As the sixty-something-year-old woman and I shook hands and sat down to get acquainted during her “new patient” visit, she pulled out a small stack of papers and a thick spiral-bound notebook. I glanced at her problem list in the electronic chart: diabetes, obesity, hypertension, anxiety — the usual. She handed me the notebook and a printed Excel spreadsheet with several columns: her medications (a handful), the supplements she takes (around two dozen), and her “allergies” (also around two dozen). The notebook she had handed me was a glossy-covered, commercially-produced bible about essential oils which, she started to explain, had changed her life.
I am a family physician, trained in the Western medical tradition. I am also, proudly, an adherent of evidence-based medicine — that is, I strive to make diagnostic and treatment decisions based, when possible, on the best available scientific evidence, taking into account the patient’s values and my own clinical experience. I work hard to read, to stay current. I know I’m not perfect. I know the evidence is far from perfect. But I am a skeptic by training and by temperament.
My patient continued on about essential oils for a good ten minutes, resisting all my best efforts to politely redirect her. The appointment, said my schedule, was for an annual physical exam (speaking of non-evidence-based traditions in medicine) and for a discussion of preventive care, her diabetes, obesity and hypertension. A third of the way into our allotted time, I’d been able to cover none of these topics because of her passionate monologue.
What is a health care professional to do in this situation? She had, presumably, come to me for medical care — Western-style, scientifically-based medical care. Yet, we were operating from two completely different frames of reference: hers, I would describe as faith-based, anecdotal, unscientific; mine, she would probably describe as close-minded, uninformed, pharmaceutical-pushing, dangerous.
I felt trapped between two conflicting professional obligations, two sets of messages I’d been taught years ago. On the one hand, I have a professional obligation to provide the best evidence-based prevention, diagnosis and treatment I can while minimizing harm. I needed to counsel her on weight loss, on her blood pressure, to make sure she’d been screened for colon cancer, to inform her about the mammography controversy, while leaving enough time to do a reasonably thorough physical examination. On the other hand, I have been taught that visits should be “patient-centered,” should allow the patient to set the agenda, should avoid paternalism. But this patient had now spent half our visit trying to convince me, proselytizing me (so I felt) about her faith in essential oils.
I felt myself becoming angry, physically tense and frustrated. I wondered why she was there if she didn’t actually want my input on her health. I wondered what she hoped the outcome would be. Did she expect me to say, “Gee, I’m going to prescribe essential oils to all my patients now! Where has this miracle cure been all my life?”
I was finally able to move her to the exam table from where she kept lauding snake oil (err, essential oils) while I examined her optic discs, palpated her thyroid, and auscultated her heart and lungs. The visit ran ten minutes over, and I felt I’d accomplished nothing at the end of it.
I’ve never received any training or read any good “pearls” on how do manage the all-too-common patient, now equipped with the Internet’s excess of misinformation, who arrives in our office already a convert (the most appropriate word, with all its religious overtones) to reflexology, to aromatherapy, to iridology, to old-school Palmeresque chiropractic. Should we confront and debate at the risk of alienating the patient and losing any therapeutic alliance (the approach I once tried with an anti-vaccine mother whom I never saw again)? Should we ignore and go about our business as best we can (the approach I now took), running the risk that our silence implies consent and wasting valuable time in which we could be intervening with real treatments? (I am haunted by the thought that this patient is now out there telling her friends, because of my tolerance, “My new doctor thinks essential oils are great!”)
I don’t know. I just know that this visit, and my personal failure to deal with it in a way that satisfies my own expectations of the care I provide, has lasted long past our thirty allotted minutes.
Paul D. Simmons is a family physician.