Under My Skin

Negotiating the Alternative


"I say, Holmes," I said, "how did you deduce that my last patient was a devotee of Alternative Medicine?"

"Elementary, my dear Rocky," he replied. Even Holmes grows informal with the times. "First, I observed that she'd brought a bottle of calendula, an emollient with cachet among those who prefer their remedies natural.

"Second, I observed that her address was in the vicinity of Harvard Square, a district rife with holistic clinics, purveyors of supplements, and establishments where cleansing detoxification may be procured.

"More important," he continued, "take note of her historical narrative. Attributing a similar rash last year to the water in her Cape Cod cape, she had showered exclusively at her health club. What disturbed her was that the affliction returned despite continued remote bathing. Blaming disease on diet and environment is a staple of Alternative thinking.

"What clinched the matter," Holmes continued, warming to his subject, "was her opening challenge to you. 'Don't just treat the symptoms,' she said, 'Get to the root cause!' The term, 'root cause,' capsulizes Alternative healing's central critique of Western medicine—that you paper over symptoms and fail to address the true source, which must come from the approved list of usual suspects: diet, water, atmosphere, hygiene, allergy. Demanding a 'root cause,' Rocky—et voilá!"

"Capital, Holmes!" I enthused.

He ignored me, as usual. "You physicians," Holmes continued, "often discuss Alternative therapies as though all that matters is whether they 'work.' This question is far too narrow, and misses the point that the Alternative world is in fact a subculture with a package of ideas linked as much by sociology as logic."

"Such as?" I inquired.

"Such as preferring nature to artifice. Such as rejecting analysis—the body as an aggregate of specific organs and systems—in favor of synthesis—the body as a whole. When you allopathic physicians diagnose a condition eczema and call it a 'skin disease,' Alternatives bristle, insisting as an article of faith that what appears on the skin must be 'systemic,' that is, must reflect what goes on within.

"This is a very old notion. Consider the word, 'eruption.' What do you think is erupting and where is it erupting from? An abnormal surface is assumed to reflect what the body has extruded in an effort to balance the humors roiling within. One stuffs it back down through the pores at peril. Hence the often-heard question, 'If you clear up the rash here, won't it just pop out somewhere else?'"

"Holmes!" I exclaimed. "Could your discussion be an instance of what has been called 'Cultural Competence' by the New England Journal of Medicine (N. Engl. J. Med. 2004;351:953–5)?"

"My subscription lapsed," Holmes sniffed. "In any case, people may express alien cultural ideas in perfect English. One ought to address members of the Alternative culture, as those of any tradition, with care and forethought."

"Have you any suggestions?" I ventured.

"Four," came his crisp retort. "First, candidly admit that you often don't know root causes. Suggest instead alleviating symptoms as a limited yet worthwhile goal.

"Second, use steroids, the Alternative's archnemesis, with discretion. If you must prescribe them, explain that circulating adrenal steroid hormones are natural, with any increment from percutaneous absorption all but imperceptible to the body.

"Third, concede the role of diet and environment, adding that this role is often erratic and individual. Advise patients to avoid what they themselves observe to consistently reproduce symptoms (shower water, for instance).

"Finally, endorse lay therapies when you have no reason not to. Aver that echinacea may be just the thing, that tea tree oil makes a lovely shampoo."

"Will this approach work?" I inquired.

"Usually," said Holmes. "Few people are doctrinally consistent about anything. Besides, a pure Alternative would not be in your office.

"As they say in the garment trade," he concluded with a flourish, "you gotta know your customers."

"Gadzooks, Holmes!" I expostulated. "This barbarous colloquialism has gone too far!"

Alas, too late. I gaped as Holmes exchanged his deerstalker for a Red Sox World Series cap, which he pulled on backwards.

"Chill, Rocky," said Holmes, with a thin smile. Turning to leave, he flipped me a small phial. "Have some of this chamomile. Calm you right down.

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