Cave! Ultracrepidarianism

“Sutor, ne ultra crepidam judicaret.”
(Shoemaker, not above the sandal judge – “stick to your last”.)

“Doctor, what do you think of alternative medicine”, a patient with Chronic Fatigue Syndrome asked me the other day. She was interested in doing something more for her severe fatigue. “Would acupuncture help me?”

I paused and, as I have done many times before, answered that my training and most of my clinical experience has been in Western, allopathic medicine. (Ironically, the word “allopathic” was first used as a derogatory term by the classically trained physician Samuel Hahnemann, who founded homeopathy after becoming disillusioned by medicine as it was practiced in his era.)

I don’t believe we allopaths have all the answers, and I have a personal interest and fascination with many other forms of healing, but I have set a standard for myself to only promote and recommend treatments that are consistent with my training, because I don’t have anywhere near the same expertise in the other forms of healing. Even within allopathic medicine I try to be really clear about what we know and what makes sense but still remains to be proven. For example, some cholesterol and blood pressure medications have been shown to decrease heart attack rates while others have not, so I make this distinction very clear to my patients.

I support every patient’s quest for health and health care that fits their belief system and temperament, and I can sometimes be a resource in understanding some of the claims made by practitioners of “alternative medicine”. But I don’t point patients in that direction unsolicited. In that sense, I very much live by the words of Hippocrates of Kos, the father of medicine, who set strict limits for physicians’ scope of practice. In the Hippocratic Oath he wrote:

“I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.”

The cobbler analogy in the old adage “Shoemaker, stick by your last” has an interesting history and is of roughly the same vintage as the Hippocratic Oath:

The painter Apelles, also of Kos, who also lived in the 4th century B.C., liked to stand back and watch spectators’ reactions to his paintings. One day a shoemaker commented on the way Apelles had painted a sandal incorrectly. Hearing this, the famous painter introduced himself and thanked the shoemaker for pointing out his mistake. Emboldened by this, the shoemaker offered further suggestions for “improving” Apelles’ work. Legend has it that the artist, angry and annoyed, cut the shoemaker off with the words “Shoemaker, don’t judge above the sandal”, or “Sutor, ne ultra crepidam judicaret.”

This quote has given rise to the word ultracrepidarianism, which is something rampant in medicine and in today’s Western societies. Doctors often feel tempted to opine in matters beyond their formal training and experience, both in their exam rooms and in national media.

I have colleagues who prescribe red rice yeast, a “natural” statin instead of Lipitor or Crestor, and almost every doctor I know screens patients for vitamin D deficiency, which is a chemical abnormality that is still in search of clinical significance beyond that seen in osteoporosis. The hypotheses for this potential elixir of youth are tempting, but still not rigorously proven. For now, I cannot in good conscience recommend vitamin D with the same emphasis as blood pressure or diabetes control.

There should be only one standard in medicine when it comes to actively recommending treatments for our patients. But doctors are often tempted to stray from good, solid science because of personal hunches, a desire to be cutting edge, or from the temptation of creating “profit centers” in medical offices, selling supplements or delivering nontraditional services for cash.

But this is where I see my job as supporting my patients’ own desire to find ways to health they can believe in. My wife once had a very spunky elderly patient, Gloria, who for forty years had taken a special B vitamin she ordered from the AARP. As the woman aged she always swore by this vitamin as one of the things that preserved her vitality.

One day during a housecall, Emma noticed that Gloria wasn’t her usual, witty and vivacious self. Going through the woman’s medication bottles, Emma noticed that the bottle of vitamins was empty. Gloria confessed she had been too tired to order another bottle, even though she knew how the vitamins always helped her. Emma encouraged Gloria to order some more, and at the next housecall, Gloria was her old self again

There is a world of difference between physicians promoting unproven, “alternative” treatments and being intrigued by or simply supportive of our patients’ pursuit of them. And, strictly speaking, I feel even most vitamins fall into the latter category, short of taking in enough vitamin C to prevent scurvy.

P.S. Cave is a fairly universally (except in the USA) known word for caution, including but not limited to drug allergies. For example, pseudocholinesterase deficient patients, who cannot metabolize the muscle relaxant succinylcholine, may have the warning “Cave! Succinylcholine” in their charts.

“Cave! Ultracrepidarianism” is a warning to all health care professionals.

There may be future postings about medical pitfalls under the new category “Cave!”

14 Responses to “Cave! Ultracrepidarianism”

  1. 1 Jo September 8, 2014 at 3:02 am

    I’m not a doctor..I was only a CNA, but I tend to agree with your approach. Also, I wonder if the word “ultracrepidarianism” has any relation to the word “decrepit”? I’ll have to look it up!

  2. 2 Anne September 8, 2014 at 6:24 pm

    I really enjoy your writing — wise, warm, and thought-provoking.

    What did you advise the patient? Do you consider CFS a real illness? If so, do you consider it more a physical ailment or a psychological one?

    • 3 acountrydoctorwrites September 8, 2014 at 11:37 pm

      Thanks for your comment.
      I believe CFS is real, possibly more than one disease. As for psychological versus somatic, see my next post, which poses that question about many conditions. I have never heard of any data on acupuncture, so I told my patient just that, but also admitted that acupuncture can be a very powerful treatment. In our rural area, though, I don’t know what the level of expertise is among the less-than-a-handful of acupuncturists within a 100 mile radius.

  3. 4 Natalie September 11, 2014 at 11:40 pm

    There is so much information on vitamin d and research that shows it supports the immune system, cardiovascular health, brain health and of course bone health. Look on PubMed, the national library of medicine.
    I find allopath doctors ignorant and unwilling to learn about anything other then a drug with side effects!

    • 5 acountrydoctorwrites September 12, 2014 at 12:41 am

      Lots of theories, no proof yet. My Job, again, is not to promote unproven things, allopathic or not. I think physicians should not dabble in alternative medicine. That would be like rabbis moonlighting in the confession booth.

      I didn’t prescribe Lipitor for ten years after it came out, because it had no outcomes data (heart attack statistics), which Zocor had.

      As for vitamin D, UpToDate ( has a good review.

  4. 6 David Felker MD FACP September 13, 2014 at 9:44 pm

    Great conclusion. Belief and bias often rule the patient decision; we can only be supportive and practice evidence based medicine. To Natalie above: “allopathic doctors ignorant and unwilling to learn…” as a medical doctor practicing internal medicine over 20 years; I am constantly learning and expanding my knowledge of patient care! Informing the truth to the patient of the ‘best evidence’ (when often there is no evidence) should not be taken as an ignorance.

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