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Primary care challenge

In this space we’ve read about the efforts of “alternative” practitioners such as naturopaths to gain the moniker “primary care provider”.  I’ve been wondering a bit about this.  I’m a primary care physician.  Specialists in internal medicine, pediatrics, and family medicine provide the bulk of primary care in the U.S. They attend a 4-year medical school, complete a 3-4 year residency, take their specialty board, and then work as experts in the screening, prevention, diagnosis, and treatment of common diseases.

So, what I’d like to do is give you a typical scenario from an internal medicine or family medicine practice.  It’s a simple one, one you might see on Step II of the USMLE boards or on a shelf exam for an internal medicine rotation.  I’d like to offer alternative practioners, especially naturopaths, an opportunity to show how they would approach the clinical scenario so that we can see what kind of primary care they provide.

Yes, every patient and every situation is different, but there are some general ways to approach health and disease based on the evidence.

Case:

A 52 year old woman comes to see you for the first time.  She has not been seeing doctors very much over the last few years.  She has a known history of hypertension, diabetes, and gout, but is not currently receiving any treatment.  Her only unsolicited complaints are some excess urination and some indigestion.

On exam, she has a blood pressure of 162/92 (which correlates with her checks at the drug store), a weight of 62 kg, and a fasting blood sugar of 353.  Her LDL cholesterol from a health fair at work was 138.

Questions:

1) What basic health screening should a primary care physician offer for this patient?

2)  What screening a prevention should the patient be offered based on the information available?

3) What interventions, pharmacologic and otherwise,  must be offered the patient?

This is a typical scenario faced by PCPs several times a day.  If you want to play with the big kids, you’d better be able to give a good answer.

I’ll ask MDs and DOs to please refrain from answering the question so that we can give the NDs, etc. time to formulate answers that won’t harm the patient and that wouldn’t get the typical primary care physician sued.

Posted in: Health Fraud, Science and Medicine

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49 thoughts on “Primary care challenge

  1. Prometheus says:

    I’m not a primary care physician, but from my experience as a patient, I could come up with a number of answers to the above “challenge”. I’ll keep them to myself, however, to allow the “alternative” practitioners a chance to answer.

    My “alternative” answers:

    [1] Basic health screening – aura check, spinal x-rays, live blood screening, iridological exam

    [2] Directed screening – yeast testing, parasite check

    [3] Interventions – chiropractic adjustment, homeopathic sugar, detoxification, colon cleanse, Feingold diet.

    Prometheus

  2. Peter Lipson says:

    Actually, in my other venue, i’ve been getting much more considered/less supernatural answers than that…however, they’ve still been inadequate. As this blog and my other one only overlap a bit in audience, I’m hoping for equally well-thought out responses here.

  3. Jules says:

    And if you’re not a practitioner of any kind?

    *jumps up and down in seat waving hand*

    Though, I suppose, having been through the academic portion of medical school, it’d be cheating…

  4. David Gorski says:

    Whoa. That’s a pretty darned high fasting blood sugar. Even a dumb surgeon like me knows that you need to do something about that.

    I know…Endocrine consult! :-)

  5. Peter Lipson says:

    And what’s damned fascinating is that the same intensive insulin regimens that save lives in SICUs kill people in MICUs. Thank goodness for EBM.

    http://content.nejm.org/cgi/content/short/354/5/449

  6. pec says:

    That patient is a typical victim of the modern American lifestyle, and of a medical industry that gives patients drugs instead of education.

  7. Peter Lipson says:

    pec, you are

    1) not a naturopath
    2) an idiot

    you are not invited to participate in this thread.

  8. pec says:

    “you are not invited to participate in this thread.”

    Why? Too much truth in my comment?

  9. daijiyobu says:

    pec lives!

    -r.c.

  10. Chris says:

    pec said

    Why? Too much truth in my comment?

    Epic fail.

    pec, in your vast education did it include going to a college that taught naturapathy or other form of alternative medicine? Are you also a healer of some sort?

