
tially, not
to
and
eradicate
safety poten-
infectious agents but does support
routine
use
of
bankedhruman milk. The statement
recommends
rigorous
donor-screening procedures
for
bankin g breast milk similar to
those for blood don.at*ion.
Toronto VOL 42: MARCH * MARS 1996 # Canadian Family Physician . Ie Medecin defamille canadien 571
