Crohn's costs
Sunday, March 30, 2008 | Permalink
I just came across an
article about a lottery in Oregon for covering
healthcare expenses. The woman mentioned in the story is $15,000 in
debt from the year's treatment of her Crohn's disease.
I've learned of a natural therapy for Crohn's disease that achieved remission in 62% of patients and improvement in 76%, much better than conventional medicine. When I initially looked into it, I thought it was expensive, with a standard first course of therapy costing in the neighborhood of $4000, but now I see that is substantially less than then conventional treatment and with much better outcomes. The treatment does seem a bit odd, but the science makes sense and it seems to work. The duration of remission is longer the younger people are, with the elderly maintaining remissions up to 2 years.
It seems like it may be helpful in other autoimmune disorders as well (asthma, MS, eczema, psoriasis, food allergies). Time will tell.
I've learned of a natural therapy for Crohn's disease that achieved remission in 62% of patients and improvement in 76%, much better than conventional medicine. When I initially looked into it, I thought it was expensive, with a standard first course of therapy costing in the neighborhood of $4000, but now I see that is substantially less than then conventional treatment and with much better outcomes. The treatment does seem a bit odd, but the science makes sense and it seems to work. The duration of remission is longer the younger people are, with the elderly maintaining remissions up to 2 years.
It seems like it may be helpful in other autoimmune disorders as well (asthma, MS, eczema, psoriasis, food allergies). Time will tell.
Announcing our nurse
practitioner!
Gaia brings a strong background in mind-body medicine to the office and has trained with the Center for Mind-Body Medicine. He has been involved in natural approaches to healing for many years in the Ann Arbor area and has worked with the University of Michigan's Complementary and Alternative Research Center.
He has been eagerly picking up Dr. Sickels' approach to medicine over the past few weeks and will often start the work-up on patients and sit in on visits, in addition seeing patients on his own.
Learn more about Gaia here.
Crashing the Airborne plane
I remember the first time I came across
Airborne at a regular grocery store. I was a little taken aback
that the box was so boldly asserting itself as a "miracle cold
buster". I figured that with that tall claim on the outside of the
box, they must have some good data to back it up or they'd be
eating their words.
Turns out they are eating their words for this advertising: they are offering refunds to people who bought it between May 2001 and November 2007 as part of a settlement for false advertising.
When I first saw Airborne, a quick look at the nutrition facts showed it had some reasonable stuff in it: a gram of vitamin C, a good bit of vitamin A, and a smattering of other nutrients and herbs. While the mix of nutrients seemed OK, I noticed that it has mineral oil (a petroleum product) as an ingredient and wasn't eager to buy it since. Later, my wife brought a tube of it home and I had a opportunity to look at the ingredients a little more closely. Besides mineral oil, it also has sucralose (the same stuff that's in Splenda), an artificial sweetener that may have some health effects. Not something I' d eagerly put in my body nor would I recommend it to others.
If they're making poor judgements about the non-nutritional ingredients in the product, why should I trust them about the nutritional ones (remembering that there is virtually no oversight of nutritional products: the FDA only looks into them if there is a complaint, and (besides being chronically underfunded) is too busy harassing (at the behest of Wyeth) compounding pharmacies for using a safe naturally occurring hormone in hormone preparations to do anything useful)? Seems like a good reason to get a refund for the tube that we've barely touched.
An interesting side note (in case I haven't made enough already) is whether this offering refunds really means anything since the tube already declares "100% Guaranteed Satisfaction", so they'd be potentially giving refunds to anyone who wants one already. Once again, the consumer gets precious little while the lawyers get a big chunk of the $23.3 million settlement.
Turns out they are eating their words for this advertising: they are offering refunds to people who bought it between May 2001 and November 2007 as part of a settlement for false advertising.
When I first saw Airborne, a quick look at the nutrition facts showed it had some reasonable stuff in it: a gram of vitamin C, a good bit of vitamin A, and a smattering of other nutrients and herbs. While the mix of nutrients seemed OK, I noticed that it has mineral oil (a petroleum product) as an ingredient and wasn't eager to buy it since. Later, my wife brought a tube of it home and I had a opportunity to look at the ingredients a little more closely. Besides mineral oil, it also has sucralose (the same stuff that's in Splenda), an artificial sweetener that may have some health effects. Not something I' d eagerly put in my body nor would I recommend it to others.
