Another crack at medical cranks

I was having lunch with a medical student a number of years ago and asked him about his previous experiences in primary care.  He hesitated for a moment, but having gotten to know me, he knew he could be honest.

“The last guy I was with saw mostly Medicaid patients, and mostly just wrote prescriptions for Vicodin.  He didn’t really do much medicine, didn’t really spend time with patients.”

About 4% of American medical school graduates go into primary care medicine.  Part of it is math:  not many smart people leaving medical school with $200,000 of debt will choose specialties with the worst pay.  But many of us are passionate about what we do and are willing to make the sacrifice (not much of one, really) and practice for lower pay and more bureaucracy.  There are a number of ways to make up for this financial “shortfall”.

Medicaid—government-sponsored care for the poor—usually pays very, very poorly (although this may be changing).  Some doctors see this as a disadvantage, and, like me, refuse to take Medicaid.  Others see opportunity, enrolling thousands of Medicaid HMO patients, too many really.  They collect the enrollment fees, so many that it’s nearly impossible to get an appointment.  The system encourages bad practice.

I doubt this is all that common, but most physicians know of a colleague who engages in this sort of less-than-ethical behavior.  Others engage in frankly criminal behavior, such as taking cash for narcotic prescriptions.

But these are a small minority.  Most primary care docs work hard to take care of their patients.  This may mean squeezing sick people into an already-crammed schedule, or spending time listening to patients that could otherwise be used to finish phone calls and paperwork.  I start on time most days, but never finish on time—people just aren’t that predictable.

One of the most important things we can do as doctors is listen.  Giving a patient time to talk will let them bring up more uncomfortable or painful complaints.  It may give a widow comfort, or some hope to a man just diagnosed with cancer.

But compassion and a good ear must be matched by sound knowledge and a skeptical disposition.  I learn a lot of medicine from my patients, colleagues, and my own reading.  I also learn a lot from bad doctors.

There are a number of so-called holistic doctors in town who claim to practice “individualized” medicine.  What this really means isn’t clear.  My colleagues and I certainly individualize the treatment plans for all of our patients, using data gleaned from decades of scientific studies of large groups of patients.  What “individualized” care seems to mean in this other context is “stuff I made up to make that patient feel more unique and special.”

Examples abound, such as “bioidentical hormones” (a fictional concept earning real dollars), and all sorts of dubious supplements, often sold from the office of the doctor who prescribes them—so you know it must be good!  Most of these doctors have ways to earn money outside of insurance, such as the sales of supplements, unproven treatments, and other cash-on-the-barrel deals.  These days, most medicines are relatively inexpensive (I can treat most heart patients with medications costing less than $30 per month).  Patients should be very skeptical of doctors selling their own branded potions for obscene prices.

Being a real patient and a real doctor is work.  There are no easy outs.  When you have diabetes, you have to work at self-care, improving diet and exercise, inspecting your feet, taking medications properly.  When you are the doctor treating the diabetes, you have to know the risks and benefits of various medications, which patients are likely to need them, which can try lifestyle changes first.  You have to know to refer your diabetics to eye doctors, to give them the proper vaccinations, to check their urine for protein and what to do about it when it’s there.

Many of these so-called alternative doctors may do that (although in my experience, they refer the patients back to me for the “real medicine”).  But they may also sell cinnamon supplements (shown in some studies to modify certain diabetes parameters, in others not to, but never shown to improve real outcomes like heart attack prevention).  Others may sell fancy salt (really, I can’t make that up), pumping up it’s supposed salubrious properties (with a cost of $6/lb, vs. $8/25 lbs of normal salt).

These practices make patients feel good, feel cared for, and sate our thirst for the “old ways”, for a supposedly more natural way to health, which is, in a word, goatshit.  Natural usually means “I made it up out using nice-sounding words.” Making things up, even with the most caring  demeanor, is wrong.  It is immoral.

All medicine involves uncertainty.  You can’t be a doctor without tolerating a great deal of the discomfort of uncertainty.  But decisions have to be made on sound science for them to be effective and ethical.  Selling magic (except in the most Clarkeian sense) is not part of our job.

Our real job is hard, time-consuming, and not as profitable as the “holistic” medicine business.  But it’s right for our patients.

14 Comments

  1. It cracks me up when kidney disease patients switch to sea salt because it’s “lower in sodium” than regular table salt.
    And it is. Some companies are willing to plaster that message on their containers.
    Sea salt contains other minerals, so each volume contains just a bit less sodium than the relatively pure NaCl that they dig out of the earth. This amount is trivial. Of course, these additional minerals include magnesium, potassium, and other stuff that is also bad for kidney patients.
    But sea salt is natural. And expensive. It must be better for me!

