The nuances of a primary care visit aren’t always appreciated

I subscribe to a financial newsletter that happens to be written by a non-practicing physician in a highly specialized field. His daily updates are a mixture of financial and health advice, and he is a proponent of evidence-based medicine. Based on the letters from subscribers, they are willing to follow his advice eagerly, and when he gives some references to support his medical opinions this seems logical. But he is so far distanced from clinical practice that some of his advice is not only glib and superficial, but disturbing.

Recently, a newsletter contained an exchange where a person wrote in that his doctor told him vitamin D is good for a healthy heart. The newsletter author crisply replied that the person’s doctor was spouting nonsense, tell the doc to provide the evidence, then stated it does not exist and fire the doctor.

Simply — wow.

Maybe the financial advisor really believes this is all that this is an accurate representation of the entire conversation on this topic and that this statement was so damaging to this patient that it requires firing of a physician. Perhaps this person paid their copay, went in to ask this question and this was the only thing told to them. However, as a primary care physician who sees a full panel of patients daily with their variety of agendas, I doubt this is true.

Many of my patients come in with one to three issues to address, work up and evaluate and provide a plan of care. Often at the end of an encounter when their chief complaints have been addressed, and we are tying up the visit, a patient will say, “Let me ask you something,” and then ask a question about vitamins or some new supplement they read about or their coworker’s disease and are they at risk, or something based on a TV news story or advertisement that I have often not seen nor heard of. To thoroughly answer some of these questions would require a detailed interview for more information or a complex literature review of supplements or the latest news stories. So sometimes, a quick answer based on best current knowledge and what is best for that patient is provided. It will not be detailed with the latest possibly competing guidelines from various societies, the pharmacologic information on an obscure supplement, nor the study that was published yesterday on the value of a certain food in the diet. But generally, it is based on my knowledge of the patient and what is best for them based on our long-term relationship.

Unfortunately, patients often have a difficult time remembering up to half the medical advice given to them even in a brief office visit, and what they remember is colored by their personal agenda for that visit as well. When multiple issues are discussed, it seems more likely that the patient is going to remember a response to the “Let me ask you something …” question they had rather than the counseling on fracture and renal function risks with long-term PPI use. I can recall encounters where I have discussed a patient’s risk for fractures and the role of vitamin D, calcium, and exercise, also mentioning that patients with lowest levels of vitamin D had higher risk of cardiovascular disease, while adding that we do not know if this means adding vitamin D will help the heart or not. Would a patient summarize that information as: “Vitamin D is good for your heart?” I do not know. But I suppose that is enough heretical medical advice that my patient should fire me on the recommendation of this newsletter.

I am concerned that this financial advisor/physician is so smug and dogmatic in his “show me the facts” mantra that is he willing to encourage a person to fire their physician over this little snippet of conversation without any further context. I would encourage him to visit a primary care office and follow a busy practicing physician for a day to see how things really go down. Maybe he would be a little less self-righteous and a lot more understanding that there is so much more that goes into a patient visit than one little question about vitamin D.

Barbara L. Pierce is a family physician.

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