If they're making poor judgements about the non-nutritional ingredients in the product, why should I trust them about the nutritional ones (remembering that there is virtually no oversight of nutritional products: the FDA only looks into them if there is a complaint, and (besides being chronically underfunded) is too busy harassing (at the behest of Wyeth) compounding pharmacies for using a safe naturally occurring hormone in hormone preparations to do anything useful)? Seems like a good reason to get a refund for the tube that we've barely touched.
An interesting side note (in case I haven't made enough already) is whether this offering refunds really means anything since the tube already declares "100% Guaranteed Satisfaction", so they'd be potentially giving refunds to anyone who wants one already. Once again, the consumer gets precious little while the lawyers get a big chunk of the $23.3 million settlement.
Good-bye BCBS PPO
Well, that was quick. I went out to the
Southfield offices of BCBSMi PPO on Wednesday (after the big
snowstorm, so it took me nearly 2 hours to get there, but they were
gracious enough to still see me despite my being late, though I did
leave my lights on and had to push-start my car when I got back
out). Friday morning, we got the letter that said they were
upholding their decision to remove me from the PPO, effective march
21.
What does that mean for my patients with BCBSMi PPO? I will no longer be in the lowest tier of reimbursement: rather than just the regular co-pay (which varies from plan to plan), visits would be subject to the next tier up payment, which also varies from plan to plan. In general, it is often a 20-50% copay and subject to the deductible (which, of course, varies from plan to plan). So, it's time to dig out that benefits book you got when you enrolled and see what your plan will do for visits to doctors who participate in BCBS but not in the PPO.
Also, if you want to find a provider in the network, it easy enough: go to the BCBSMi website and look up your plan and see who's covered.
Other interesting things from the meeting:
The fundamental issue is that I don't fit in their business model, which groups things together by objective criteria (like doctor's specialties) and then looks for places where costs are going out of the normal range for that group. Since I'm not practicing the way the average family doc is practicing (which also happens to be the reason many people seek me out), I'm and outlier and not compatible with their plan. In a way, it acts as a gatekeeper for people in their PPO: to go to Dr. Sickels, patients would have to need to see me enough to justify their going out of the PPO network.
They did bring up the previous entries on this blog about the audit, seemed a bit miffed about them, and asked me why I posted them. As I told them, the potential for them take all that money back is a big deal for me: it can put me out of business and leave my patients out in the cold. As far as I know, I didn't sign away my right of free speech when I signed up for the PPO. I think it's important for people to know what's going on and if my office suddenly closes, I want people to know why.
I don't know what this means for MiChild. I suspect this means it will no longer cover visits and they'll have to pay to see me themselves. Too bad they can't take the thousands of dollars I've already saved them and use it for other people.
What does that mean for my patients with BCBSMi PPO? I will no longer be in the lowest tier of reimbursement: rather than just the regular co-pay (which varies from plan to plan), visits would be subject to the next tier up payment, which also varies from plan to plan. In general, it is often a 20-50% copay and subject to the deductible (which, of course, varies from plan to plan). So, it's time to dig out that benefits book you got when you enrolled and see what your plan will do for visits to doctors who participate in BCBS but not in the PPO.
Also, if you want to find a provider in the network, it easy enough: go to the BCBSMi website and look up your plan and see who's covered.
Other interesting things from the meeting:
The fundamental issue is that I don't fit in their business model, which groups things together by objective criteria (like doctor's specialties) and then looks for places where costs are going out of the normal range for that group. Since I'm not practicing the way the average family doc is practicing (which also happens to be the reason many people seek me out), I'm and outlier and not compatible with their plan. In a way, it acts as a gatekeeper for people in their PPO: to go to Dr. Sickels, patients would have to need to see me enough to justify their going out of the PPO network.
They did bring up the previous entries on this blog about the audit, seemed a bit miffed about them, and asked me why I posted them. As I told them, the potential for them take all that money back is a big deal for me: it can put me out of business and leave my patients out in the cold. As far as I know, I didn't sign away my right of free speech when I signed up for the PPO. I think it's important for people to know what's going on and if my office suddenly closes, I want people to know why.
I don't know what this means for MiChild. I suspect this means it will no longer cover visits and they'll have to pay to see me themselves. Too bad they can't take the thousands of dollars I've already saved them and use it for other people.
The joy of chart audits: and justice
for...
Today I got to experience a "chart
audit" by Blue Cross. This is where BCBS sends me a registered
letter informing me that they want to look at some of my patients'
(and their insurance holders') medical records. They go through the
records to see if my documentation of the visit justifies the
charges they got. The trick is that they send the records to their
physician reviewers and if the charges aren't justified in their
view then they reject it and want me to give them the money
back.