    Or did you just skip the reading comprehension in college?

    Look again at the second paragraph at the top of this page (added emphasis to help pec understand it better):

    I’d like to offer alternative practioners, especially naturopaths, an opportunity to show how they would approach the clinical scenario so that we can see what kind of primary care they provide.

    In plain English: the call was for those who practice alternative medicine to answer the question, not computer scientists.

  11. shadowmouse says:

    The prick – err, pec – babbles on. Chris nailed it ^^^

  12. sarah says:

    Even if the call had been for computer scientists to address the questions, assigning blame (accuracy aside) does nothing to manage the patient’s medical conditions that were the actual questions at hand. Still waiting for that thoughtful ND response…

  13. Chris says:

    Aw, gee, thanks!

    I don’t know if this changes anything about “prickiness”, but pec is female.

    (and so as to not to be too politically correct, so am I… except I do not try to comment beyond my understanding of the world as a lowly mechanical engineer)

  14. overshoot says:

    I do not try to comment beyond my understanding of the world as a lowly mechanical engineer

    Please belay “lowly.” MEs don’t get enough respect. Personally I suspect that it’s because everyone can see the artifacts of ME [1] and therefore think they know something about it.

    That’s about as valid as “I have a body so my opinion on medicine counts!”

    [1] Unlike my field: transistor-level circuits. Gets a lot of “oooooh!” but really isn’t all that complicated.

  15. Joybobington says:

    Can we post here with joke answers?

    For example:

    1. She’s overdue for a prostate exam.

    2. Aura re-alignment.

    3. Switch to organic foods.

  16. Chris says:

    overshoot said

    Please belay “lowly.” MEs don’t get enough respect.

    Again, thanks!

    At my kids’ high-school there a group of parents working to support and improve the science department. Many of the parents in this group happen to be professors at the local university (which is less than a mile from the high school, and we happen to live half way between the high school and this university). I happen to be both the treasurer and secretary of this very small group.

    I mentioned at one of our meetings that Son #2 had been accepted at the university and would be studying mechanical engineering with a minor in physics.

    “Oh, no!” said one of the dads… he told me my son was too bright to be just a mechanical engineer. He told me it would be better for him to apply his mathematical talents to physics, since that had some higher caliber than mechanical engineering.

    R..I..G..H..T…….

    Then I heard this Science Friday bit: Scientists on Wall Street

    I switched to engineering after realizing that a pure science education would require an advanced degree and less pay per credit hour taken. As one person told me “I see you went for the money!”… oh, yeah!

  17. shadowmouse says:

    Chris – you’re welcome :)

    Continual willful ignorance is prickish, no matter the chromasome count.

    Speaking of which…how long before the ‘crapzone’ folk catch wind of this challenge?

  18. bridgeman says:

    @ overshoot

    Unlike my field: transistor-level circuits. Gets a lot of “oooooh!” but really isn’t all that complicated.

    Actually, circuit design is rather complicated, particularly in the analog/mixed-signal/RF. It takes years of experience to become a competent analog/RF circuit designer, and years more to become an expert.

    On the other hand, typical digital circuits aren’t so hard. A second-year undergrad can build them on a protoboard. But digital does become challenging when pushing clock speeds above 1GHz, or when working in cutting-edge technologies.

    This aside brought to you by a grad student in electrical engineering, who also happens to be addicted to biology and medicine.

  19. If those numbers were mine, I’d light up a cigar, grab a good bottle of scotch, and think “well, I’ve lead a good life.”

    To Chris. After medical and graduate school, I said “wait a minute, you mean I can’t afford a Ferrari during my residency?” Went into business, to the eternal disappointment of all family members.

  20. By the way, a certain other blog has all the answers. :)

  21. tommyhj says:

    hmm, maybe convert that blood sugar and LDL into international units, mmol/l too (instead of ounce/pint? :), so the international naturopaths (NOT myself included!!) can join the fun?