    • Med School Odyssey

       /  January 2, 2012

      …and also potentially unhealthy for them, since many sea salts do not contain iodine.

  2. The “individualized” care meme is interesting. We really do all want to be special snowflakes. (My doc accomplishes this by complimenting my children while he’s washing his hands.)

    The alt-medicine crowd frames the issue as an insult against mainstream patients: “blindly following doctor’s/govt/CDC recommendations…” regarding vaccinations, or what-have-you. It sets people up to decide between the straw-man unfeeling robot-doctor, who is all about one size fits all, and the sounds-like-doctor surrounded by tastefully decorated medical-esque regalia, whose only motivation is to lovingly and painstakingly craft expensive, targeted, nature-based regimens for each unique patient. Everyone who buys into this nonsense has to ignore the fact that they’ve personally met very compassionate and competent actual doctors.

    • I have a feeling often that doctors are like politicians…people hate them, except for their own.

  3. I’m disappointed to read that you refuse to take patients with Medicaid. Isn’t this like taking out your beef with the system on poor patients?

    I’m sure you have reasoned through this, and it probably, as you say, does not make sense economically, but it also gives Medicaid patients no choice but to enroll in practices where they will receive bad care.

    • I simply can’t afford to. Uni and hosp affiliated clinics often have the resources to and receive federal funds to help. There may be some changed coming to improve reimbursement.

  4. orange

     /  January 6, 2012

    Ouch! This crank felt the crack. It made my body tingle, just like when I was trying to get away with something in the kitchen while my mom was in the living room and she’d say “What are you doing?”.

    Those body sensations get me tongue tied but I like to think they are the reason I enjoyed dancing lessons so much. I loved feeling the music, expressing the pain or words of the song. Whoops, I sound too flowery but it is true. Most of us know the only reason to enroll your children in artistic types of things is so they will be good in the real and meaningful things like math and science.

    I am not a so-called holistic doctor, I am a Traditional Chinese Medicine Practitioner. Individualized is usually said as crack at ‘real’ medicine and it shouldn’t be said like that. Some TCMPs also say they treat the root cause rather than the symptoms. This also is said as a crack. Individualized does mean something to me as it does to MDs, because of course they individualize and try to treat the root cause. In general, the chief complaint is differentiated into things like Wind, Heat, Shen disturbance, Qi stagnation, etc based on the patients sleep, bm, urination, pain, etc. There should not be a standard herbal formula or acupuncture treatment.

    The herbs I bring in are expensive! $60-$80 per month. I have no idea why they cost so much. I know I chose the company I do because if a test was needed (HPLC etc) it is available and I know they have not been contaminated. It would be preferable if I didn’t have to bring them in at all but where would I tell the patients to get the herbs from. I use cinnamon. What’s wrong with cinnamon. :( Gui Zhi, cinnamon twig is good for Exteropr Wind Cold and heart palpitations from Yang Qi stagnation and warms channels. Rou Gui, cinnamon bark is good for Kidney yang deficient and Qi and Blood stagnation conditions.

    You could try a raw herbal tea for the next three times you get a cold or flu and see how you feel. It tastes super yucky and is very stinky. Yucky tasting medicine is the way to go in my opinion, it reminds you to take care of your lifestyle.

    I don’t do ‘real’ medicine. That is not my job. Never is what I do a replacement for that.

    Science can become a god. All traditions have something to offer but it is harder to understand if you have a highly developed way of seeing health already.

    Thank you! If MDs and TCMPs were on an island together and we had to pick who could save more lives I would pick MDs but that doesn’t mean what I have to offer is mumbo jumbo.

  5. orange

     /  January 8, 2012

    That is a good question but “whatever it is you do” isn’t that nice of a way to ask .

  6. orange

     /  January 9, 2012

    Too mean.

  7. What’s happening here is that Alternative Medical Practitioners are giving their patients hope, thereby improving their outlook on life and consequently (indirectly) their physical health. My father was an MD Anesthesiologist who recommended alternative medical treatments and used them on himself. I believe these treatments are what gave him the hope and positive outlook that enabled him to fight cancer for 18 years, but I do not believe they did much at all to affect a direct change in his health. The change was an indirect effect of his improved outlook on life. I am currently enrolled in an Allopathic Medical School. A top priority as I consider my patients’ needs will be to address their outlook on life, before, during and after the application of demonstrated and studied medical interventions.

  1. Science-Based Medicine » On the “individualization” of treatments in “alternative medicine,” revisited
  2. Links 1/2/12 | Mike the Mad Biologist
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