Assuming they'll decide that some amount of the charges aren't justified, they'll give me an opportunity to appeal, but it'll still go to some "physician reviewer" (who may get bonuses for rejecting claims, as documented by Linda Peeno MD in SiCKO) who will just re-reject them. I asked one of the people who came to collect all the records what happens if they demand all the money back and the answer is that I just get nothing: I can't bill the patients, I just spent that time for nothing.
Let's be clear: no matter how much time I actually spend with a patient and document clearly in my records and precisely, they can decide that it wasn't justified and demand the money back, regardless of how much benefit the patient got. In that circumstance, I would be better off working at McDonald's to pay my bills.
At this point, they've only asked for a few patients' records for 8/06 to 7/07. If they decide that they don't want to pay me for those visits... I'm having enough trouble paying the bills now. What's to stop them from deciding, "hey we concocted reasons to deny a bunch of claims and got a bunch of money back, let's get more!" Can they eventually go back over the the whole past year and retroactively deny those claims, too? This would mean that any payment I get from BCBS PPO would need to be held in trust for 18 months in case they decide to pull their money back.
This is a risk of taking any insurance. Medicare can be even more risky: if insurance decides I did something against their inscrutable rule-books, all they can do is demand their money back. If medicare decides something I did somehow violates their volumes of arcane tomes, I can go to jail.
So why would I be so dumb as to set myself up for these risks?
Is it that it's the only way I can get patients and get paid? No, I'm booked up for 4 months to get in to see me as a new patient. If some patients don't come because I'm not in their network, I'll still be fine.
It's because my patients will lose out. The patients who can't afford to pay out of pocket or who can't afford the higher co-pays for out-of-network will get thrown back to the 6 minutes for a prescription and get-out-of-my-office treatment that is becoming the standard of care these days.
Why did I even bother to appeal the last decision to kick me out of their PPO? For these patients who wouldn't otherwise be able to see me.
Let me tell you about one of my early patients, a young lady who have been developing upper respiratory infections so often that she was going to the ER monthly. She had gotten tot he point where she was allergic to just about every antibiotic, so there was nothing the doctors could do to help her.
Her mom brought her in to see what other options she had. We tried some IV vitamin C and it worked fantastically. I was a bit nervous about using it in someone so young, so I started with small doses, and she got a little better but it would come back. I progressed to larger doses and got the infections to clear up. It worked so well, in fact, that her grandmother told me that the only side effect of the IV vitamin C treatments was that her eczema would clear up.
Once we got the infections under control, we did some searching for the reason for her problems and found that she had several food allergies. Taking her off those foods kept her from getting sick and now she gets sick less often that the average kid. She hasn't been back to the ER since her first appointment with me, over two years ago, saving the insurance considerable money.
She is one of the patients who will lose out. She's can only see me via the SCHIP program in Michigan called MiChild that allows working people who can't afford insurance to get their kids into BCBS PPO.
However, it has become clear that if I continue to subject myself to insurers' whims, I will be forced out of business and won't be able to help anyone. My days of participating in insurance are coming to an end.
Assuming they'll decide that some amount of the charges aren't justified, they'll give me an opportunity to appeal, but it'll still go to some "physician reviewer" (who may get bonuses for rejecting claims, as documented by Linda Peeno MD in SiCKO) who will just re-reject them. I asked one of the people who came to collect all the records what happens if they demand all the money back and the answer is that I just get nothing: I can't bill the patients, I just spent that time for nothing.
Let's be clear: no matter how much time I actually spend with a patient and document clearly in my records and precisely, they can decide that it wasn't justified and demand the money back, regardless of how much benefit the patient got. In that circumstance, I would be better off working at McDonald's to pay my bills.
At this point, they've only asked for a few patients' records for 8/06 to 7/07. If they decide that they don't want to pay me for those visits... I'm having enough trouble paying the bills now. What's to stop them from deciding, "hey we concocted reasons to deny a bunch of claims and got a bunch of money back, let's get more!" Can they eventually go back over the the whole past year and retroactively deny those claims, too? This would mean that any payment I get from BCBS PPO would need to be held in trust for 18 months in case they decide to pull their money back.
This is a risk of taking any insurance. Medicare can be even more risky: if insurance decides I did something against their inscrutable rule-books, all they can do is demand their money back. If medicare decides something I did somehow violates their volumes of arcane tomes, I can go to jail.