  22. overshoot says:

    I mentioned at one of our meetings that Son #2 had been accepted at the university and would be studying mechanical engineering with a minor in physics.

    “Oh, no!” said one of the dads… he told me my son was too bright to be just a mechanical engineer. He told me it would be better for him to apply his mathematical talents to physics, since that had some higher caliber than mechanical engineering.

    When taking my twins about to university visits some years back, we interviewed both physics and EE faculty at several universities. Curiously, all parties agreed on one thing: you can never get too much math or physics, regardless of what you do with them later. That certainly agrees with my own experience; almost all of the EE I learned thirty-plus years ago is collecting dust but the physics and math are still helping me learn new tricks.

    So far, the boys agree — one is still studying physics, and the other is finding that prospective employers perk up when they find out that he has a physics degree as well as an EE.

  23. sowellfan says:

    Woo-hoo – Mechanical engineers representin’.

    There’s a dearth of responses from naturopaths here…

  24. daedalus2u says:

    I am a chemical engineer now specializing in nitric oxide and (if I were providing treatments which I am not) this is how I would think about it. My treatment philosophy is that there is much more that is not understood about physiology than is understood. In the absence of clear evidence that some regulatory pathway is going wrong, our default should be that it is actually adaptive. As a chemical engineer I see organisms as very complex chemical plants, which have exquisitely precise, robust and redundant control systems that are distributed throughout the organism.

    I see her primary problem as low basal NO, likely secondary to menopause (estrogen activates nitric oxide synthase and generates NO). This low NO has caused her hypertension by increasing vascular tone and by reducing capillary spacing. It has also caused her hyperglycemia by decreasing oxidative phosphorylation by reducing mitochondria biogenesis. Gout is caused by sodium urate crystals. Uric acid is produced by xanthine oxidase which is also highly involved in NO/NOx physiology (xanthine oxidoreductase reduces nitrate to nitrite to NO).

    Her most critical problem is the high blood sugar. Not that a high blood sugar by itself is bad, but because it signifies insufficient mitochondria and insufficient glucose delivery to peripheral tissues. That is why the body’s control system raises blood sugar, because cells too far from a capillary are not getting enough glucose, and the only way the body can increase delivery to those cells is by invoking hyperglycemia (to increase glucose concentration) and hypertension (to increase extravascular fluid flow by increasing pressure drop though capillary beds) and insulin resistance (to increase insulin delivery to peripheral tissues).

    Increasing her NO/NOx levels will address the 3 problems. More NO decreases vascular tone and will decrease blood pressure. More NO will increase mitochondria biogenesis and decrease the amount of glycolysis that peripheral tissues do, increasing their ATP production by oxidative phosphorylation and decreasing their need for glucose. More NO will also inhibit xanthine oxidase. Xanthine oxidase makes either NO or superoxide. When it makes both, the superoxide and NO combine to form peroxynitrite which irreversibly inhibits xanthine oxidase. More nitrate and nitrite will help get that cycle back in sync. The major nitrate/nitrite cycle is where nitrate is concentrated from plasma into the saliva (~10x) where it is reduced to nitrite by heterotrophic bacteria on the tongue. This cycle can be disrupted either by insufficient dietary nitrate (major source is green leafy vegetables, which contain a few tenths of a percent nitrate), or by killing the bacteria with antiseptic mouthwashes (or I think by alcohol consumption, particularly distilled alcohol).

    The interventions I would suggest are to first obtain and maintain the proper commensal bacteria flora. On the skin, these are the autotrophic ammonia oxidizing bacteria which metabolize ammonia into nitrite. In the mouth these are heterotrophic bacteria which reduce nitrate to nitrite. Second she should increase her nitrate intake by eating green leafy vegetables several times per day. The half life of nitrate is sufficiently short that it needs to be taken several times during the day. Third she should start a modest aerobic exercise program. This would need to be followed up in a month or so and/or if any symptoms get worse.

    There really isn’t enough information given to exclude a lot of conditions. My assumption is that PalMD wouldn’t consider allowing alternative practitioners or naturopaths to “treat” something even semi-serious even for a fictitious hypothetical patient.

