Potentially Unsafe Low-evidence Treatments: Adam Marks, Laura Taylor, & Jill Schneiderhan

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GeriPal - A Geriatrics and Palliative Medicine Podcast 45 min 3 speakers 6 chapters transcribed 9 hours ago

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What is a Potentially Unsafe Low‑Evidence Therapy (PULET) and why was the term created?

Eric Widera 0:00

This episode of the Jerry Pal podcast is CME eligible.

Alex Smith 0:04

To claim credit, please go to the CME tab on jerrypal.org.

Eric Widera 0:09

Welcome to the Jerry Pal podcast. This is Eric Widera. This is Alex Smith. And Alex, today we're going to be talking about potentially unsafe low evidence therapies, how we address that with our patients. But before we do, who's with us today?

Alex Smith 0:25

We are delighted to have three guests from my undergraduate alma mater, the University of Michigan. First up, we have Adam Marks, who is a med peds and palliative care physician and associate professor at the University of Michigan. Adam, welcome to the Jerry Pal podcast.

Adam Marks 0:42

Thanks for having

Alex Smith 0:43

me. And we're delighted to welcome Laura Taylor, who is also med peds and a palliative care doc and assistant professor at the University of Michigan. Laura, welcome to the Jerry Pal podcast.

Laura Taylor 0:53

Thank you.

Alex Smith 0:54

And we're delighted to welcome Jill Schneiderhan, who is a family medicine and integrative medicine doc and associate professor at the University of Michigan. Jill, welcome to Jerry Pal.

Bruno Satin 1:04

Great

Jill Schneiderhan 1:05

to be

Eric Widera 1:05

here. So we're going to be talking about a paper that was published. Oh, Adam, what journal was it published in again? American Journal

Adam Marks 1:13

of Palliative Medicine.

Eric Widera 1:15

And we'll have a link to it on potentially unsafe low evidence therapies and approach to dealing with that. But before we jump into that topic, Adam, I think you have a song request for Alex.

Adam Marks 1:26

Yeah, I'd love to hear Bad Medicine by Bon Jovi. Very apropos, why did you choose this song? Well, I think this topic has to do with sometimes the decisions our patients make that can be confusing and maybe even upsetting for us as clinicians. And so this seemed a very appropriate song. Great. Alex, head away.

1:49

All right. I got a fever, got a permanent disease. It'll take more than a doctor to prescribe a remedy. I got lots of money, but it isn't what I need. Gonna take more than a shot to get this poison out of me. I got all the symptoms, count them, one, two, three. That's what you get for falling in love. You get a little, but it's never enough. That's what you get for falling in love. And now this boy's addicted because your kiss is a drug. Your love is like bad medicine. Bad medicine is what I need. Shake it up just like bad medicine. Ain't no doctor that can cure my disease.

Eric Widera 2:44

Wonderful, Alex. Amazing. Alex loved that song, I can tell. I did. I did love that song. All

Alex Smith 2:53

right. Yeah, that's a lot of fun.

Eric Widera 2:55

So we're going to be talking about potentially unsafe low-evidence therapies. And you created an acronym for this. Is it French? Poulet? Alex, how would you say that in French? Poulet. Poulet.

3:14

Poulet.

Alex Smith 3:14

What

Eric Widera 3:15

is a poulet or what is this?

Adam Marks 3:23

We do the hard tea here in the Midwest. And so for us, it's pullet. Pullet, like a mullet. You got it. And what is a pullet? Well, just as it says, it's a therapy that has little to no evidence and we believe that poses a significant risk of harm to the patient that's pursuing it. And so this term was developed by our group to capture either non-traditional therapies or really conventional medical therapies that patients may be pursuing with little hope of reaching the goal of care and significant risk.

Eric Widera 4:01

And Jill, you practice complementary alternative and integrated medicine. Did I say that correctly? Is it CA? You just drew all

Alex Smith 4:09

the

Eric Widera 4:09

terms together. I am

Jill Schneiderhan 4:12

now. So actually, we prefer just integrative medicine

Eric Widera 4:15

now

Jill Schneiderhan 4:16

because we're trying to really combine things into one medical system. So we've kind of let complementary alternative go by the wayside.