So why would I be so dumb as to set myself up for these risks?
Is it that it's the only way I can get patients and get paid? No, I'm booked up for 4 months to get in to see me as a new patient. If some patients don't come because I'm not in their network, I'll still be fine.
It's because my patients will lose out. The patients who can't afford to pay out of pocket or who can't afford the higher co-pays for out-of-network will get thrown back to the 6 minutes for a prescription and get-out-of-my-office treatment that is becoming the standard of care these days.
Why did I even bother to appeal the last decision to kick me out of their PPO? For these patients who wouldn't otherwise be able to see me.
Let me tell you about one of my early patients, a young lady who have been developing upper respiratory infections so often that she was going to the ER monthly. She had gotten tot he point where she was allergic to just about every antibiotic, so there was nothing the doctors could do to help her.
Her mom brought her in to see what other options she had. We tried some IV vitamin C and it worked fantastically. I was a bit nervous about using it in someone so young, so I started with small doses, and she got a little better but it would come back. I progressed to larger doses and got the infections to clear up. It worked so well, in fact, that her grandmother told me that the only side effect of the IV vitamin C treatments was that her eczema would clear up.
Once we got the infections under control, we did some searching for the reason for her problems and found that she had several food allergies. Taking her off those foods kept her from getting sick and now she gets sick less often that the average kid. She hasn't been back to the ER since her first appointment with me, over two years ago, saving the insurance considerable money.
She is one of the patients who will lose out. She's can only see me via the SCHIP program in Michigan called MiChild that allows working people who can't afford insurance to get their kids into BCBS PPO.
However, it has become clear that if I continue to subject myself to insurers' whims, I will be forced out of business and won't be able to help anyone. My days of participating in insurance are coming to an end.
No change with Blue Cross yet.
It turns out the reason the two docs
wanted to come out to my office had little to do with my
association with BCBS, but was more about they're wanting to see my
electronic medical records system (EMR). Physicians have found EMRs
to be something of an double-edged sword: while they promise
considerable time savings, data accessibility and reduction of
errors, they have (in practice) turned out to be (in general)
boondoggles. Most EMRs are outrageously expensive (requiring annual
fees in addition to the startup costs, if you don't pay the annual
fee or the company goes under your patient records could get locked
out and inaccessible), slow, cumbersome, and a waste of resources.
Often written by people with little clinical experience, they often
require the physician to conform to the system's way of evaluating
patients and may even work by having the physician select choices
from a menu for each phase of an exam. There is much promise in
using EMRs, but I haven't seen it realized in practice. I know 2
offices that tried to implement eClinicalWorks in their offices and
both abandoned it quickly despite having thrown thousands of
dollars at it.
I've been using an open-source EMR that doesn't cost an arm and a leg and I'm quite content with it. I had mentioned it to the doctor at my original BCBS PPO appeal and he asked if he could come out and take a look at it. I had forgotten about that, but that seemed to be the main reason they came out.
A week ago, I got another letter from Blue Cross saying they upheld their decision after the first appeal. So, if I want to keep having them cover the >50% of my patients with their insurance I have to either continue to fie appeals or give the same level of care they could get anywhere else.
I'm appealing again, but I expect it isn't going to last and the days of BCBS PPO coverage will come to an end. The tragedy is that this may lead to a domino effect with all insurances and going to a cash (or credit-card) only practice. It turns out that many physicians who practice a little off the conventional way are cash-only, so I'm not breaking new ground, and will probably survive. I'm mostly worried about all the patients who wouldn't be able to continue to see me: after years of inadequate care, they may get thrown right back to it.
I've been using an open-source EMR that doesn't cost an arm and a leg and I'm quite content with it. I had mentioned it to the doctor at my original BCBS PPO appeal and he asked if he could come out and take a look at it. I had forgotten about that, but that seemed to be the main reason they came out.
A week ago, I got another letter from Blue Cross saying they upheld their decision after the first appeal. So, if I want to keep having them cover the >50% of my patients with their insurance I have to either continue to fie appeals or give the same level of care they could get anywhere else.
I'm appealing again, but I expect it isn't going to last and the days of BCBS PPO coverage will come to an end. The tragedy is that this may lead to a domino effect with all insurances and going to a cash (or credit-card) only practice. It turns out that many physicians who practice a little off the conventional way are cash-only, so I'm not breaking new ground, and will probably survive. I'm mostly worried about all the patients who wouldn't be able to continue to see me: after years of inadequate care, they may get thrown right back to it.
