Yesterday I issued a challenge to naturopathic physicians to justify why they should be considered competent primary care physicians. The best and most comprehensive answer received so far is the one from "Mona". Here is my analysis.
Her response, while not entirely "wrong", shows a frightening level of chaotic thinking and unsophistication.
As a naturopathic physician graduated from National College of Naturopathic Medicine in 1988, and having done a year's residency there in Family Practice I am happy to answer your relatively easy question. I see many diabetic patients who come with the complications oftentimes associated with that condition itself, or as part of the Metabolic Syndrome criteria which are aligned with insulin resistance and pre and actual diabetes.
In the real world of medicine, a family medicine internship (or one year of residency) is considered inadequate training, and would disqualify you from sitting for your boards.
My first office visit is 1.5 hours. In that time I do an extensive history of the patient and his conditions--learning when conditions began, how they have progressed, how he is being treated (type and dosage of meds), etc, the typical doctor stuff, including mental/emotion issues, life stresses and so forth. I look at any blood work or any medical records he brought in. I do a physical exam including vitals, heart/lung, neuro check on his feet, and any other pertinent PE based on office visit. If not PE in a long time, then the DRE and so forth is included.
OK, so far as it goes, I suppose. Rather vague.
As a naturopathic diabetic expert, I would do the following with him:
Blood work including CBC, CMP, LFT, Ferritin, GGT, F/T Testosterone, Thyroid panel, PSA, A1C, glucose, c-peptide, fibrinogen, random microalbumunuria, 25(0H) Vit D. I require all patients who come to me with diabetes to have a dilated eye exam no more than 6 months previous to our visit--this is because I am so successful in lowering glucose levels so quickly there is a risk of worsening of any established diabetic retinopathy. I have figured out a supplement regimen which prevents this worsening. I would send him for an EKG and cardiac work-up to discern what his exercise capabilities are; and a podiatrist if any foot ulcers, signs of Charcot etc are evident. Has he had a routine colonscopy yet?
Some of the blood word you've mentioned requires justification. For example, what evidence is there for ordering free and total testosterone? By the way, a CMP includes LFTs. PSA is controversial, but common. Thyroid panel is usually not required, unless there are symptoms that point to thyroid disease. C-peptide is a curious choice, but not entirely ridiculous. Fibrinogen is insane. Random urine microalbumin is indeed a requirement, as is the foot exam, which should, of course, include microfilament testing. I'm not sure what supplements you propose for DR, but it should be treated by an ophthalmologist, preferably one with a specialty in retinal diseases.
I send him home with "Dr. Richard Bernstein's Diabetes Solution" written by an MD with Type I DM for 65 years, a diabetologist with whom I preceptored. He has to read at least the chapters on the diet. He does a diet diary for a week and records his fasting, and 1.5 hr post-prandial glucose levels as well. If he needs a new glucometer, test strips, lancets--I'll write scripts for that. Is he on BP meds; probably, right? I need to discuss with the patient if I am taking over as primary doc to deal with all his condition or if he wishes to continue to work with his MD--most patients, in fact, almost everyone, wishes me to take over everything. I would then increase his BP meds a little for right now. I'm not too concerned with his 230 blood sugar; with my protocol that will come down substantially and one more week is not a problem, although I tell him to guarantee me he'll keep himself fully hydrated. I'll send him away with blood work orders at local lab, diet diary, chart to record his blood sugars, prescriptions if necessary, Bernstein's book, a clearly detailed Treatment sheet.
I'm not sure how handing him a book qualifies as appropriate care, but if you're following him closely...
His blood pressure is certainly not at goal, and given that he is not overweight, it is unlikely that dietary changes are going to have a large impact on his blood sugar or blood pressure.
He'll come back next week when I'll go over the blood work with him, describe the strict Low Card diet he must follow via a very detailed handout I have, which includes components of eating healthily as well. I also go over the supplements I'll put him on (vitamins, minerals, fish oils, herbs, accessory nutrients), recommend exercise (if he has been cleared by the cardiologist), stress relaxation techniques which resonate with him, if necessary.
Why would you put him on a strict low-carb diet? There is no evidence to support its use. Why are you putting him on supplements? There is no evidence to support that practice.
Let's say he's NOT on insulin, so I don't have to describe all the comprehensive ways I deal with that. I give him directions that if his blood sugars go down frequently below 100 mg/dl to call me and stop his Sulphonylureas (imagining him to be on Metformin and Glyburide). I recheck his vitals and his BP is lower, 140/82, which is okay for now. I will see him weekly or every two weeks until he is stable and we have dealt with all problems, which usually just takes 2-3 visits. We will lower or remove medicines, as necessary. Follow blood work every three months.
140/82 is not "OK for now".
Let me review the evidence-based guidelines for this patient.
a 65 year old male comes to you for an initial primary care visit.
What is your initial approach to the patient?
Aside from what you may find on evaluation, what prevention and screening recommendations will you make?
Let's say the patient has a history of diabetes, hypertension, and coronary heart disease, and had a drug-eluding stent placed in his LAD about one year ago.
Today's vitals are significant for a weight of 66 kg, blood pressure of 160/92.
His fasting blood sugar today in the office is 230. His LDL cholesterol level is 98.
OK, an initial approach would of course include taking a thorough history and physical exam, reviewing old records, etc. Plus, the below.
1) Prevention and screening: aside from his chronic medical conditions, it is time for him to have a colonoscopy for colon cancer screening, a digital rectal exam, and perhaps a PSA. It is also time to make sure his tetanus vaccine is up to date, as well as his pneumovax and flu vaccines. If he is a smoker (male, over 65) it would be reasonable to get an abdominal ultrasound to screen for aortic aneurysm.
Disease specific screening would include (for the diabetes): dilated eye exam done by an ophthalmologist, foot exam including micro-filament testing, serum creatinine, urine microalbumin-creatinine ratio, Hb A1C, weight/BMI, LDL cholesterol (the goal in this patient is less than 70). For his coronary heart disease, many of the above apply, plus a 12-lead EKG.
2) Disease-specific recommendations: this patient is at very high risk for continuation of his coronary heart disease and other micro- and macro-vascular complications of diabetes. The following medications have been proven and significant benefit in secondary and tertiary prevention in this patient:
--ACE-Inhibitors (or ARBs)
--and perhaps, depending on the details of his stent, Plavix.
These are not "maybes". These are required, if tolerated by the patient. Not adhering to these recommendations puts you very far outside the mainstream of evidence-based practice.
For this patient, his goal systolic blood pressure is less than 130 mmHg, his goal LDL less than 70, and his goal A1C less than 7.0. His BP and LDL are not going to be at goal without medication. We don't know yet about his blood sugars---he may or may not require insulin vs. oral medications, but more likely than not he will require one of them.
It is important to know a bit about these medications. For example, if his creatinine clearance is significantly reduced, metformin and a sulfonourea are contraindicated. If he is on insulin, caution must be used with his beta blockers.
If he has a drug-eluding stent, and it has been less than a year, he cannot yet have a colonoscopy.
Obviously this may take place over two visits, since the patient may be overwhelmed by the amount that must be accomplished.
The ND's recommendations would have gotten her a failing grade from any family medicine or internal medicine board.
By the way, the drug regimen which he will likely need will cost him approximately (minus the plavix) $18/month. Especially without the supplements.