American College of Physicians: Internal Medicine — Doctors for Adults ®

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Friday, October 11, 2013

Naturopathic medicine and the answer to the challenge

Readers were kind enough to give their feedback on a recent challenge I presented to them. Since naturopaths want to be considered primary care providers, I was curious how they would approach a typical case. The data are admittedly limited and may not provide a true window on naturopathic practice (but from my reading, I think it does).

So, can naturopaths be primary care docs? From the limited data, the answer is a resounding “Oh, HELL no!”

I encourage you to peruse the comments on the post, but let’s look at the case again, and approach it the way a real doctor would.

Mr. L is a 66 year old man who doesn’t like doctors very much. Still, he came to the office at the urging of his family. He has been complaining of a pounding in his chest for months. It sometimes keeps him up at night and since it began he can’t walk much further than the mailbox.

He doesn’t take any medicine and eats and drinks without regard to his family’s advice that he make better choices.

On questioning, he recalls being told he “had a heart attack once.” He has also noticed that he has been up at night urinating frequently and has felt very thirsty during the day. He denies having any pain in his chest. He has a biting sense of humor and loves baseball.

On exam, his blood pressure is 170/100, his heartbeat is irregular with a rate of 120. He is fat around the middle. His fingers are stained with tobacco and his clothes smell of old cigarettes. His lung sounds are very quiet. He has a bit of swelling around his ankles.

Lab results show a hemoglobin of 18 (high), a blood sugar of 320 (also high), and an LDL cholesterol of 120 (yeah, that’s kind of high too, depending).

An EKG shows that his heart is beating at about 120 beats per minute in an irregular pattern called atrial fibrillation.

He feels bad enough that he is willing to try whatever you tell him.

Mr. L. is a pretty typical American, suffering the effects of an unhealthy lifestyle combined with genetics and chance. He has a few obvious conditions that need to be approached immediately and in the long term.

The most acute problem is his heart. As many of the commenters noted, he likely has atrial fibrillation, a common heart problem, combined with some heart failure. By history it would appear to be chronic.

There is a decision point right here, one on which reasonable people could disagree. He could be sent to the hospital for slowing of his heart rate and anticoagulation to prevent stroke, and to make sure he hasn’t had a recent heart attack. He could also be treated directly in the doctor’s office with medications and close monitoring. We’ll leave that be.

There are certain goals that must be met for this patient to have the best chance of living a comfortable and hopefully long life. These goals are quite simple and based on decades of evidence.

Given his diabetes, the goal for his blood pressure is generally agreed to be 130mm Hg or below. The goal for his LDL cholesterol is similarly agreed to be 70 mg/dL.

The goal for his blood sugar is based on a measure called HbA1C, which should be below 7.0 g/dL.

Based on the data, he should almost certainly be on a statin, an ACE-inhibitor, aspirin, and probably a beta blocker.

These goals can be achieved rapidly with drug therapy. As he is stabilized on medication and his risk of stroke and heart attack are rapidly lowered, we can work on the harder stuff—changing how he lives.

He must quit smoking, eat healthier, and exercise. There is no way to know how close he will come to his goals with lifestyle changes, but they are essential. They also take a long time, a time during which he should not be exposed to high blood pressures, cholesterol, and high blood sugars. To wait for lifestyle changes to kick in with this patient would expose him to very high risks of stroke and heart attack.

This is not a case a primary care doc should refer out, and there is much that can be done without further testing (but that testing should eventually include, as many commenters noted, an ultrasound of the heart, and probably a stress test).

This sort of case can be treated immediately out of training (as one commenter put it “I’ve only been in practice two years”). It does not require a gaggle of specialists, and from the comments, the naturopathic approach has no added value (supplements mentioned provide no proven benefit and quackery such as homeopathy has no place).

The idea of naturopathic primary care docs scares the daylights out of me. Not for economic reasons—a good doc will always do OK. It scares me because patients who need the services of a real doctor will mistakenly think that their ND is one.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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