Precious metals

In this blog post I’m going to talk about a subject that has gotten significant media attention: Dr. Oz and his dubious recommendations of supplements and fad diets. This anecdote isn’t a success story or a tragedy; it’s about the complexities of working with real patients as individuals and not as “viewers.”

First, my own recent experience in clinic.

I walked into the room and greeted a friendly, middle-aged woman (I’ll call her “Angela”) who was here for a “regular checkup.” Immediately, I saw the familiar marker of a patient who is engaged in her medical care: her prescription bottles were brought in from home and already organized on my desk.

This was my first time meeting Angela, though she had been a patient at the clinic for years. I asked her what brought her in today. She said her blood pressure had been high in the past. She had been given some medications to take. I looked at her chart and saw that her blood pressure today was 146/98, slightly elevated according to standard recommendations. However, I looked at her past blood pressures, and they had been markedly higher — up to 185/102. Over the past year-and-a-half they had been gradually trending downward.

While not “optimal,” this lower BP would drastically reduce Angela’s risk of a stroke or heart attack. Since I am a product of the modern medical milieu, I instinctively said “I guess the medications you were prescribed are working!” She calmly responded, “Oh no, I haven’t been taking them.”

She then pointed to one pill bottle in particular, an over-the-counter Zinc supplement. She said that it was recommended to lower blood pressure on the Dr. Oz show, and she had been taking that instead. Imagine my surprise as an outspoken critic of “alternative medicine.” Could the Zinc be working?

I quickly looked for another cause (we all have our biases). Reading through her chart, I found a more palatable explanation. I noticed her weight had significantly dropped over the last two years. Angela had steadily lost over 60 pounds.

I asked her about her weight loss. She had stopped eating junk food and tried to eat more home-cooked meals heavy on vegetables. She made sure she walked every day, often miles at a time. Angela said she felt better than ever, and was very happy with the way the Zinc had been working.

What was I to do? I certainly congratulated her on her weight loss, and reinforced the benefit of these reasonable lifestyle changes. I could have said “keep doing what you’re doing” and sent her home without bringing up the specter of the heavy metal. After all, Zinc isn’t as dangerous as many of the supplements being sold; but it’s not harmless. It can have toxicity associated with high doses1, and potency is not well-regulated in supplements. Anyway, I was pretty sure her weight loss and diet changes were the main cause of her improved blood pressure.

There was a more pernicious problem. Angela was very suspicious of “pharmaceutical” blood pressure treatments. There wasn’t a single reason for her suspicion. Some of it was what she heard from the media, but she had also had some negative experiences with a past physician, who she believed was dismissive of her fear about certain side effects.

But her blood pressure still wasn’t “optimal” by our standards. Angela was having great success with lifestyle changes, but as we age it can be harder to maintain low BP with just diet and exercise. In the future, Angela may need medical therapy for her hypertension. I didn’t want to implicitly reinforce a negative view of what I believe are drugs proven to significantly help people. Over time, high blood pressure is deadly and morbid; modern drugs have been shown to make it far less so.

I had the benefit of being a medical student with only a few patients to see. I had a long discussion with Angela, where we calmly exchanged ideas. We reached a compromise. I suggested that we officially “discontinue” her BP meds, since she wasn’t taking them anyway. In return, she would run a trial: stop taking the Zinc, as well, and continue checking her BP at the drug store and in the clinic. If her BP remained low, she wouldn’t need to restart the Zinc. If it went higher, she could restart the Zinc anytime she chose. I also asked her to consider the possibility of medical therapy for hypertension in the future, if needed. I promised her that there were many options and if she feared the side effects of certain drugs, then we wouldn’t prescribe those to her.

This is a complex story, far different than the one I usually seem to be telling on this website. It has less bluster about quacks and bogus medicine. But that tone is rarely therapeutic with patients. However, general bluster is certainly a lot easier than having a face-to-face conversation with an individual. Luckily, in clinic, I have the luxury of being a medical student with lots of patient time and an unmistakable naïveté.

What is it like for other medical professionals who are more time-constrained? Take the experience of Tina Schallhorn, a registered dietitian, who writes:

“As a Registered Dietitian in an outpatient setting, I usually spend, on average, an extra 15 minutes per appointment with a patient who has a question about something they are doing, which was promoted by Dr. Oz. It takes time to explain why there is no evidence behind the practice and why it can even be harmful. This is an extra 15 minutes, on average, of health care dollars spent on undoing the damage he promotes. In a country where health care is as expensive as it already is, it is ridiculous to spend our time and resources trying to fix what Dr. Oz is doing. I would say, on average, I see about 3 patients per week who are following some sort of advice from him.”

Mass media can bring out the ideologue and salesman in all of us. When you’re not looking an individual patient in the eye and dealing with his or her life story, it is easy to make exaggerated recommendations. I haven’t personally met Dr. Oz, so it can be easy to vilify him as an abstraction. We’re all vulnerable to this behind keyboards or cameras.

Healthcare providers “in the trenches” don’t have this freedom. They have a responsibility to gather information from the patient, tailor recommendations, and then explain those recommendations in a way the patient can understand and support. This is a time-consuming process that’s only made more difficult by media-savvy entertainers like Dr. Oz. He can make sweeping, unproven recommendations without taking into account the unique lives of the people who are listening to him.

1. Plum LM, Rink L, Haase H. The essential toxin: impact of zinc on human health. International journal of environmental research and public health. 2010;7(4):1342-1365.

January 8, 2015 | Benjamin Mazer