10 December 2008

How would you handle this?

I recently saw a patient who was sent to the ER for treatment of an acute DVT.   I was surprised that he was not already on warfarin because he had a history of multiple previous DVTs and even two pulmonary emboli, with no clear explanation as to why he had recurrent clots.   He explained that his primary care doctor was opposed to warfarin and had put him on a "natural blood thinner," which was also good for his cholesterol.  I looked this med up (I can't remember the name) and found some references which stated that this substance was essentially worthless for either of these indications.   He was being treated by a local naturopath, he added, who had told him that the warfarin was damaging his kidneys and his liver.   He seemed a bit skeptical of this, since he had been maintained on warfarin for many years without any side effects.   I explained to him that he was going to need to go back on the coumadin (and low molecular weight heparin) for at least the next six months, and probably, given his history, for the rest of his life.   He seemed quite content with this plan.

His wife expressed some concern about the quality of care her husband was getting from his doctor.  He was rather medically complex, with blood pressure, heart and vascular disease, diabetes, and other chronic medical conditions, and I was frankly surprised that a naturopath would care for such a complex patient.   They both wondered whether he would be better off going to an internal medicine doctor, and his wife openly asked if I trusted naturopaths.  She hoped that I could set him up with an internist to manage the initiation of coumadin; the patient himself seemed amenable to this, and looked to me for a recommendation.

Tough one.  I hate to steer someone away from their doctor; it feels unprofessional or discourteous.   But it was the patient and his wife who had opened the door...

So what do you think I should have done in this situation?   I have the standard MD bias that naturopaths are credulous purveyors of woo, which in this case was supported by the fact that his hypercoagulable state was being treated with a placebo.   In addition, this gentleman was quite genuinely complex from a medical management point of view, and I felt he would probably menefit from an internist's expertise.  On the other hand, I am completely ignorant about the training and scope of practice of NDs, and a review of the records showed that a reasonably competent work-up had been done for hypercoaguability (Factor V, Homocysteine, anticardiolipin, though not a complete work-up), and that he had been seen by appropriate medical specialists when needed.   Calls to the ND's answering service were not returned.

So how would you handle this?  Would you send him back to the ND?   Would you set him up with an appointment at the local internal medicine clinic?   Is there a compromise position here?

Cast your vote in the comments, and show your work.


  1. They call it "complimentary health care modalities" for a reason. I'm sure the naturopath has many useful and helpful suggestions about how to stay healthy, but without consulting an allopathic doctor as well, he's putting himself in serious danger, as evidenced by his recurrent DVTs. Lucky he didn't die, eh?

    Unfortunately, people are often put into the position of having to think critically about their own health and the care they're receiving, a task most people simply aren't cut out for (that's why they have a health care delivery system, right?).

    I'd say a good compromise is to use the services as they're intended: a compliment to regular medical care, not a replacement. The fact that your patient was being treated for a problem that someone else told him would go away but didn't - was probably the wake-up call he needed to fold in more allopathic medical care in with his usual regimen.

  2. I don't think you are in danger of being either discourteous (you were asked) or unprofessional. It is your job to get this man the best possible definitive care you can.

    My opinion, plug him into a good internist. I suppose the "compromise" could come by way of the internist agreeing to allow the patient to continue the placebo if the patient had strong feelings about it. But it seems at least in this case that this man could really benefit from some good old fashioned, allopathic, evidence-based, woo.

  3. One way might be to present it to the patient as you did in your post.

    Neglecting to point out the risk of the clotting condition, for which he is receiving untreatment, is being more respectful to the naturopath, than to the patient, in my opinion.

    One of the mistakes the naturopath appears to have made is that he looked at the side effects of warfarin without taking the history of the patient into consideration. That the patient has been taking coumadin (without apparent problems) suggests that his body is not predisposed to the side effects. Side effects might develop later on, but many side effects are evident early.

  4. Naturopaths do not even have any sort of license/monitoring in most states in the US (they do in your state). The training is not really associated in any way with traditional medical training.

    They're throwbacks to the days before antibiotics, diagnostic testing, and evidence-based practice.

    I actually had a friend who went to a naturopath (that someone he knew recommended) for his depression and he ended up turning into a reclusive drunk who lost his rather prestigious management job because the naturopath had him convinced that there was a "worm" in his head causing his symptoms and prescribed him some mumbo-jumbo to deal with that. No anti-depressants nor counseling was ever recommended and there essentially had to be a family/friend intervention to get him to see a "real" doctor where he was appropriately treated.

