Posted by: notdeaddinosaur | June 10, 2016

Dialog: Doubling Down on Dropping Out

Dr. Wible and her young colleague have responded to my previous post: [Cross posting with her comment section, to share the clicky love as we continue the dialogue]

A few corrections to your blog Lucy:

1) I do NOT have a subscription practice. I see all-comers and I take insurance.

2) I have never turned anyone away for lack of money. I don’t believe in a two-tiered health care model.

3) Diet and nutrition is not woo (and is certainly not taught in med school). There are HUGE problems with allopathic medicine which does not prepare us to care for patients in an outpatient setting when it comes to prevention, lifestyle, and common sense things people can do to prevent taking drugs for the rest of their lives.

4) PAs and NPs are providing primary care in an outpatient setting with a lot less training and most are doing a great job. Physicians who want to practice outpatient medicine should not be held hostage to 3-4 year residency programs. There are not enough residency programs to meet the needs of current med school graduates. These students with 300K+ loans should not be sitting at home twiddling their thumbs when they could be caring for people like NPs and PAs.

5) And yes, I believe that residency programs can be shortened. How does working in the NICU help me provide care in an outpatient setting? There are so many parts of residency that could be structured in a more personalized way to meet the ACTUAL needs of patients and docs who plan to open neighborhood family medical clinics. A tertiary-care hospital-based Pharma-heavy medical indoctrination is not appropriate for everyone.

I could go on . . .

~ Pamela

P.S. I allowed my community and patients to design and define their OWN ideal clinic (which I opened based on 100 pages of their submitted testimony) and what they want and what residencies deliver are not a great match. Patient engagement is important – in fact essential – so let’s stop holding everyone hostage to a one-size-fits-all medical education system (that need to be TOTALLY revamped).

1) and 2): My bad. I seem to recall you talking about your practice being “full,” having a waiting list and so on, meaning you manage a panel. (I don’t.) Most people who do that are DPC or otherwise subscription based. Apologies.

3) Diet and nutrition (may as well throw in exercise as well) are not woo at all. I never said they were, nor does any legitimate doctor I know. However they are often used by alt med practitioners as a bait and switch for their actual woo, like naturopathy, chiropractic, homeopathy, and so on. As for that old canard about nutrition not being taught in medical school (not true, BTW) what we do learn about biochemistry and physiology allows us to understand nutrition at a much deeper level than anyone else, if we’re paying attention. In fact, truly understanding the basics allows us not to fall for each new fad diet that promises instant loss of belly fat. The really exciting new stuff about nutrition has to do with the gut microbiome, and how different people respond completely differently to exactly the same foods. Real doctors are the ones doing that research, not the ones with books to sell.

Use of the adjective “allopathic” is another flag that you’re setting up a false dichotomy between drugs and non-drug treatment, where presumably doctors ONLY use drugs. I use lifestyle measures (like diet and exercise) and “common sense” for prevention and treatment every single day. The idea that taking drugs represents some kind of failure is, in my opinion, foolish. Many people still need medications for things like blood pressure and diabetes even after optimizing their lifestyle. They certainly don’t have to “take drugs for the rest of their life,” but their lives will likely be shorter. The ability to use drugs appropriately is one of the skills developed in training. Opting out of that education is very much throwing the baby out with the bathwater.

4) Yes, there are many people providing primary care who are not residency trained physicians. However I reject your assertion that they are doing a “great job.” Google the Dunning Kruger effect: the less you know about something, the more confident you are about your knowledge. I’ve written about this with regard to PAs and NPs before. Patients love their NPs and PAs, just like they love their naturopaths, which basically means that they’re either never going to realize what lousy medical care they’re actually getting, or that if something untoward happens, they’re not going to blame them. Is graduate medical education perfect? Hell no! But fix it; don’t forego it.

5) I disagree strongly that residency should be shortened. Re-structure it? Absolutely. Spending more time in various outpatient settings, possibly free clinics where trainees can experience true undifferentiated primary care while still under the supervision of experienced faculty, would be fantastic preparation for independent practice. But one year of postgraduate training is nowhere near enough time to become familiar enough with primary care to practice safely and effectively on one’s own. All the CME in the world doesn’t make up for treating patients with someone who knows more than you do looking over your shoulder, pointing things out to you, and providing guidance. No, tertiary-care based training isn’t appropriate for everyone. Guess what! I did mine at a community hospital. Again, you’re offering a false dichotomy of “indoctrination” vs “following the dream.”

