Balancing Medical Knowledge with Patients' Beliefs

We recently had a parent who refused routine newborn screening for her infant. The mother explained to us that she “would know if something was wrong” with her baby. In her opinion no lab screenings were necessary. We patiently explained to her that most of the conditions screened for are commonly asymptomatic until permanent damage is done and that is why screening is necessary, but to no avail. This mother knew best.

That same day, a parent called us stating that her toddler had a cough. Our micropractice model allows for easy telephone access (and someday soon, e-visits) to our providers. We thoroughly explained to the parent that she was handling the illness appropriately at home and there was nothing more we could provide with an appointment.

Still, the parent insisted that we see the child and we submitted to the request since we knew from past experience that if we refused, this particular parent would end up in the ER before the end of the business day. On her way out of the office after her appointment (a 99213 in which, as predicted, we couldn’t do any more than we had advised over the phone) the parent told the receptionist, “I can tell [my child] is already feeling better having just seen the doctor.”

That's a less expensive placebo than a trip to the ER to be sure, but a significant concern for looming payment models that pay us the same low price regardless of whether there is 1 or 20 visits in a year.

When we started our micropractice eight years ago, we designed it to help strengthen the doctor-patient relationship through longer appointments, easier telephone access, and effective utilization of marketing-communications strategies. For the most part the model has worked; parents recommend us at a very high rate to friends and family and we’ve celebrated a number of victories in steering anti-vaccinator parents toward compliance. Still, the model is not enough when competing with slick pharmaceutical advertisements and the charms of Dr. Oz and Dr. Sears. We need more support and we think it has to come in the form of government intervention to police medical lies.

There is another layer to be added here, and it’s an important one: Sometimes we just don’t know the right answer, diagnosis, or treatment. At our practice we consciously balance dispensing our best medical advice with being open to possibilities beyond our education, training, and experience. Our patients employ a number of treatments we would never recommend; parents give their children Vitamin C to prevent or cure colds, gripe water for colic, gluten-free diets for autism, multi-vitamins for picky eaters, and probiotics for ADHD.

None of these have proven to be effective, but then again, none of these are harmful. When asked by parents about treatments like these, we smile and say we don’t believe the remedy du jour will help, but it can’t hurt, so go ahead and try it. And who knows, maybe in the near future one of these theories will pan out beyond a placebo effect.

So, we have patients refusing good treatments, patients insisting on unnecessary treatments, and many more unanswered medical mysteries that are easy pickings for snake-oil salesmen. Some days it feels like we are losing more than we are winning.

For example, a recent dangerous trend has parents refusing intramuscular Vitamin K, putting a high number of newborns at risk for hemorrhagic disease. Unfortunately providers are no match for Internet fearmongers who encourage parents to insist on oral Vitamin K even though the science supporting this choice just isn’t there. In our opinion, the government has a duty to prosecute individuals and organizations who mislead patients for any reason.

Our hope is that by being open to what we don’t know and being honest with patients looking for easy answers that we don’t have, we can build trust so that, when patients want to do something potentially harmful (like skipping a screening or refusing intramuscular Vitamin K) or costly (like visiting an ER for a cough) they will comply with our advice. We believe this, in combination with government agencies empowered to crack-down on medical liars, is the only way we can have a healthier America.