    A patient has a right to do what he wants, but you have a DUTY to direct him to the care that is going to get him well/prevent illness or death. Since naturopaths aren't trained medically, they may not even know that he needs the life-saving therapy that you recommended. I don't consider a naturopath a part of any sort of credible medical team.

  5. Ha! Leave it to Gruntdoc to cleave the Gordian Knot.

  6. I was always more of a Gaugamela guy, myself. :-)

  7. I'd simply tell the patient and his wife that when it comes to medicine, you respect everyone equally, but you follow the evidence.

  8. Really? If a patient asks you for a referral to an internist you consider this a huge moral dilemma and don’t, out of courtesy toward the person (neighbour, health food store clerk, naturopath or doctor) who is currently counselling the patient but who the PATIENT DOES NOT TRUST AND WANTS TO SWITCH FROM???

    Really? So if I told you I would rather see a “real” doctor you would consider honoring my request for a referral to be UNETHICAL TOWARDS THE WOO PRACTITIONER?

    Shadowfax, you are one of the nicest medbloggers out there. But you have just announced that you consider protecting the practice of someone who IS NOT TRUSTED BY THEIR PATIENT to be more important than the health of the patient, when the patient is asking you for help.

    As a patient myself, I find this terrifying.

    What happened to “always ask for a second opinion,” “second opinions are a win-win, either they agree with the first doctor and confirm their judgement, or the first doctor gets a chance to learn something”? All of a sudden when someone is asking for a second opinion — they apparently don’t even trust their naturopath for an appropriate referral — honoring the patient’s request becomes unethical?

    Anyway. Terrifying.

    In the future, when seeing a new doctor, I will deny every having seen a doctor in the past. I want any doctor I see to have my best interests at heart; I don’t want them worrying about hurting another doctor’s feelings.

    There can be excellent reasons for a patient to flee a particular doctor, even an MD, never mind a woo practitioner. The MD may be too old, or impaired, or just very very weird or prejudiced. If all other doctors are honor-bound to return the patient to the doctor they are trying to escape from...

    Anyway. Terrifying.

  9. I would feel no professional loyalty or duty toward this naturopath. He's obviously trying to kill this guy. Totally agree with Alison Cummins. Even if the pt liked the naturopath, I would encourage him to follow up with internal medicine, and I would explain to him in plain and scary terms what he risks by not being treated appropriately. The pt is there for my medical opinion, and it's my job to give it to him.
    --Midwest ER Doc.

  10. This guy needs a REAL doctor! Don't worry about hurting some guy's feelings who is either, best case, incompetent or, worst case, trying to kill this guy. He needs an internist and DON'T feel bad about refering him to one.

  11. I think that the principle of "first, do no harm" applies here. By sending him back to someone who will not treat his DVT/hypercoag. with the gold standard and accepted treatment is setting him up for harm.

  12. Multiple PEs and not being appropriately managed for the next one which may just kill him, and put on essentially a placebo as treatment? Get the patient as far away as possible from the ND. You have to know your limits as a physician--MD, DO, or even ND--and clearly this one doesn't.

  13. They practically asked you to refer them to a traditional medical internist because they had their own doubts about the naturopath.

    Is your duty to the other doctor, or to the patient, whose best interests (in your opinion, if I read that correctly) weren't being served by the current treatment modality.

    I vote refer. What did you do?

  14. This one's easy. The naturopath isn't a doctor. This guy needs one. Refer. Quickly. Do not pass go; do not collect $200.

  15. I think a conversation like this might be directed along risk analysis lines. You could talk about there being risks in any treatment, and any "health care provider" has a clear duty to help the patient manage, balance, and choose between those risks. The NP clearly doesn't grasp this, and seems to think that any possible side effects from "evil western medicines" are completely unacceptable. You might point out that while warfarin has side effects that must be monitored, the side effect of being acutely dead from his placebo treatment might be slightly more distressing.