BCBS, insurance, and the question of
cost
A couple weeks ago, I had a meeting
with one of the medical directors at Blue Cross. They're coming
tomorrow to meet with me here at the office.
A little over a year ago, BCBS PPO send me a registered letter warning me that I was "overutilizing." Apparently, since I spend more time with patients than most doctors, it was setting off alarms. When they noticed this, they sent me a letter pointing out that my utilization is higher than other family docs' and gave me 6 months to bring it down into the same amount as others.
During the ensuing 6 months, I tried to have shorter visits with patients, but I found that it is impossible to look at the entire picture of a patient in a shorter period. Some uncomplicated patients don't need much time and I get them out quickly, but a good proportion of my patients are complicated enough that we have to address 5+ issues in a visit and go over the different approaches to treatment.
So, in December I got a second letter saying that over the second period, my utilization had not gone down and had actually gone up. Therefore, they were going to disenroll me from the PPO. I could appeal their decision, and I did, which let to this meeting at BCBS office.
Now, let me mention that appealing this is not as simple a decision at it might sound. When I discussed this issue with some other physicians who have been practicing CAM for longer, they universally recommended against appealing and recommended just dropping insurance altogether. Some insurances have been known to report physicians like me to the state board of medicine, which can be quite rabid in some states about doctors who don't toe the conventional line in their practice of medicine, so there is substantial risk to getting involved in this. Even though everything I do is supported by research and improves my patients, just dealing with a board investigation can take a tremendous toll not only financially, but emotionally as well.
The meeting was interesting: their issue is that they have to keep costs down so that when employers are looking to buy insurance they will be competitive and be able to stay in business. It's clear from their practice that when they keep skimming off the top utilizers they put a negative pressure on all the rest who will scramble to reduce how much service they provide to they don't end up in the top and get themselves skimmed. In this endless quest to reduce costs, at some point quality will decrease and the patient will suffer.
My contention is two fold. First, having acquired a reputation for being able to fix things other can't, I attract sicker patients than a typical doctor would get, many of whom have already made the rounds of all the regular doctors and specialists, which requires a little more time and care than a typical visit. Second, by spending the time at the beginning to get people on the right path, total expenditures go down: fewer hospitalizations, ER visits and specialists.
Unfortunately, they don't tie total expenditures (including hospitalizations and specialists) to a provider. So, a doctor could come in looking good by kicking people out of his office after 6 minutes and charging a level 3 visit (getting in 10 visits an hour) for each one and then they end up going to urgent care or the hospital because they don't feel any better or they get a side effect they weren't warned about. In this scenario, while delivering lousy care, the doctor would be bringing in five times what I am by seeing people for 40-60 minutes and charging for a level 5 visit. Meanwhile, I'm spending time educating patients and looking at the big picture, keeping them out of the hospitals, and they accuse me of overutilizing as if I'm where all their money is going.
Using their own figures, this isn't born out: my "high" utilization comes out to less than $500 per patient per year. A single visit to the ER could cost more than that! A single hospitalization would cost several times what my care costs. Their money must be going somewhere other than to primary care docs and office visits. Since the monthly cost of a BCBS PPO plan at the U of M is $466 a month, they bring in over $5,500 for each patient each year. If my costs average out to $500 on those patients and I keep them out of the hospitals and other big ticket places, they're keeping over 90% of what they bring in. They could be doing pretty well if what I'm doing works out.
To the credit of the doctor I talked to, he seemed supportive of what I am doing with patients, but wasn't sure it is economically viable as an insurance reimbursable service.
So, tomorrow they're coming to see my office and tell me their decision. I hear there will be two docs coming to see me. I appreciate that this must seem to be important to them: taking a couple hours of 2 docs' time isn't small potatoes, so someone must think this is important. My hope is that they're coming with a real interest in maximizing care for patients and not just looking for an excuse to get me shut down. We'll see what happens tomorrow.
A little over a year ago, BCBS PPO send me a registered letter warning me that I was "overutilizing." Apparently, since I spend more time with patients than most doctors, it was setting off alarms. When they noticed this, they sent me a letter pointing out that my utilization is higher than other family docs' and gave me 6 months to bring it down into the same amount as others.
During the ensuing 6 months, I tried to have shorter visits with patients, but I found that it is impossible to look at the entire picture of a patient in a shorter period. Some uncomplicated patients don't need much time and I get them out quickly, but a good proportion of my patients are complicated enough that we have to address 5+ issues in a visit and go over the different approaches to treatment.
