When a patient asks for the unusual

Here’s the conundrum:
Let’s say your patient’s insurance has decided that they will pay for 12 sessions of reiki for, say, back pain. All that the patient needs to have this therapy approved and paid for is their primary care doctor’s referral.

Let’s say that doctor has examined the evidence, and found reiki to be unsupported for any use. You explain to the patient the correct evaluation and treatment of low back pain, and explain that you will not be making the referral.

The patient is angry. She doesn’t want to have to pay for the treatment out of pocket.

What would you do?

Now let’s say you have a patient with cancer. It’s incurable, but the patient is receiving several standard and experimental treatments to prolong his survival. Otherwise, same scenario. Now what?


37 responses to “When a patient asks for the unusual”

  1. I would think “not medically necessary”, however politely phrased, would be the way to go. If that doesn’t work, explain that reiki accomplishes nothing and that referring her for it on the insurance company’s dime would be de facto, if not de juri, insurance fraud.

  2. Yeah, try that again. “De jure”. Eye kan spel reel gud.

  3. Patrick

    The first one, I would not sign it. The evidence is in, reiki doesn’t work.

    In the later case, it would matter what sort of experimental treatments we’re talking about. If it’s wooey stuff, or treatments that the evidence suggests does not work, then I probably wouldn’t sign it. If the experimental treatment is part of a study for a new technique or something like that, why not?

  4. I would give them the referral, in either case. However, in the former, I would ensure that they knew there was no scientific basis, no solid evidence, and no reason to believe that the Reiki would help them at all, as a condition of giving my referral. If they still wanted to try the treatment, then, fundamentally, it’s they’re choice. I’m not a doctor, so perhaps I can’t fully grasp the emotion of a patient going to someone who you know can’t help them, but I still fundamentally believe, that unless I’m putting someone else in danger, I should be allowed to take whatever kind of medicine or psuedomedicine available to me.

  5. Now let’s say you have a patient with cancer. It’s incurable, but the patient is receiving several standard and experimental treatments to prolong his survival. Otherwise, same scenario. Now what?

    Depends on if these are legit treatments. If so, then I don’t see why not other than possibly giving some false hope which you could explain to them.

    If anything the patient possibly helps fine tune the treatments.

  6. Brendan S

    Anyone who knowingly prescribes or refers therapies they know will not work, but will be charged for anyway, are directly responsible for rising healthcare costs.

    I want to know who’s insurance these days covers reiki. I thought it was hard enough to get then to cover real therapy.

  7. Goldstein

    I would change doctors. I wouldn’t want an arrogant smuck like you treating me.

  8. PalMD

    Well, I may or may not be an arrogant schmuck, but I’m curious what you would do, not whether or not I’m arrogant…that part is apparently settled.

  9. Jon H

    If the 2nd patient were seeking an alternative therapy for a symptom caused by the cancer treatment (nausea, say, or lack of appetite), and had experience that the treatment helped them, then I’d probably do the referral.

    Maybe it’s just the placebo effect, but if it improves quality of life, and doesn’t hurt or displace a proven treatment, why not?

  10. Would you prescribe a placebo to a patient if it seemed likely, or even just possible, that it would benefit them and they specifically request it? It has been observed that while pain is biological with real biological causes and effects suffering is a matter of the persons contextualization of themselves in pain. Suffering, as a psychological phenomenon, has deep psychological effects and this can lead to real physical issues?

    Reiki may not have any role in curing lower back pain. but it may have a role for some individuals in reducing suffering and may allow them to relax and feel cared for. This then may have a significant role in real healing of the direct problem or at least make dealing with it easier.

    Reiki seems unlikely to cause any significant additional damage. If a therapy has little chance of harm and some chance of helping I would think you would be better getting off you high horse and allowing it. You not being consulted in the role of woo debunker or guide to lead the patient into the righteous path of science and reason.

  11. I would not refer for an intervention known to be ineffective. After explaining this to the patient and watching them leave (a la Goldstein) for a second opinion from a doctor unencumbered by science, I would contact the medical director of the health plan to let him know about the incident. It’s entirely possible that he’s unaware than one of his staff authorized the reiki. I’d be surprised if it was truly a benefit of the plan.