    I don’t expect any alternative practitioners or naturopaths to suggest a treatment. They don’t have an understanding of physiology so they have no idea of what is going wrong or of what interventions might fix it.

  25. Newcoaster says:

    Daedalus2u

    I don’t really have any problems with your first paragraph. After that it goes of the deep end a little.

    I’m familiar with your NO obsession as I’ve seen your posts here in the past. While your ideas are interesting, and possibly plausible (I’m just a humble MD with basic bio and organic chemistry, so I can’t really comment..nor am I interested/motivated enough to do the fact checking necessary) the single mindedness of your citing NO disturbances as the ultimate cause of everything seems more of an ideology than actual science.

    Similar to how “energy” healers view everything as a problem with the flow of chi, or chiropracters see everything as a subluxation interfering with innate energy. Essentially, yours is a philosophical worldview that looks only for confirming evidence, and rejects/ignores contradictory explanations. Creationist wing nut Ken Hamm talks about needing to look at the world with “Bible glasses”. to “properly” understand it. You look at the world with “NO glasses”.

    I appreciate that you seem sincere in your belief, and that you certainly know a lot more about NO than I do.
    However, it seems you have more of a belief system…granted a fairly original one…than a true scientific hypothesis.

    And so far, not a single answer from an “alternative” healer to a clinical situation I run across every single day….

  26. daedalus2u says:

    My single mindedness has nothing to do with whether my ideas are correct or wrong.

    I don’t consider my ideas on the importance of NO to be original because they are not. Most of them have come from George Stefano and have been published in peer reviewed literature. My contribution has been the discovery of the commensal bacteria that set the basal NO level.

  27. Daedalus2u, I enjoy your NO discourses very much, and while more green leafies and exercise is a great idea, wouldn’t you also want to give her a shot o’ insulin with a fasting blood glucose that high?

  28. pec says:

    MY POSTS ARE VERY THREATENING. SO THEY HAVE TO BE DELETED.

  29. pec says:

    No, don’t let anyone see that this patient has metabolic syndrome resulting from physical inactivity and processed carbohydrates. No, we must sell drugs!

  30. overshoot says:

    MY POSTS ARE VERY THREATENING. SO THEY HAVE TO BE DELETED.

    Sorry, pec, but you’re not really in a position to demand that your posts be deleted.

    You’ll just have to learn to live with the fact that your posting history, sordid as it is, is on the record for everyone to see and mock.

    If that really bothers you, you might consider not posting narishkeit rather than posting it and then trying to reverse the moving hand.

  31. Harriet Hall says:

    pec,

    We are all in agreement that it is better to prevent disease. We are discussing a patient who did not follow preventive guidelines (for whatever reasons) and who now has disease. You are not a naturopath but you seem to be arguing from the naturopathic perspective. You seem to be against using drugs. What would you recommend for this patient? Do you deny that conventional drug treatments might help this patient? Do you have any reason to think non-drug treatments would be preferable? Do you think lifestyle changes alone at this stage would be efficacious?

  32. Peter Lipson says:

    And, as the commenters on my blog seem to have forgotten, not all diseases are preventable.

  33. Prometheus says:

    Quoth “pec”:

    That patient is a typical victim of the modern American lifestyle, and of a medical industry that gives patients drugs instead of education.

    Now folks, let’s not give “pec” a hard time – after all, he’s right…in a way.

    If this person had not been born into the modern American lifestyle, she wouldn’t have diabetes or hypertension – she’d already be dead.

    Look at mortality figures – especially for women – before the Industrial Revolution. A woman of 52 years would – statistically speaking – be dead.

    Prometheus

  34. overshoot says:

    And, as the commenters on my blog seem to have forgotten, not all diseases are preventable.

    Not all of us, surely?