  16. So what do you think I should have done in this situation?

    I would have politely explained that my 5 year-old was available for
    consultation at a much lower rate than his Naturopath, and since the
    quality of care would be the same, that would benefit everyone. Of
    course that would be a lie, because your son might actually generically
    recommend "medicine" which would be an improvement over Naturopathy.
    Also, your son's general confusion over what "natural" means probably
    more closely resembles the actual distinction between "natural" and
    (what?), "unnatural", so there'd be better information flowing between
    "doctor" and "patient". Oh, and don't discount the additional benefit
    that the "patient" would actually *know* he was a victim of
    malpractice, so there's a benefit there as well.

    All in all, I guess I'm saying he should hang out a shingle and
    start pulling his own weight around your place.

  17. One of the mistakes the naturopath appears to have made is that he looked at the side effects of warfarin without taking the history of the patient into consideration.

    I think the main mistake the naturopath has made is that he is practicing medicine with no actual qualifications to do it.


  18. ShadowFax, as I've posted before I'm not a health care professional, so this is only how I imagine I'd handle the situation.

    I appreciate your reluctance due to ethical concerns. For example, who knows how accurate the patient's report to you is? Who knows what the patient even told his ND? Who knows whether that ND even knows the patient is going around saying the ND is the primary care provider.

    The ND loses credibility, though, and big time in my book, by not returning your phone call. What's the usual turnaround on a call back to another doc? You had to call the answering service a 2nd time, so that sounds like a delay. So I say you're in the clear for referring the patient elsewhere.

    The patient wants some kind of complementary care and allopathic care too. And the patient needs his providers to talk to each other.

    Why not refer the patient to an internal medicine doc who works closely with CAM providers? In the Pacific NW there are clinics of integrated medicine like this around. I don't know what state you live in, but if you're in Seattle, why not figure out which MDs are associated with a program like this --

    http://www.fammed.washington.edu/predoctoral/cam/ --

    and tell the patient these MDs have experience working with NDs too.

    IMHO you're following the spirit & the letter of your work in connecting these dots.

  19. do naturopath's have liability in your state? i wonder what standard of care is considered? same as for physicians or whether they have their own standards? do they need evidence based therapies?

  20. I was wondering if you were refering to a Osteopathic medicine doctor (D.O.) as opposed to a Naturopathic one.

    I can imagine having a similar thought pattern there.
    Doesn't matter is this provider was a md, do, no, pa, rn, etc...
    The patient wanted a new doc, they came to the ER with something serious.

    I agree he is a good canidate for and internal medicine doc (as opposed to a family prac)

    Just do it

  21. Doc, I understand that it was the wife that wanted to know about the ND vs. an IMED doc, and not the patient. That does put you in a grey area.

    I would present what an internist could do for the patient and what you recommend as the therapy. Present it as a second opinion and let the patient make the decision.


  22. It is my opinion that internists specialize in the management of multiple complex medical problems. Doesn't sound like his current doctor would be willing to manage appropriate f/u (INR,etc) as he doesn't believe in that particular treatment. So a referral to IM would definitely be in the patient's best interest if he wanted to persue full-dose anticoagulation. I don't think you'd be doing anything other than following through on a complete plan of care. Of course, I may be a little biased as I'm an internist:)

  23. This is pansy-assed liberalism at its worst. Why are you even wringing your hands over this? Naturopathy is quackery and the dude should be seeing a medical doctor. Believing anything differently and you are delegitimizing your own degree.


  24. Not a doc, but maybe you could say that the naturopath treatment just wasn't strong enough anymore, and now he needs to have an internist take over. I think many people can buy into a disease getting worse and having to do more to treat it.

  25. This is a big load of PC bullsh1t. A "naturopath" is NOT a real doctor. You have an ethical duty to inform him that he is seeing a quack and that he is being mismanaged. Refer him to a *real* doctor immediately.

  26. MD = Me Doctor
    ND = Not a Doctor

    Would you send your mother with a C3 fracture to a chiropractor?

  27. It has been said enough, but as another medical provider I have to echo the many comments here. I would feel zero professional responsibility towards a generic naturopath, and towards this particular individual especially. I would use very polite language with the family, of course, but I would also make it clear that naturopaths do not necessarily follow science based medicine.

  28. I must preface this by saying I generally agree with your stances and love your blog. However, holy smoke, Shadowfax, there is such a thing as being so open-minded that your brains fall out. Send this guy to a real doc immediately, please, so he doesn't sue you for keeping him on placebo for real problems, if nothing else.