    Cancer is a different story since many of the current modalities are part of clinical trials and can therefor be deemed experimental. There’s nothing about reiki that’s experimental. In my state, the law requires health plans to pay for cancer treatments even if they’re experimental. I’m not sure how universal that is.

  12. Matt Platte

    I would throw the fat man on the tracks to stop the train from running over the villagers…. Oh, I see. Wrong conundrum. Sorrry, my bad.

  13. azqaz

    I’d give them the referral as long as it was worked out with the patient that the woo doesn’t replace the real medicine. In the case of something serious I would be more inclined to give a referral for the woo as additional treatment so that the patient doesn’t abandon real medicine for woo alone. My only rationale for this is that someone I knew about 20 years ago abandoned real medicine for woo alone when she and her doctor had a falling out over using reflexology and acupuncture as additional treatments. The alternative treatments didn’t send her breast cancer into remission, needless to say.

  14. Having a plan that covers all sorts of woo is not unheard of. I have one. I get massage, reiki, acupuncture and a bunch of other stuff covered. Very odd. Never used any of it however. It just seems kind of creepy. ‘

    I also have chiropractic coverage. And have been told by docs to try it – well for other people in my family to try it. Not so much.

    If insurance companies want to keep costs under control I would think they might start here. It might make sense not to pay oodles for silliness.

  15. Concerning insurance, coverage of woo may be mandated by law in some places. In other plans, sending the “worried well” to quacks may be seen as cheaper than sending them to MDs. Other times, it is just stupid. I once read a complaint by someone, who had serious vision problems, whose insurance would pay more for chiropractic than for opthalmology.

    In the first instance, I would not refer to reiki because that puts a burden on the health-care system. The patient has the right to choose; but not to be a free-loader. The second case is really the same (except, you are pulling on the heart-strings).

    Perhaps one could look for another option. For example, many people (not me!) enjoy massage, and if I recall correctly, it is as useful as anything for back pain. The same for the cancer patient, some people with intractable problems find massage cheaper than a vacation. It may even be covered by insurance.

  16. Quote: “I would change doctors. I wouldn’t want an arrogant smuck like you treating me.”

    I’ll take an arrogant doctor who tells the truth over a “compassionate” candy-coated liar any day of the week and twice on Shabbos. And the word is “shmuck.”

  17. Oldfart

    This is insane. I can’t get medical insurance that covers the 3 things old farts need most: eyes, ears and teeth but some insurance programs cover woo? What bullshit. Do some programs cover lap dancers? Now there’s some woo that might really reduce pain and suffering….

  18. I’m with OldFart. Well, except for the lap dancing.

    I think explaining the no evidence part, and maybe compromising on a massage (no happy ending!!) might be the way to go. They feel better, and it’s certainly relaxing.

    But I would rather have a doctor give me the evidence than just sign off on something that wouldn’t help me.
    I don’t think I’m a representative sample of the public, though.

  19. Oldfart

    Actually, lap dancing was a poor example. I’ve never understood why grown men would pay to have a nude (or semi-nude) woman perform a mating dance and yet be totally unable to touch her and complete the act. But, then, I’m sort of a single-minded person.

  20. The problem with a doctor signing off on bullshit like reiki is the doctor should be the gatekeeper on claims. It is designed into the plan that the doctor isn’t going to waste the insurance companies money on crap that has no place in treating a patient. If a doctor does prescribe something that he knows beyond a reasonable doubt will do nothing for the patient, he is a shmuck.

    If it is for lower back pain, wouldn’t physical therapy provide the same “laying on of hands” effect and actually stand a chance of doing some good? If it is cancer and the doctor feels there is some sort of palliative benefit from a good foot massage or reiki or whatever else he wants to prescribe AND he feels it is as good or better than anything else he could do, then go for it. If, however, there is something that has a better track record and you feel it is more likely to be effective, he should feel a responsibility to educate the patient regarding the treatments.

  21. When I was in the securities business, there was a saying that I kept in mind when someone wanted my advice on some off the wall investment, “Will the judge understand it?” I would think that same question would apply in the medical profession. Can you explain to the judge why you went along with this and will he agree with your decision.

