Private practice with Dr Seth Bilazarian

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Managing discussions of nontraditional therapies with your patients

Aug 5, 2009 09:30 EDT


General consensus among practitioners is that "natural" or "naturopathic" therapies have shown little or no evidence-based value and in many cases may prove harmful. How do you manage discussions with a patient who is interested in such nontraditional therapies, such as vitamin therapy? Is there an effective way to balance sensitivity to their interest with communication of the hard facts about these therapies? What is your approach?








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Managing discussions of nontraditional therapies with your patients
# 1 of 1
September 6, 2009 12:18 (EDT)
Card2009

The hard realization here is that the "General Consensus" is not always based on scientific fact, and the "evidence-base" assumed to be of "value" may turn out to be false.  Likewise, some of the "non-traditional" therapies do have "evidence" and scientific merit, however the average practitioner may not have the time or knowledge base to either drill down to it, or understand it.

For example the controversy regarding homocysteine.  The popular internet medical resource "UPtoDate" reflects your opinion that treating homocysteine is not indicated based on scientific trials.  Please refer to the following review from the European Heart Journal for another perspective:

Charalambos Antoniades, Alexios S. Antonopoulos, Dimitris Tousoulis,Kyriakoula Marinou, and Christodoulos Stefanadis, Homocysteine and coronary atherosclerosis:

from folate fortification to the recent clinical trials,  European Heart Journal (2009) 30, 6–15.

 

Are there some clinical circumstances where the benefit outweighs the risks, or where the benefit is possible and the risk unlikely (perhaps except for cost of screening and cost of the supplment), is it unreasonable, particularly if the patient is willing to bear "the cost". 

It is now recognized that vitamin D is a hormone with multiple interactions in  biochemical and metabolic pathways exerting influence outside of bone metabolism, including diabetes.  Vitmain E has different formulations.  Are our conclusions about Vitamin E concerning all varieties?  The same can be said about the effects of estrogens in women.  Is the biochemical and hormonal effect  from a melange of molecules obtained from horse urine the same as the "bioidentical" hormone? Heart failure has been described as a multiple endocrine disorder, and testosterone is now being proposed to have a role as well.  These have all been included in the realm of "non-traditional" medicine.  What really is the science?

What you explain as "Naturopathic" remedies may be, and sometimes are legitimate therapies.  And some of our "evidence based therapies", are just wrong, based on poor trial design, implementation, or as has been shown, unethical conflict of interest.

Lets face it, we can't  agree on what to tell our patients  to eat (low fat, vegetarian, low glycemic, or low carb) when they are obese, dyslipidemic, or diabetic. 

Each physician has an obligation to his patient, which we all feel is an honor and privilege.  Before we criticize another practitioners "art and practice of medicine" (and this is where our patients get their information) we must examine our own first.  Sometimes by virtue of our own training and experience, our perceptions are altered, which interfere with our ability to best serve our patients.


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About Dr Seth Bilazarian
Seth Bilazarian MD has been a Clinical and Interventional Cardiologist at Pentucket Medical Associates in Massachusetts since 1993. He is board certified in Internal Medicine, Cardiovascular Medicine, Nuclear Cardiology, Vascular Ultrasound, Interventional Cardiology, and Vascular and Endovascular Medicine.

Dr Bilazarian performs coronary and peripheral interventions at Lahey Clinic and Massachusetts General Hospital. He has been an investigator in the interventional laboratory for new devices including drug-eluting stents, distal protection devices, imaging devices (OCT and InfraRed), and anticoagulant pharmacotherapy.

Dr Bilazarian is an active participant in clinical trials in congestive heart failure, hypertension, coronary disease prevention, prediabetes management, anemia, atrial fibrillation, and anticoagulation/antiplatelet therapies in the outpatient setting. He has authored numerous papers and book chapters in clinical cardiology. He was appointed as a physician advisor to the circulatory device panel of the FDA in 2008.
About this blog
My intent is to create a forum for dialogue on issues pertinent to private practice cardiology around topics such as:

  • Integration of new data and guidelines on inpatient and outpatient practice in clinical and interventional cardiology
  • Practice approaches to the extra clinical issues in dealing with managed care insurers
  • Strategies for navigating the restrictions of pharmacy benefits managers (PBMs) on pharmacologic therapies for our patients
  • Experiences with restrictions on testing and imaging
The video blog (VLOG) will provide an opportunity to share broadly different approaches to the common conundrums we face in caring for patients. My hope is that this forum will provide useful data points for practice outside of tertiary and academic centers and a look inside community hospitals and physician?s practice patterns in the office, starting with mine.