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 by Peter Lipson

Peter A. Lipson, MD 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. He currently maintains a private practice, and serves as a teaching physician at a large community hospital He also maintains appointments as a Clinical Assistant Professor of Medicine at Wayne State University School of Medicine and at Oakland University William Beaumont School of Medicine, the first being a large, established medical school, the latter being a newly-formed medical school which will soon be accepting its first class of students.  He blogs at White Coat Underground at the Scientopia blog network. A primary goal of his writing is to illuminate the differences between science-based medicine and everything else.  His perspective as a primary care physician and his daily interaction with real patients gives him what he hopes is special insight into the current "De-lightenment" in medicine.  As new media evolve, pseudo-scientific, deceptive, and immoral health practices become more and more available to patients, making his job all that much more difficult---and all that much more interesting. Disclaimer: The views in all of of Dr. Lipson's writing are his alone.  They do not represent in any way his practice, hospital, employers, or anyone else. Any medical information is general and should not be applied to specific personal medical decisions.  Any medical questions should be directed to your personal physician.  Dr. Lipson will not answer any specific medical questions, and any emails and comments should be assumed public. Dr. Lipson receives no compensation for his writing. Dr. Lipson's posts for Science-Based Medicine are archived here.