  22. Back pain will sometimes go away on its own and may have a psychological component. Lacking any medically proven intervention and depending on the injury, reiki may be as good as other therapies, even massage. Your second question would be more interesting if the cancer was curable. There, real harm may be done by pursuing an alternative therapy. In an incurable cancer, I believe it’s whatever makes the patient’s time left more meaningful.

  23. Stagyar zil Doggo

    I’ll take an arrogant doctor who tells the truth over a “compassionate” candy-coated liar any day of the week and twice on Shabbos.

    (R)Amen Brother!

  24. @Bill, that is a good point; but I assumed Physical Therapy was already in the medical mix. As I recall, PT, massage, medical management (analgesics and time) all have about the same success. If reiki or reflexology want to be added to the list, they have to prove themselves.

  25. Carlie

    Isn’t the whole point of requiring GP referrals that a medical doctor is supposed to be a decent judge of what is medically necessary, more so than the patient? That’s why even medical specialists are hidden behind referrals, so patients don’t go running off for unnecessary tests and/or treatment when something else is called for. Absolutely a doctor shouldn’t make a referral for something they think is crap, the same way he or she wouldn’t make a referral for something medically sound but unnecessary. The patient is free to do reiki all they want on their own time, but not to scam their insurance company for it.

  26. The reiki stuff doesn’t make any sense, but the lapdances might be a legitimate treatment for erectile dysfunction…

  27. PalMD

    OK, substitute any disproven treatment for reiki. In the first case, I pretty much won’t prescribe it. If they want it that bad, they can pay out of pocket. I don’t want my name on an order for something that goes against the standard of care.

    In the second case, as some commenters mentioned, I’d probably try to steer the patient to other comfort-based therapies such as massage or meditation—therapies that aren’t based on scientifically implausible ideas and aren’t disproved.

    As others have mentioned, it’s hard enough getting evidence-based therapies paid for—we probably shouldn’t waste a whole lot of money on woo.

  28. yaksman

    In both cases, so long as the Reiki is not replacing real treatments, and is not costing the patient anything, let them enjoy their placebo.

  29. I can understand that many doctors would not want to sign such a referral to reiki. It goes against everything they are and what they do, and furthermore they do have a responsibility towards the insurance company.

    However, I am not a doctor and have been a patient, and I think that as a patient and the client who is paying for the insurance policy, if it is covered by my policy and approved by the company then I am having my d*mned reiki. I am not a disease, I am a person and I want to feel better. I do agree that doctors can overrule me regarding treatments and medicine in general, but if reiki does not hurt and it does not replace proper treatment, give me reiki.

    Again, I repeat a doctor not wanting his/her name associated with quack practices, but I do think the pation should have a vote. I may be sick, I may be ill or I may be injured, but I am still an adult and this body is mostly mine. Give us reiki or give us death, and all that.

    PS: I myself would not touch reiki with a ten-foot pole.

  30. Argh. Apologies for the spelling errors.

  31. By design, insurance “spreads the risk” over many for the benefit of the few. (Quite oversimplified, but bear with me.) I pay premiums not only for me to be able to receive medical services, but for others insured by the same company to be able to receive these services.

    Many look at insurance as an individual investment and, unless you get more in services than what you paid in premiums, then you didn’t get your money’s worth. That is not the case. You are not prepaying for medical services. You are paying to shift the RISK of catastrophic costs from you to the group.

    If you need medical services that will help your condition, then by all means, I want you to receive those services. If, however, you feel you are entitled to services that are not medically justified, you are mistaken. You are not just spending your money, you are spending mine as well.

    If you think some of these unproven treatments will help you, spend YOUR money and get them. But, don’t expect the rest of us to chip in on it. I am a healthy 47 year old nonsmoker that pays over $250 a month for health insurance with a $2500 deductible. That is due to the uninsured getting services that get passed on to insureds, the underinsureds getting services that the balance gets passed on, medicare recipients paying less than cost for services, etc., etc. I don’t need to add your reiki to the list of things that cost me money.

  32. That’s a dangerous line of reasoning, and not just because it can be nullified by the “voting in democracy argument” (in actuality, a single vote or a single reiki treatment will not cause measurable shifts in our everyday experience including medical bills).

