Blog | 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.