Most people don’t tell their doctor what they’re doing for their health beyond what was prescribed. The magnesium at bedtime. The probiotic a friend swore by.
Some keep quiet to protect the doctor’s feelings. They don’t want to seem like they’re second-guessing the expert. Others assume the doctor doesn’t want to hear it. In many cases, the patient is right on both counts.
When I was in practice, I told my patients that if they ever felt they had to take care of my feelings when it came to their health, they needed to find another doctor. I meant it. My job was to be their guide.
I never liked the phrase “taking care of patients.” A while back I watched a series of videos of physicians at a major New York medical center. When asked what they loved most about their work, one after another said, “I love taking care of patients.” It made me cringe. I don’t doubt their intentions. But the phrase assumes the person in the gown is helpless, and most people aren’t. I saw my role as giving people the knowledge and tools to take care of themselves.
There are obvious exceptions. Nobody should be removing their own gallbladder. Outside of situations like that, most people are capable of managing their own health, and they do better when they do. They need a guide who is willing to hear everything, including what isn’t on the prescription list.
That raises a question most patients never ask. Who guides the guide?
Doctors like to believe their opinions rest on evidence, and much of the time they do. But evidence has to be paid for, and whoever pays has a lot to say about what gets studied.
Many medical journals depend heavily on pharmaceutical money, through advertising and through reprints of favorable studies that companies buy in bulk and hand out to doctors. In 2005, Richard Smith, the former editor of the BMJ, published an essay titled “Medical Journals Are an Extension of the Marketing Arm of Pharmaceutical Companies.” Marcia Angell, who spent two decades at the New England Journal of Medicine, including as its editor-in-chief, wrote in 2009 that “it is simply no longer possible to believe much of the clinical research that is published.”
Most academic researchers don’t work for drug companies. They don’t have to. Their standing depends on publishing and on bringing grant money into their institution. Publish or perish is real. Researchers also have mortgages, kids heading to college and a department chair watching the numbers. Nobody has to be corrupt for this system to shape what we know. Money tends to flow toward what is profitable and popular, and research tends to follow it.
Look at GLP-1 drugs right now. They are useful medications, and I’m not dismissing them. But part of the reason for the steady stream of studies linking them to benefits beyond weight loss is where the money is. A cheap supplement that no company can patent may never get a large trial at all. When no one has studied something, we simply don’t know whether it works.
This is where fear enters the exam room, on both sides. A patient afraid of upsetting the doctor stays silent. A doctor can be afraid too: afraid a patient might know something he doesn’t, or afraid of looking foolish in front of colleagues for recommending something outside the guidelines.
I know that last one firsthand. When my patients were in the hospital on IV antibiotics, I had them take their own Florastor probiotic. When I mentioned this to a gastroenterologist on the case, he snickered. The antibiotics were necessary, and I never questioned that. But broad-spectrum antibiotics wipe out healthy gut bacteria along with the infection, opening the door to C. difficile, a gut infection that has been a scourge in hospitals for decades. It can be severe and sometimes deadly, especially in older patients. I thought the specialists were dismissing a cheap, simple way to lower that risk.
I didn’t have a large randomized trial. I had my patients. Not one of them got C. diff on my watch.
Since then, the research has moved in that direction. A Cochrane review updated last year found that probiotics lowered the risk of C. diff diarrhea by about 60% in people taking antibiotics. The American Gastroenterological Association suggests certain probiotics for prevention, including the yeast in Florastor. The American College of Gastroenterology recommends against them. Two major GI societies, same evidence, opposite conclusions. The question isn’t settled, and I won’t pretend it is. What I can tell you is that my patients did well.
That experience shaped how I handled what patients brought me. If someone believed a supplement helped and there was no downside, I didn’t see the point in arguing. I never argued with results. A doctor who dismisses everything outside the lines is letting the funding decide, usually without knowing it.
Your doctor should know more medicine than you do. That doesn’t mean your doctor knows more about you than you do.
At your next appointment, bring the bottles, or at least a list. Put them on the counter and tell your doctor what you’re taking and why. If you get a real conversation about risks and benefits, you’ve found a guide. If you get an eye-roll, you’ve learned something important about your doctor.
Related: The Loudest Voice in Your Head Isn’t Always Telling You the Truth
