In my first years out of Naturopathic Medical school, the point of my greatest frustration was that I left with so few clear protocols. My notes and binders (I am dating myself here…) are full of algorithms. 1) Rule out life threatening conditions xyz 2)Rule out conditions that may quickly become life threatening. The notes then dissolve into possible scenarios across physiology that may have led to the patient’s condition. These then need to be paired with binders of information on nutrition, herbal medicine, manual medicine, medications, etc that may support the strained system. Dr. John Bastyr, a famously gifted Naturopathic physician for whom my medical school was named, left us with the parting advice, “Do What Works.” After decades of a busy family practice, his roster of options was probably quite deep, but in the early days of my own clinical care, “What works” was a pretty labor intensive confection.
In spite of the mud that is relentlessly slung at Naturopaths for not being evidence-based, PubMed is my happy place. PubMed is a database on-line that indexes biomedical citations. If a therapy has been tried on a cell-line, animal or human, the study is in PubMed. It does not list studies that companies do on their own products. In our internet age, it is a great way to cut through the conflicting claims and just look at who responded to what and how the study was set up. It’s great when these studies are big, because it prevents the whole data set from being affected by the outliers. The number of people studied in a trial is referred to as the N. A study in which they gave probiotics + Vitamin C or placebo to 57 preschoolers to learn if it kept them from catching colds (it sort of did) had an N of 57. The Women’s Health Initiative had an N of more than 160,000 and the data was digested in over 7,000 research papers. Guess which one dominated the news for a while?
To introduce Naturopathic Medical students to the riveting task of interpreting research, our professor asked us to come to class ready to present on the evidence for soy. Unbeknownst to us, we scrambled out the door with our preconceived notions. When we returned, she was able to divide us into pro and con groups, each side only vaguely aware that the adversary had been walking in our own midst. Surely we all were on the same page with the benefits/evils of soy?? PowerPoint after Power Point scrolled by, stacking the evidence on either side. All well-cited, though each citation was systematically deconstructed by the next group. “Yes, this study is in favor of soy’s protective phytoestrogenic effects, but the study had a very small N and this other trial demonstrates a significant increase in breast cancer.”
“This one shows a decrease in breast cancer”
“Sure, but other dietary factors were not controlled for.”
“This study was in mice”
“That one was on soy extract, not food.”
It was also clear that the strength of the argument was easily enhanced by the presenter. A presentation by an energetic group carried the day more effectively than the soundest of science read quietly from notecards.
So, great. Here I was, new ND, tasked with doing “what works”, which I could find on PubMed, but could also deftly deconstruct. To make matters worse, all of my patients are outliers. I primarily see people with chronic illness. Patients come to me, feeling unwell, after being told that “everything is normal” based on a work-up by conventional medicine doctors and specialists. Life-threatening and recognized diagnoses are ruled out, so they are dismissed.
My first visits are 60-90 minutes and sometimes I scramble to finish a visit on time. I take a comprehensive history of their health, including diet, stress factors, environmental exposures. It is usually the first time they have been asked about all of these together. When the group of symptoms fail to add up to a diagnosis, the problem is with the functioning of a system, and my job is to find it. It is exhaustive and exhausting, but there is always something. And it is often surprising.
Just this morning I saw the mother of a young patient, who stopped me to let me know that her child’s chronic stomach pain resolved completely when she stopped eating almonds. Yep, almonds. I can just imagine how her GI team at Boston Children’s Hospital received the news. In the mix, I assure you, is relief that she feels better. While nothing in PubMed would connect stomach pain and almonds (I checked), for her it worked. N of 1, Resolution of Stomach Pain with Avoidance of Dietary Almonds. It’s not in PubMed, but it actually is in my binders of notes. “Remove the obstacle to cure”. For this child, almonds were the obstacle, and once they were out of her diet, her body’s youthful regenerative ability kicked in and she recovered quickly.
By now, I am nearly 10 years past graduation. I no longer resent not having been told what to do in my binders of education. I have matured to appreciate the critical thinking capacity I was forced to cultivate. I scour PubMed to stay current, but not to give me my first treatment ideas. I agree with Dr. Bastyr. Every person, the ones who see great benefit and low side effects from prescription medicine, and those who need their own dose and still create their own categories of side effects, can and should be well. The studies help make sure that what we are doing is safe. They point us towards interventions that may work. The practice of medicine will evolve hand-in-hand with the evolution of research, which is slowly making room for individual outcomes. Meanwhile, know that the best result is the one that is successful for you, the N of 1.