    In Canada, the vast majority of traditionally-trained MDs have no respect for CAM and no compunction about saying so. Our MD programmes often include modules on various theories underlying the different modalities, and the evidence regarding them. My teacher for said module was Joe Schwarcz, chemist and woo-buster extraordinaire (http://www.canada.com/montrealgazette/columnists/joe_schwarcz.html).

    And for the record, on almost everything else I am a textbook candy-ass liberal.

  29. Send him to a real physician, and Internist. Jeve

  30. i respectfully disagree - not with the comments per se, but with the tone of the discussion here.

    i think that the ND did the best s/he could with the tools and experience s/he had under the circumstances, and that once the pt was under your care it was right for you to do the best you can with your tools and experience.

    however, i feel that - while we cannot ignore our own biases - we can't let them rule our actions. referring may be the right thing, but the way that it has been suggested here (saying that the ND was "obviously trying to kill" the pt or that considering the repercussions of your actions is "pansy-assed liberalism") speaks volumes of the rift within healthcare in the US (just as your concern for being unprofessional and discourteous speaks volumes about your professionalism and the caliber of your pt interactions).

    like it or not, pts are going to see multiple types of healthcare providers and while you are justified in feeling that you are superior, pettiness and snkariness will do nothing to serve the pt at any point. i'm not suggesting that anyone be "so open-minded that [their] brains fall out", i'm merely suggesting that as a doctor your pt deserves factual, unbiased information about their options and that you're right to consider all providers with some respect...even when you disagree with them.

  31. Naturopaths are for healthy people. He's not trained to manage a medically complex patient, and will probably kill him if this continues. No loyalty to someone who won't call it when he's in over his head.

  32. Shadowfax, thanks for your professionalism.

    I agree with the poster who pointed out NDs do wellness and preventive medicine. I agree that professionals, including MDs, must say so when they face a patient who needs something else, or something more.

    But for the record, I'm with Sarah in disagreeing respectfully with the tone of many responses in this thread.

    If we open up the notion that licensed practitioners such as NDs are "not real doctors," then we have to ask, how'd they get licensed?

    Let's say we think the NDs got licensed through political influence. I tried that idea on, but it presents a problem. As soon as we allow for political influence in health care. . .

    (1) we also have to acknowledge the political influence of the AMA.

    (2) We have to look at the political influence of drug companies creating trials with such low enrollments that they have insufficient power to find differences in adverse effects between control and drug conditions. Then the companies say they found no significant differences in adverse effects. And this is what some of us are calling evidence-based medicine. Not evidence-based enough, unfortunately.

    (3) We have to look at the inadequate funding for evidence based medicine on herbals etc. NCCAM of NIH is not funded at an institute level. Can we agree that if we don't ask the questions, we won't get the answers? Can we agree to support asking the questions?

    (4) Then I start thinking about the drugs patients get from some MDs, because the MDs accept free samples from the drug reps. When MDs participate in medical marketing, are they still "real doctors."

    (5) I'm trying to remember the naturopathic equivalent of the DES disaster or thalidomide babies. MDs, so-called real doctors, prescribed these drugs and they harmed a lot of people. Not evidence-based enough, unfortunately.

    I respect my own MD(s) enormously. But I don't see a basis to call MDs real docs and NDs not. My own request of MDs who are so dismissive of others' training is: let's all take 3 deep breaths and respect our own professional training while considering the possibility that other professions may also have perspectives to offer. I think this ought to be covered under "do no harm."

    Thanks for reading.

  33. From my reading of your post, it sounds like this patient has an unidentified coagulopathy. I'd be tempted to refer him to a hematologist as well as an internist. You did mention that he had been referred to specialists as appropriate; I can't imagine that a competent specialist hadn't recommended coumadin. If the ND isn't listening to his consultants, he's dangerous. Either way, not sending this guy to follow up with a board-certified IM guy (at the very least) strikes me as less than standard of care.

    Which leads us to the "respect" issue. The comments have some backlash about taking naturopaths (and other CM types) seriously, and respecting them appropriately. Yes, they're trained. Yes, they're licensed. Yes, they are permitted to call themselves "doctor". But a doctor is only someone who has studied extensively, not necessarily an expert in the healthcare field. PhDs are doctors too, but I wouldn't want a biochemist treating my diabetes, no matter what he knew about the tertiary structure of insulin. Patient care should be guided by physicians, by which I mean MDs or DOs.
    The licensing process for physicians is not perfect, and the evidence-based process is flawed, but this shouldn't lead us to throw out the entire stew and try to practice medicine based on the doctrine of signatures and other folk hokum. What it should do is encourage us to be thorough in our reading of the literature, vigilant in our practice, and aware of our limitations (which the ND in this example apparently isn't).

