Most physicians never forget their first Code Blue. I’ll never forget my first Code White.
I was on call in the hospital when it came over the loudspeaker. This alarm signals a violent patient, one that could pose a danger to staff and other patients. I ran up to the ward, where three nurses were huddled in a patient’s room. One of them was trying to restrain a highly agitated adolescent. His worried parents stood nearby.
Andrew (not his real name) had been admitted a few days earlier for delirious behavior that may have been related to viral encephalitis — an infection in the brain. The night before the Code White, he had been agitated and aggressive, prompting the resident to give him an antipsychotic drug. One of the nurses asked if I wanted to repeat that treatment. I wasn’t sure. I needed to assess him first.
As I approached his bed, Andrew was breathing heavily, his dark brown hair soaked in sweat. It looked to me like a panic attack. After examining him, I asked everyone except his parents and one nurse to leave the room.
I then tried a guided imagery technique — one I had learned just a few weeks earlier at a course that covered mind-body approaches for children. I asked Andrew to imagine the last time he felt happy and relaxed. For him it was boating in the Caribbean with his family. With his eyes closed, I asked him to imagine what that moment looked like, felt like, even sounded like. As he imagined the scene, his breathing began to slow and deepen, and he became calmer. After a few minutes when Andrew opened his eyes, I asked if he needed something to help him sleep. He shook his head, saying he felt a lot better. He soon fell asleep.
Afterward, his father told me that deep-breathing techniques had helped Andrew calm down before. The problem here was that no one ever asked what had worked for him in the past.
Talking about alternative approaches
Alternative medicine has been in the news lately, this time as the consequence of a Cleveland Clinic physician’s online article full of anti-vaccine rhetoric. In response, the clinic affirmed its emphasis on evidence-based medicine and noted plans to halt the sale of alternative medicine products. Controversies about alternative therapies and vaccines disproportionately affect children, who have little say in their own health choices.
The debate over alternative therapies, which has been erroneously linked to the anti-vaccine movement, has largely ignored the conversation that needs to happen between physicians and their patients. It’s one thing to say that doctors shouldn’t prescribe unproven treatments. It’s another to tell people that they cannot use these legally available remedies. So doctors need to ask patients “What else have you tried?” This becomes particularly important as alternative medicine use among children — largely driven by their parents — is more common than we realize.
Complementary health approaches, as they are called by the National Institutes of Health, include any healing approach that falls outside of the realm of conventional medicine. This can include botanical therapies, mind-body techniques, supplements, and more. The National Center for Complementary and Integrative Health provides updated summaries evaluating the evidence for or against many complementary health approaches in a way that is easy for both patients and physicians to understand. The center also has a clear stance in favor of vaccinations for children, and presents reputable links to information about vaccine safety and effectiveness.
Mindfulness, which is considered to be a complementary health approach, has decent evidence supporting its use. Last September, the American Academy of Pediatrics released a detailed report summarizing the research behind various mind-body medicine techniques for children and adolescents, expanding on what we already know about mindfulness in children. For instance, yoga and guided imagery may work well for most children, while biofeedback has good evidence of effectiveness only for certain conditions.
Up to 71 percent of children may use complementary health approaches at home, yet only 36 percent of parents disclose their child is using one, fearing stigma, physician judgement, or that it might affect the care their child receives. The Tell Your Doctor campaign, an effort spearheaded by the Children’s Complementary Therapy Network, is aimed at helping physicians know what therapies a child is using.
While there are few serious adverse events related to using complementary health approaches, when they occur they can be catastrophic — often a result of caregivers or alternative providers who are poorly informed on how to recognize the signs of serious illness, or choosing an unproven alternative approach over a proven one or a vaccine.
Regardless of clinicians’ personal views, they need to be aware of these alternative approaches. That awareness starts with asking the question, “What else have you tried?” It should be asked non-judgmentally and empathetically.
Physicians might even explore mindfulness for their own work. A new book, “Attending: Medicine, Mindfulness, and Humanity,” by Dr. Ronald Epstein, expands on how doctors can use mindfulness themselves to help build rapport with their patients. This can be particularly helpful for challenging topics such as vaccines.
What many alternative providers do well — likely due to additional communication training and the time they can allocate to patients through their practice structures — is listen and empathize. Conventional providers should “attend” to their patients, as Epstein describes, and “show up, be present, and listen.”
As children often cannot speak for themselves, it is even more important for physicians to take the initiative and start these conversations — it could make all the difference now that the tension between alternative and conventional health approaches (and their users) has never been greater.
Amitha Kalaichandran, MD, is a pediatrics resident and a Munk Global Journalism Fellow at the University of Toronto.
I am apprising the ScienceBasedmedicine.org people of this.
Thanks Bobby for reading, and glad we connected about this offline. Just to add here: the original title was “What Else Have You Tried,” the point being that physicians should have open conversations about what patients use for treatment (which we may or may not agree with). That way we a) get an idea of what they believe works b) if there is evidence for effectiveness with little to no harm (e.g. deep breathing exercises/mindfulness), we can try it c) if it doesn’t work/can be harmful then we can advise them of this (if they don’t tell us we don’t know). d) many doctors are rushed and don’t take the time (often because their days are packed) to have these important conversations. It sounds like these ideas may not have come through clearly in the article but glad we discussed.
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