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Alternative prescribing and negligence

BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7386.455 (Published 22 February 2003) Cite this as: BMJ 2003;326:455
  1. David R Blake, professor of bone and joint medicine (david.blake{at}rnhrd-tr.swest.nhs.uk)
  1. Royal National Hospital for Rheumatic Diseases, Bath

    Negligence is the lack of proper care and attention; carelessness or an act of carelessness. A negligent act may be of no consequence. It may be of the utmost consequence and for the licensed medical profession, a negligent act can lead to criminal charges and removal of your name from the Medical Register. We are trained to avoid negligence and are now regularly audited to ensure this. Fear of negligence determines much of modern medical practice. Are similar standards applied to others?

    There would have been no form of redress if the treatment had failed

    My story concerns an alternative medical practitioner/pharmacist, an example of the kind of non-traditional practitioner, with apparent training in holistic medicine, that the House of Lords and other bodies have recommended.

    It was a damp Friday evening when I set out from a lecture to return on the train to Bath. Walking along the crowded pavements I was troubled once again by a recurrent low back pain, a longstanding complaint relieved for the most part by intermittent non-steroidal analgesics and relaxation. My customary relaxation technique having failed, I sought the former remedy. Failing to locate a Western-based pharmaceutical outlet, I entered a Chinese herbal-based alternative medicine holistic centre. The shop was empty and I approached the alternative practitioner stating that I was looking for a painkiller. She promptly offered me one at £8.99. I questioned whether just one drug was adequate given the level of my pain and she asked where the pain was. She offered me an additional remedy and informed me that it acted in a synergistic fashion. I looked concerned and then told her the following story, which she had not asked for.

    For the past month, I explained, I had been much troubled by an unremitting pain in the lower back, present both day and night, aggravated by movement, and not relieved by rest. I added that I felt very unwell, was shivering, and that I had lost weight. My expression and demeanour demonstrated, I hope, the pain, anxiety, and suffering. The practitioner handed me the two “synergistic bottles” of medication, but I could assess neither of them as the labels were in Chinese. She offered a course of acupuncture, telling me how much it would cost and how long it would last. I hesitated, awaiting further questions; none were forthcoming. I asked for evidence of the efficacy of the medicine and was informed courteously that Eastern medicine had a tradition that extended over a thousand years, that evidence was based on serial anecdotal observation with a constantly changing practice to refine and optimise the therapy. I was told that it was only Western medicine, which had a much poorer historical base, that required the scientific proof that I appeared to request. I did not purchase the compounds and bought a non-steroidal from the nearest Western outlet. I was advised to seek medical attention.

    We teach doctors in training that “common things occur commonly,” a dictum with which one cannot argue. This, no doubt, was the basis of my alternative practitioner's prescription and lack of advice. Statistically it was most likely that, despite my history, I still had mechanical low back pain and therefore there would be little adverse consequence to my taking the medication offered.

    Our pronouncements to medical students are reinforced by a second dictum: always diagnose the treatable and important, even if it is not the most common or likely explanation for the patient's symptoms. A medical student or a Western pharmacist should have been alerted by the “red flags” indicating potentially serious pathology. Testicular cancer with secondaries would be on the list, as might an infection.

    In medicine and pharmacy our training is arduous and long and it licenses us to proceed with caution, provided that we are assessed and audited on route. My alternative practitioner was, I believe, negligent. She was operating from premises licensed by the local council and advertised as offering Chinese medicine. She was therefore providing a service of which I had a reasonable expectation of benefit and for which she charged. There would have been no form of redress if the treatment had failed or if, as a consequence of her lack of diagnostic skills, I had died. The House of Lords and other bodies encourage us to embrace alternative medicine. They must re-examine their position.

    I am hoping to conduct an appropriate national audit using “stealth methodology” with a clearly defined primary end point to test the null hypothesis that an alternative medical practitioner is more likely to advise a physical examination for symptoms suggestive of serious pathology than an outlet that prescribes standard Western medicines.

    Footnotes

    • Competing interests DB has a degree in “evidence based medicine” and a licence to practise from the General Medical Council. He receives programme and infrastructure support from the Arthritis and Rheumatism Council (UK). The views expressed here are his own and do not necessarily reflect the views of his employers (NHS/university) or sponsors.

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