  35. pec says:

    Prometheus,

    No one knows what the normal lifespan is for people who survive childhood, in a natural environment. There have been periods when lifespans were short because of dirty crowded conditions in cities. And lifespan data is meaningless if you include infant mortality, since a high percentage of infants will normally die without medical interventions (this is true in all species).

    There have been a small number of life-saving medical advances over the past hundred years, including antibiotics and surgical technology.

    But the new drugs cannot be credited with improving health and longevity, in any meaningful way. There is no data to support that, even though it is the marketing cry of the medical industry.

    Recent increases in longevity can be at least partly explained by a decrease in cigarette smoking.

  36. Prometheus says:

    pec,

    Humans haven’t lived in a “natural environment” for over 10,000 years. Look up “history of agriculture”.

    Of course, we could look at the few remaining groups of humans still living a hunter-gatherer lifestyle in South America and Australia (?Africa). In those societies, a person of 40 years is old and a person of 60 years is rare.

    I’m reminded of the writings of a “Natural Philosopher” of the 1700′s (I can’t remember his name) who wrote about the indigenous people of the Amazon basin.

    He was quite amazed by the absence of “…the halt, lame and infirm…” as well as the “youthfulness” of the people. Of course, it never occurred to him (or pec) that the reason there were no sick, crippled or old people was that people in those categories died very quickly.

    This may not be “…the best of all possible worlds…”, but people live longer and healthier lives now than they did in “the wild”.

    I eagerly await pec’s next explanation of why a longer life span and lower child mortality (by the way, pec, those two can be easily separated) don’t mean that we are healthier now than in the past.

    Prometheus

  37. overshoot says:

    There have been a small number of life-saving medical advances over the past hundred years, including antibiotics and surgical technology.

    I suspect pec would keel over from apoplexy rather than give any credit to vaccines.

  38. David Gorski says:

    MY POSTS ARE VERY THREATENING. SO THEY HAVE TO BE DELETED.

    More like your posts are very repetitive and tiresome; so they deserve to be ignored.

  39. HCN says:

    Dr. Lipson said “And, as the commenters on my blog seem to have forgotten, not all diseases are preventable.”

    I noticed that. I also noticed that you did not specify which kind of diabetes, Type 1 or Type 2.

    When I was first diagnosed with high cholesterol I was already in the midst of building up an exercise routine, so I then dropped eating all the fun food (eggs, cheese, whipped cream, sausage, etc). At the end of the first year my numbers were down to an acceptable level, but at the end of the 2nd year my numbers were back to their original levels. Apparently my liver compensated for the diet and exercise. So I am now on a low dose of lipids (the levels are just over some number, and I have high HDL — but since my family history is clouded with adoptions, I am on the meds).

    My step-mother comes from family with a genetic form of hypertension. The typical lifespan was usually between age 40 and 60. After the diuretics used to reduce blood pressure came available in the 1950s, she and her siblings lived into their 80s (except for the one who was married to a Christian Scientist, though the lifestyle they advocate did help him get almost to age 70).

    My son has a severe genetic heart condition, hypertrophic cardiomyopathe with obstruction. It is a physical anomaly of the heart… no amount of lifestyle changes will correct that. Fortunately beta-blockers reduce the blood pressure across the already damaged mitral valve. Several years ago on the JREF forum I challenged many homeopaths to tell me exactly how their active ingredient free fake remedies would treat HCM, I never really got a straight answer.

    Dr. Gorski said “More like your posts are very repetitive and tiresome; so they deserve to be ignored.”

    Gah, I always ignore pec, wales/just the facts and the others who are just as clueless.

  40. pec says:

    “Of course, we could look at the few remaining groups of humans still living a hunter-gatherer lifestyle in South America and Australia (?Africa). In those societies, a person of 40 years is old and a person of 60 years is rare.”

    The lifespan of hunter-gatherers is not known; people just make it up to fit their preferred medical theories. For one thing, hunter-gatherers do not keep track of their birth dates. And, as I said, their average lifespan is low because of infant mortality.

    I very much doubt you would find many 40-year-old hunter-gatherers with the health and appearance of a sick old person. That is a myth, not based on any kind of reliable data.