Eric Widera 4:23

So, um, I guess from your perspective, how often does this come up when we're thinking about these, uh, bullets, potentially unsafe, low evidence therapies in the work that you do?

Jill Schneiderhan 4:36

Yeah, I think it's actually really interesting because when Adam first brought this to me, I was like, oh, you know, there's so much of what we do that actually has more evidence than we think it does. And I think sometimes the bias is none of these things have evidence. But the truth is, and especially more recently, I'd say in the integrative space, people are coming in asking us about things that are much more on the unsafe, no evidence side much more often.

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Chapters

6 chapters

1 What is a Potentially Unsafe Low‑Evidence Therapy (PULET) and why was the term created? 0:00–14:34 2 How do clinicians define “potentially unsafe” versus “low evidence” in the PULET framework? 14:34–22:14 3 What common PULET examples (ivermectin, stem cells, chelation, etc.) are patients asking about today? 22:14–25:45 4 How did the team handle the real‑world case of a patient seeking intrathecal stem‑cell therapy in Mexico? 25:45–30:14 5 Why do patients request therapies like chemotherapy at the end of life or CPR for metastatic cancer? 30:14–41:11 6 What communication strategies (VitalTalk, REMAP, humble inquiry) help clinicians discuss PULET requests with patients and families? 41:11–45:25

Speakers

3 identified

Eric Widera 8 min Alex Smith 5 min Bruno Satin

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Topics in this episode

COVID 1 cancer 1 Alex Smith 2 University of Michigan 2 Eric Widera 1 chemotherapy 1 ivermectin 2 Bon Jovi 1 Jerry Pal podcast 1 Vital Talk 1 chelation therapy 1 Right to Try Act 1

Source

Recorded24 Apr 2025

Publisherrss.libsyn.com ↗

Transcriptspeaker-named · 100+ languages

Handlerec:20524511

Show notes

More and more people are, "doing their own research." Self-identified experts and influencers on podcasts (podcasts!) and social media endorse treatments that are potentially harmful and have little to no evidence of benefit, or have only been studied in animals. An increasing number of federal leaders have a track record of endorsing such products. We and our guests have noticed that in our clinical practices, patients and caregivers seem to be asking for such treatments more frequently. Ivermectin to treat cancer. Stem cell treatments. Chelation therapy. Daneila Lamas wrote about this issue in the New York Times this week -after we recorded - in her story, a family requested an herbal infusion for their dying mother via feeding tube. Our guests today, Adam Marks, Laura Taylor, & Jill Schneiderhan, have coined a term for such therapies, for Potentially Unsafe Low-evidence Treatments, or PULET. Rhymes with mullet (On the podcast we debate using the French pronunciation, though it sounds the same as the French word for chicken). We discuss an article they wrote about PULET for the American Journal of Hospice and Palliative Medicine, including: What makes a PULET a PULET? Key ingredients are both potentially unsafe and low evidence. If it's low evidence but not unsafe, not generally an issue. Think vitamins. If it's potentially unsafe, but has robust evidence, well that's most of the treatments we offer seriously ill patients! Think chemo. What counts as potentially unsafe? They include what might be obvious, e.g. health risks, and less obvious, e.g. financial toxicity. What counts as low-evidence? Animal studies? Theoretical only? Does PULET account for avoiding known effective treatments? Do elements of care that are often administered to seriously ill patients count? Yes. Think chemotherapy to imminently dying patients, or CPR. How does integrative medicine fit in with this? Jill Schneiderhan, a family medicine and integrative medicine doc, helps us think through this. How ought clinicians respond? Hint: If you're arguing over the scientific merits of a research study, you're probably not doing it right. Instead, think VitalTalk, REMAP, and uncover and align with the emotion behind the request. Does the approach shift when it's a caregiver requesting PULET for an older relative who lost capacity? How about parents advocating for a child? For more, Laura suggests a book titled, How to Talk to a Science Denier. And I am particularly happy that the idea for this podcast arose from my visit to Michigan to give Grand Rounds, and the conversations I had with Adam and Laura during the visit. We love it when listeners engage with us to suggest topics that practicing clinicians find challenging. And I get to sing Bon Jovi's Bad Medicine, which is such a fun song! -Alex Smith

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