In keeping with JAMA Network policy, the author advises that following blog post is fictional and the details within do not refer to an actual patient, but rather represent a frequently experienced doctor-patient dialogue.
“My eyes are so much better! Aren’t they, Doc?” enthused the elderly patient sitting in my office. The patient’s vision was stable, within just a few letters of the last recorded measurement.
“I wouldn’t say that the eyes are improving,” I said. “At this stage of dry macular degeneration I wouldn’t expect them to get better. However, I am very happy that they are stable and there are no signs of new wet macular degeneration. This is excellent, and exactly what we are hoping for from visit to visit.” “But I am seeing better!” insisted the patient. “It’s all due to those terrific acupuncture sessions. They told me that they could help me with my eyes and I think they’ve done it! It’s been a lot of money and a lot of visits. Couldn’t it have helped my eyes?”
Internally, I sighed at the thought of the resources he had spent pursuing acupuncture therapy. I sighed even more that I was going to be the one to have to burst his bubble. “There’s no proven evidence that acupuncture will help improve macular degeneration” I said gently. “We don’t have any good data from clinical studies that suggests that your eyes would have benefited from these treatments. I’m glad if you feel like the vision is better, but I don’t see any objective improvement from the tests that we ran today.” Seeing the look of disappointment, I added “I can’t absolutely rule out that the acupuncture might have had some small benefit for you or might have prevented the eyes from getting worse. Still, I think this is unlikely. My best medical advice is to not continue with the treatments since I don’t think they will help your eyes.”
My poor patient was crushed. I fielded several more phone calls from both patient and spouse in the weeks after our appointment asking further questions about the expected course of age-related macular degeneration. Over time, and after second (and, I suspect, third) opinions from various retina specialists, they were reluctantly convinced to stop the acupuncture sessions.
Patients are especially motivated to look for holistic or alternative treatments when traditional medicine doesn’t have much to offer them. And there are innumerable alternative remedies out there. In addition to acupuncture, over the years I’ve heard about antibiotics, magnet therapy, meditation, and various herbal medicines for various stages of age-related macular degeneration, retinal vein occlusion, and diabetic eye disease.
Most of the time, my patients ask my opinion before they start an extensive or expensive course of alternative therapy. It can be challenging, however, in the subsequent discussions to make them understand that most, if not all of these therapies lack credible evidence-based support. A technical discussion of the differences between levels of evidence (Level 1: randomized controlled trials; Level 2: non-randomized controlled trial; Level 3: observational studies with controls; and Level 4: observational studies without controls) is beyond the scope of most of my discussions with patients. Despite the challenges, it is important to help patients understand why randomized controlled trials provide superior evidence for clinical efficacy than a few anecdotal cases highlighted in the local news advertisements. At the same time, I try to honestly acknowledge the enormous gaps in knowledge that we have in the field. I think it is likely that some herbal remedies do provide benefit, but we just haven’t yet designed studies to effectively demonstrate their medical efficacy.
Toward the end of our discussions, patients often say “But this therapy isn’t like real medicine with side effects. It’s just [vitamins, minerals, magnets, etc…]. Those can’t hurt me, right?” I emphasize the fact that nearly every treatment has potential associated adverse events. This is especially true if it involves a systemic medication or is an invasive procedure. Furthermore, because holistic therapies and supplements are not regulated in the same rigorous manner as prescription medications, lack of oversight and lack of standardization in dosage and formulation can potentially lead to widely varying effects related to efficacy and toxicity, even among different lots of the same product. A recent, highly alarming example of unexpected toxicity from a homeopathic remedy was the rash of pediatric deaths earlier this year from a widely-used teething product that contained belladonna.
So I tread carefully when it comes to advising patients about alternative therapies. When there are other therapies already established to have efficacy in a particular disease, I strongly urge patients to pursue these first. When there are no other effective treatment options, I still try to make them understand that there are potential risks with every therapy and I caution them against unrealistic expectations from unproven treatment modalities.