  34. What is the ethical concern in referring your patient to a competent doctor as opposed to sending him back to the quack he was seeing?

    Why is this any moral or ethical dilemma at all. I am really at a loss here.

    You say you don't know much about naturopathy. Why not? Your lack of curiosity once again amazes me. Perhaps instead of blogging about how much you don't know you should spend your time reading and studying.

  35. Having read many comments, here's what I think about MDs & naturopathy. On this topic I see 3 subgroups of MDs:

    (1) MDs who know a fair bit about naturopathy (small group it seems),
    (2) MDs who don't know much at all but think they do (large group it seems), and
    (3) MDs who don't know much at all and say so (small group it seems).

    Cheers Shadowfax, you're in subgroup 3, a decent place to be.

  36. This is what i think:

    its optimal that MD's and CAM practitioners dialogue about their pts and attempt to coordiante care(you tried and were unsuccessful, thats cool that you were willing to do so!)

    I would (and have in a few situations thus far) provide medical education (depends on how much time you have available) addressing the risks of not treating a medical condition w/o meds yet express openness to hearing the pts motivation for pursuing CAM

    the compromise position is: Send the pt (or recommend they find) a health care provider trained in Complementary and Alternative Medicine (CAM) AND allopathic medicine ( aka: MD's that practice "Integrative Medicine"). They will be more informed about the risks and benefits of managing pts condition via allopathic vs CAM therapies, and potential interactions if they are combined.

    good luck, this is one of the new frontiers of medicine!

  37. As a psychologist who is more than happy to scream for a psychiatrist when it seems they might be needed, I certainly agree that if the patient seems at risk, you address the risk not the relationship with a ND who won't even call back! That's unprofessional no matter what the profession.

    As a tangent, I should mention I know someone in acupuncture school who often gets patients with what MH people call Axis II disorders ( eg non-psychotic paranoid personalities )
    Sometimes these people have wrapped medical personnel "into their complex" as I call it. They've become so suspicious of MD's, sometimes because of their offputting personalities, or their paranoia, or their shame about poverty or some other failing; that they've decided to go an alternate route-- many times with negative effects.

    On the other hand, I've had psychiatrists recruit me to complement their practices, as they get tired ofreducing patient sumptoms with medication, and establishing enough stability for the patient to progress in their life, only to see them stagnate because "pills don't give you skills", in other words, the remedial social learning needed that didn't occur because of mental illness.

  38. Shadowfax,

    You never followed up explaining 1) what the ethical dilemma you saw was or 2) how you handled it. Your post genuinely frightened me. The confabulated example you gave was of a patient with complex physical conditions. As someone who takes an antidepressant and a mood stabilizer, I have long feared that a doctor is going to write something dismissive of me in a chart somewhere and that "something" will stay there forever and I will never be able to make myself heard over the voice of medical authority. Now I learn from you that isn't necessary. That all patients' wishes and best interests - whatever their diagnosis, with or without psychiatric elements - will be ignored as necessary to protect the reputation and income of even the most unethical, incompetent non-doctor.

    That ultimately, patients may never have confidence that the doctor they are consulting is acting in their interests, and must always assume a sinister cabal.

    If that's not what you meant to communicate to the public, or the example you meant to set for other doctors, please set us straight.

    I want to be able to trust my doctor, but if I must not... well, that's good to know, I guess. But then, like, what are we supposed to do? There is no alternative.

  39. Non doctor here:

    coumadin and LMWH are SOP for a DVT. No exceptions, or rare, if they exist. It's the standard of care, and is also reasonable and necessary.

    Why would a doctor risk a PE by deviating from what is most beneficial and life-saving for such a patient? I'd do a cardio consult as well.

  40. My opinion: you answered the question yourself. When you call a practitioner's answering service, and get no response, then that practitioner is not equipped to care for any type of patient who might have any kind of urgent or emergent condition. End of story. If it were the patient sitting at home, wondering why their breathing has become difficult, waiting for the naturopath to call back, imagine the consequences. These practitioners who want to have equal privileges to care for patients often abdicate the responsibility of the consequences of their care when it gets complicated.


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