discussion · 12. September 2021
Our goal with sofi talks is to examine the relationship between people and plants from all different perspectives. At sofi, we share the belief that by creating a discussion that revolves around a diverse array of perspectives, and by working out the differences between them, we just might uncover some new and impactful truths. As the very first of our sofi talks, we are excited to feature the opinion of professor and physician Dr. David Casarett, and can’t wait to share with you his thoughts.
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I'll start with a confession.
Not too long ago, when patients came into my office with a big list of natural remedies — chamomile, lemon verbena, St. John’s wort, for example — I would cringe just a little bit. To me, back then at least, it would just mean more complexity, more work, and more things to figure out and learn in a busy clinical schedule.
Looking back, I think that reaction is really interesting. I’m not sharing it with you because I’m proud of it — I’m certainly not — but I’m sharing it because there are two key reasons I find it interesting.
One — it’s pretty common.
In fact, I think lots of healthcare providers think the same way; practitioners of mainstream medicine, whether they care to admit it or not, tend to look down on plant-based medicines.
There’s actually a good body of research that found that overall mainstream medicine providers don’t understand or trust plant-based medicine, and we’re actually a little bit biased about people who do believe in that body of medicine. As a result, my reaction wasn’t that unique.
Two — that reaction I’ve admitted to: it’s totally illogical, and I’ll even go out on a limb and say its kind of stupid.
Even just a little bit of medical history will tell us how misguided that bias against plant-based medicine is. The embarrassing truth is that a lot of medicine we use today is plant-based. Aspirin was originally derived from Willow bark, caffeine from Coffee beans, Digoxin from Foxglove, Taxol from the Pacific Yew Tree, Morphine from Poppies… the list goes on and on. And while it’s true that most of the medicines that we use under those names today aren’t extracted from plants directly, their precursors certainly were.
As a result, I’ve compiled a list of 10 reasons why I believe there exists a somewhat fraught relationship between physicians and plants.
1. Medicine, safe to say, is pretty tradition based
Medicine on the whole is adverse to innovation, and providers already have a lot in their heads. Thankfully that’s fixable. Healthcare providers change — sometimes slowly — but they change, and education relating to the benefits of plant-based medicine is possible.
2. Providers look for innovation through very specific channels
Countries have very particular drug approval processes, and providers rely on those processes to tell them what’s okay. Without that system in place, providers often feel a little lost. Plant-based medicines largely fall outside of those channels — but that’s fixable too. It just means that if we’re going to encourage providers to be more open to using plant-based medicine, we need to give them the evidence. Maybe we need more evidence, or maybe we just need better evidence. It’s the same thing that they’d expect with any new drug.
Think about the names of plant medicines: chamomile, sawtooth, palm meadow, st. john’s wort — they just don’t sound like scientific medicines, or at least the version that providers are used to hearing.The drug companies know that and from A to Z — say, Abacavir to Zyrtec — they create drug names that sound hard-hitting and scientific. These names sound almost futuristic, which is attractive to healthcare providers.
Plant-based medicines might not sound hard-hitting and effective, but they do sound safe, comforting, natural. As a result, any efforts to bring healthcare provided on-board need to emphasize that before anything else.
4. Plant based medicines don’t require a prescription
If you’re a patient that’s a big advantage, but for providers who want to control patient’s medical regimens, giving control to patients is a little scary. But this will change too and luckily we can create tools that allow people to track their use of plant-based medicines in a way they can share with their healthcare providers, and potentially with each other, creating a community of citizen scientists.
5. Providers say there’s not enough evidence to justify the use of plant-based medicines
That’s not quite true, of course, millions of people use plant-based medicines everyday. But I think what providers mean when they say evidence, is evidence from big randomized controlled trials that involve hundreds or thousands of people. And that’s unlikely to be fixed.