    That is dangerous because it means I get to have a vote on your lifestyle as well. A promiscuous sex life, sedentary habits, obesity, dangerous hobbies, trips to undeveloped countries… Following that line, I am paying for that if it results in medical treatment: carpal tunnel syndrome from all that internet porn, for instance, or dental care for teeth that you seem to have in surplus.

    I see the point, but I think that the logical conclusion would be to change your insurance to another company that does not cover those treatments. Let us not forget that the patient was (I assume) offered the option of contracting such an insurance as it covered it – probably at a higher price.

  33. Changing insurance companies IS the only way I get to vote, as you point out. I don’t personally have any say in what is paid for or not paid for. The insurance company should, however, act in a fiduciary interest. They also “passed the buck” to the doctor in the example above. If the doctor signs off and prescribes the treatment, he is saying there is possibility of a benefit from the treatment. He is acting as gatekeeper on the insurance companies behalf. Plain and simple. Your argument is baseless since there is nothing stopping the patient from paying for services out of their own pocket. Just don’t expect the insurance company to fund it.

  34. Why not? If it is covered by the insurance, why not? It’s not asking for a free holiday trip to Bahamas, it *is* included in the contract somehow. The patient has already paid for it, shouldn’t it be the company itself that specified in writing “unverified alternative medical treatments will not be covered”?

    Again, I do understand that the doctor may feel bound to act in the best interest of the insurance company – he is being paid to do so, as a part of his duties.

  35. “The patient has already paid for it…” Again, the patient (insured) did NOT already pay for any services. They paid to pass a large percentage of risk from themselves to be spread out over a large group of people. Adding useless expenses merely increases the cost of the group without benefitting anyone. The insurance companies claims people are not doctors. They do not practice medicine. In cases involving a drug or treatment that isn’t specifically addressed in their policies, they often depend on doctors that are seeing the patients to determine what is best for their patients. Others will send the claim to a company doctor for approval or denial. Poor gatekeeping is definitely not the only cause for rising medical costs (not even close to the largest, but that would be the topic of another thread), but it is definitely a factor. Dr. Lipson is right in not recommending a useless procedure on the grounds of the patient “feels” they deserve it.

  36. sruths

    For what its worth, I had an occasion to test two CAM modalities in quick succession. I was on a weekend away, far from my local GP, doing an intensive Tai Chi seminar. I had begun to experience the familiar symptoms of cystitis, but at the end of the day, a new unfamiliar pain began to assert itself in my mid-back around my kidney area. I went to my lodgings and lay down prepared to suffer until I could get to my doctor on Monday, when I was offered a reiki treatment by one of the other seminar attendees. “Why not?” I thought, pain getting worse. The half hour session felt like nothing and did absolutely nothing for the pain. It was slightly embarrassing. Half hour later though, pain worse, another conference attendee offered acupuncture. Again I thought, “why not?” She inserted six needles, and I immediately felt the pain recede. The pain had completely disappeared by the time the needles came out again about 10 minutes later, and did not return. It still took about 3 days to clear the cystitis infection, but the immediate pain relief of the acupuncture vs the reiki was pretty impressive. I know this singular experience does not count as useful evidence and is no more than an anecdote, but what does it mean about how a placebo works? Do different placebos work better for different people? As far as I can tell, there was no difference in my mindset or circumstances between the receipt of the reiki or the acupuncture. Also, as far as I can understand the cumulative evidence on most CAM procedures shows not that they are completely ineffective, just that they are “no more effective than a placebo” – in practice, getting back to the hypothetical question asked, does this not mean that any individual MAY get some relief from a CAM treatment – as from a placebo, but that its effectiveness cannot be vouched for for any given large population? In other words, while it is certainly scientifically valid to say that in RCT trials, reiki works no better than a placebo, is it equally valid or even possible to state unequivocally that “reiki will be completely ineffective for Mr X or Ms Y”?

  37. Richard Eis

    I would have thought it was obvious. Tell them to whip off their shirt and lay down. Wave your arms over them for 5 mins while asking about feeling tingly and then send them on their way.
    then sign the forms for yourself (if you want-you earned it).

    Next time you see them, ask how they are getting on. If they are doing better, tell them what you really did and that it was placebo. If they are feeling worse, point out how ineffective the reiki was.

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