    In case you don’t understand how infant mortality influences the data — let’s say the average lifespan is 40 years and 25% die before age 7, then people who survive childhood are surviving to over 60 on average.

    And if you leave out adults who die from hunting accidents and inter-tribal violence, then their lifespan is similar to ours.

    Besides, even supporters of the new drugs at these blogs do not claim that our lifespan has increased because of the drugs. No one claims that, because there is no data to support it.

    Antibiotics, surgical technology, vaccines (which I assumed you understood was included under decreased infant mortality), improved sanitation, decreased cigarette smoking — all those have helped increase lifespan in our civilization.

    I doubt you can find much if any scientific (no I don’t mean anecdotes) evidence for improved health or longevity because of the new drugs.

  41. HCN, that sounds similar to my case. I think I am destined for statins one way or another. After 4 months of exemplary diet and exercise, my LDL is still 147. :P

    I wish all the people bitching about the modern lifestyle would step away from their computers and– oh, here’s a thought!– go live a hunter-gatherer lifestyle.

  42. pec says:

    “After 4 months of exemplary diet and exercise”

    FOUR MONTHS?? I hope you’re kidding.

  43. The Blind Watchmaker says:

    Ooo, Ooo, Ooo (raising and shaking hand Horshack style)!!

    I know this one. Shoot. I’m not supposed to answer.

  44. Pec, I’m not some couch potato corrupted by the “American lifestyle.” I weigh 128 lbs, ate a very healthy diet already, and used to walk 30 minutes per day.

    For the last four months I have upgraded “very healthy diet” to “exemplary diet,” and I stepped up the exercise to at least an hour a day of aerobics. Sorry– should I be foraging leaves and berries for my dinner for eight hours per day instead?

    Sorry for the snark, but your insinuation really pisses me off. There is only so much that diet and exercise can do for someone who is already in good health except for their damned genetic predispositions. If I have the choice between taking a statin for the rest of my life or having a stroke like my father just had, and like his mother had at an even younger age, I will take the f*#%ing pills.

  45. daedalus2u says:

    Perky, giving insulin might be ok, it might not be. If the problem is “just” the metabolic syndrome, a little insulin won’t be a problem. It won’t address the real problem either. I think the other interventions to lower blood sugar, such as metformin are not a good idea. The “problem” isn’t high blood sugar in the bulk blood, the problem is not enough glucose in the extravascular fluid (where it is most important). The only levers that physiology can pull to increase delivery of glucose to peripheral tissues is to increase blood sugar, induce insulin resistance and induce high blood pressure drop across the capillary beds to increase extravascular flow. Most cells get glucose from extravascular fluid and not from bulk blood.

    From the person’s weight, it might be that visceral fat is not a problem. But it could be depending on body composition. If so, that confirms the metabolic syndrome, and suggests there are insufficient mitochondria in the liver which would cause fatty liver and elevated liver enzymes.

  46. DarwynJackson says:

    Are there really no naturopaths in the crowd? Not even an acupuncturist or some

  47. DarwynJackson says:

    thing?

  48. Prometheus says:

    Quoth pec:

    The lifespan of hunter-gatherers is not known; people just make it up to fit their preferred medical theories.

    Not known by you does not equal “unknown”.

    For one thing, hunter-gatherers do not keep track of their birth dates.

    True enough – not having a calendar (an agricultural device), they don’t have dates. However, they do keep track of years. You don’t need to know what day a person was born to know their age – a simple number of years will suffice.

    And, as I said, their average lifespan is low because of infant mortality.

    If you know how old people are when they die, you can eliminate the skewing caused by high infant mortality. It’s a simple mathematical procedure.

    I’m also curious how you could know that their “average lifespan” is low if you don’t know how old they are. Isn’t that an impossibility?

    So, perhaps, we can tell how old people in hunter-gatherer societies are? In that case, we can easily determine the life expectancy for those who survive infancy.

    Prometheus

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