It’s unlikely we’re going to be able to get a trial of 2,000–3,000 people for lemon verbena, for instance. Interest in studying medicines is driven by funding, plain and simple, and anything that has money behind it will get studied. In this way, it’s really a catch 22: Doctors don’t trust plant-based medicines because there’s not much evidence… so no-one studies them… so there’s no evidence, and so on and so forth. But I think the strategy there is to think differently and creatively about what we mean by evidence.
I think we need to rely less on large randomized controlled trials to figure out what works for populations, and instead think of smaller ‘N-of-1’ trials that tell what works for a particular individual. That’s evidence that’s just as valuable and just as hard to ignore.
6. Variable composition
I think some providers are worried about variable composition — they’re not sure what patients are getting. That might be fine for chocolate or wine, but it’s not so good for medicines. That’s something that’s pretty easy to address though. We just have to have trusted brands, formulations, and doses. I think that’ll go a long way to easing those concerns.
7. Providers want to know what the active ingredients in a formulation are
It’s a fair want, but there’s always some degree of uncertainty. Even if the ingredient is known, it can be hard to decipher the effects of that specific ingredient, versus a change in diet or lifestyle or even a small amount of sleep. And again I think the argument here is for individual results. If something works for you then what’s in that formulation matters less. What’s important to ensure is that people are taken care of, and that whatever they take is what works for them.
8. No Advertising
Like it or not, advertising with slick magazine images gives medication legitimacy — without a corresponding marketing effort, plant-based medicines seem less scientific, less valuable, and less legitimate to healthcare providers, even if they’re just as effective and safe. I think that will become less of a concern over time as we get more evidence and that evidence drives advertising.
9. Plant-based medicines aren’t taught in healthcare education
Or if they are, teachings are often about drug/drug interactions, what to avoid, and what concerns to have. As a result, So many providers, myself included, come out of school biased against plant-based medicines. They think of it in terms of risk, and that’s harder to fix — but not impossible.
Healthcare providers learn in school, but we also learn on the job, and we learn from our patients. So, until plant-based medicine has a significant amount of real estate in healthcare education curriculum, we just need to be creative about how we teach providers after school.
10. There’s something kind of odd about plant-based medicines
You know, they don’t fit with medicine’s scientific image, and medicine has gotten really adept at sterilizing plant-based medicines. Pharmaceutical companies are turning cannabis into sativex, or tree bark into chemotherapy and making it seem just about infinitely more scientific. But that doesn’t work if the medicines you’re using are the plants themselves.
That’s probably the most difficult objection to deal with from providers and there are no easy answers. With that being said, a lot of the work — maybe all of it — comes down to evidence. We’re not going to wipe out decades of prejudice with a single controlled trial, but we can chip away at it gradually, one patient at a time and one data point at a time.
Plant-based medicine and mainstream medicine should be intertwined and, in reality, they once were. The good news is that I think things are changing. Millions upon millions of patients rely on plant-based medicines, providers are increasingly open to natural remedies, and there are new sources of data that help both patients and providers track what’s beneficial in order to find solutions that really work.
I think if we, as providers, are more open to different ways of learning and engaging, and if we’re open to finding different ways of creating generalizable knowledge and evidence, then the sky is really the limit in terms of what we do when it comes to plant-based medicine.
We just need to be creative about what evidence and more specifically what collecting that evidence could look like.
Usually things in the research world are based on a new drug that’s been tested on animals and needs to go into humans. The main concern becomes how do you find a thousand humans to test this new drug. With plant-based remedies, we’re talking about a therapy or a set of therapies that people are using everyday.
You don’t need to find a thousand people to test the medicine, you’ve already got tens of thousands of people who are using their version of plant-based home remedies everyday.
We’re really in a unique position to collect the information available using different innovative techniques, and this is the gap in the market that I think sofi was designed to fill.
A huge thank you to Dr. David Casarett for his time and incredible insight. You can find the extended version of this conversation, among our other sofi talks, on the sofi website.