PS I’ve read all about your clinic, and I’m happy for you. Somehow I managed to wind up in pretty much the same place, but without going through the burnout phase that you did. Believe it or not, NOT everyone is driven the brink of suicide by medical training and practice.

As for “allowing patients to design and define” their ideal clinic, you have to remember that patients are not customers and are not always right. All too often they want things that are not medically appropriate. I have patients who would say that their Ideal clinic would be a place where they could get antibiotic prescriptions called in without a visit. Trying too hard to please patients can also lead to inappropriate narcotic prescribing. Slippery slope, that. I stick to treating my patients the way I want to be treated: same day appointments, communication any way they want, all labs called back personally; friendly, attentive, thoughtful, medical care. They seem to like it.

“Patient engagement” is indeed important, but it’s just the new term for what I’ve always done; involving patients in their own care, soliciting their input to treatment decisions, and providing lots of patient education. Frankly, my patients are most grateful when I take the time to explain why all those alternative treatments they found on the Internet are a waste of their time and money.

Her disciple, Kat Lopez, weighs in too:

…Did you mistake the Institute of Functional Medicine for woo-woo? You may want to check into it. The IFM is run by highly experienced MDs who have become world-renowned for their success in healing difficult diseases; the Cleveland Clinic just opened a functional medicine program because the efficacy of the approach is unparalleled (addressing the underlying causes of disease using nutrition and approaches to decreasing inflammation in the body).

Have you heard of Dr. Esselstyn or Dr. Fuhrman, eminent cardiologists who reverse severe coronary artery disease with diet alone? They’ve written several books, you may want to read one, they’re amazing. I think it should be illegal for docs to NOT reveal to their patients that there is a failsafe nutritional method to getting off their cholesterol meds, antihypertensives, diabetes meds, and gaining radiant health. Try reading up on those guys.

Also, writing off Mind-Body Medicine (I trained with Harvard’s Center for Mind-Body Medicine) as woo is a mistake – their unique approaches to mental health disorders (which I now teach as ongoing classes at my clinic), such as severe PTSD, has been shown my extensive research to far exceed the success of counseling and medication combined.

Sorry, Kat, but yes, every last modality you mention is nothing but solid woo, magical thinking, and pseudoscience. I urge you to check them all out at Science Based Medicine, my go-to site whenever I need to sort out science from pseudoscience.

On the topic of mental health, by the way, check out the writings of a wonderful young psychiatrist named Maria Yang MD. I’ve been following her through training, board exams, and now practice. She avoids the stereotypical portrayal of psychiatrists as the ultimate drug pushers without ever invoking the kind of woo at Harvard (no, the name doesn’t impress me) and elsewhere. Food for thought, as you say.




  1. Might the Phila Inquirer reprint these last 2 blogs? Their readership would undoubtedly enjoy your refreshingly-retro perspective. Apropos this, today’s NYT ran an article about a NJ Emergency Dept which utilizes a roaming harpist & various self-proclaimed practitioners to help eliminate or minimize opiate administration. Huh? In my nearly 30 years of practicing Emergency Medicine, there have been scant patients for whom this would have likely been efficacious. Reduce residency training? Adding a year would be more advisable (for all the reasons you mentioned & then some).
    Overall, you articulated/defended the pro-science position quite effectively — a particularly bold stance given your practice’s proximity to Kimberton!

  2. I couldn’t agree more. Courageous debate here and you are right-on that patient engagement is not the same as quality medicine. Also “designing” your own practice with scant training is both dangerous and a trick to the patient. After 30 years of IM practice, I wish I had more formal training, not less. Medicine and helping patients is complex and the best doctors are humble and don’t pretend to know everything. Patients want a physician who is skilled and knows more than they do. Sorry if training is taxing and not to her liking. That’s why not everyone should be a doctor.

  3. A roaming harpist? Really?

  4. Just wanted to say that I, too, follow (and adore) Maria Wang! I’m a social worker and love that she gets that people interact within systems that may improve or hamper their function.

  5. Oops, typo, Maria Yang…

  6. As a practicing hospitalist, I couldn’t agree more with you Dr. Lucy. “Integrative Medicine” or alternative medicine is unfounded. I have more problems with herbal remedy drug interactions than successes. Evidence-based medicine is the only way to practice medicine if you want to follow our oath to “Do no harm”.

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