So, in December I got a second letter saying that over the second period, my utilization had not gone down and had actually gone up. Therefore, they were going to disenroll me from the PPO. I could appeal their decision, and I did, which let to this meeting at BCBS office.
Now, let me mention that appealing this is not as simple a decision at it might sound. When I discussed this issue with some other physicians who have been practicing CAM for longer, they universally recommended against appealing and recommended just dropping insurance altogether. Some insurances have been known to report physicians like me to the state board of medicine, which can be quite rabid in some states about doctors who don't toe the conventional line in their practice of medicine, so there is substantial risk to getting involved in this. Even though everything I do is supported by research and improves my patients, just dealing with a board investigation can take a tremendous toll not only financially, but emotionally as well.
The meeting was interesting: their issue is that they have to keep costs down so that when employers are looking to buy insurance they will be competitive and be able to stay in business. It's clear from their practice that when they keep skimming off the top utilizers they put a negative pressure on all the rest who will scramble to reduce how much service they provide to they don't end up in the top and get themselves skimmed. In this endless quest to reduce costs, at some point quality will decrease and the patient will suffer.
My contention is two fold. First, having acquired a reputation for being able to fix things other can't, I attract sicker patients than a typical doctor would get, many of whom have already made the rounds of all the regular doctors and specialists, which requires a little more time and care than a typical visit. Second, by spending the time at the beginning to get people on the right path, total expenditures go down: fewer hospitalizations, ER visits and specialists.
Unfortunately, they don't tie total expenditures (including hospitalizations and specialists) to a provider. So, a doctor could come in looking good by kicking people out of his office after 6 minutes and charging a level 3 visit (getting in 10 visits an hour) for each one and then they end up going to urgent care or the hospital because they don't feel any better or they get a side effect they weren't warned about. In this scenario, while delivering lousy care, the doctor would be bringing in five times what I am by seeing people for 40-60 minutes and charging for a level 5 visit. Meanwhile, I'm spending time educating patients and looking at the big picture, keeping them out of the hospitals, and they accuse me of overutilizing as if I'm where all their money is going.
Using their own figures, this isn't born out: my "high" utilization comes out to less than $500 per patient per year. A single visit to the ER could cost more than that! A single hospitalization would cost several times what my care costs. Their money must be going somewhere other than to primary care docs and office visits. Since the monthly cost of a BCBS PPO plan at the U of M is $466 a month, they bring in over $5,500 for each patient each year. If my costs average out to $500 on those patients and I keep them out of the hospitals and other big ticket places, they're keeping over 90% of what they bring in. They could be doing pretty well if what I'm doing works out.
To the credit of the doctor I talked to, he seemed supportive of what I am doing with patients, but wasn't sure it is economically viable as an insurance reimbursable service.
So, tomorrow they're coming to see my office and tell me their decision. I hear there will be two docs coming to see me. I appreciate that this must seem to be important to them: taking a couple hours of 2 docs' time isn't small potatoes, so someone must think this is important. My hope is that they're coming with a real interest in maximizing care for patients and not just looking for an excuse to get me shut down. We'll see what happens tomorrow.
Integrative Pediatrician new in
town
I had the pleasure the other night of
having dinner with Richard Linsk MD, a pediatrician who has
recently opened an office here in Ann Arbor on south Main street.
He's focusing on the treatment of autism and ASD, and does general
pediatrics. He used to be in the University of Michigan health
system, but as he started doing more treatment of autism he invoked
the ire of the systems' autism "specialists" (who don't seem to do
much more then sedate the kids) and has had to branch out on his
own.
In talking with him that evening, I came to appreciate his tremendous honesty. Not only is he honest about his own limitations (an unusual feat in most doctors), but his honest perception of the shortcomings of conventional treatment are what drove him to expand into functional medicine and other modalities.
During dinner, I realized that he was one of the pediatricians I had rotated with in medical school (over 8 years ago). He was working out of a small building with a couple other pediatricians and I ended up spending most of my time there with him. Something about him made me think I had the most to learn from him, and in retrospect I think some of it was his willingness to seek the truth despite the pressure of being harried with a full (over) load of patients and those annoying medical students.
In addition to his regular office visits, he offers HBOT in roomy chambers (that you can rent out) and single-reagent immunizations. His website is www.integrativepediatrics.net.
In talking with him that evening, I came to appreciate his tremendous honesty. Not only is he honest about his own limitations (an unusual feat in most doctors), but his honest perception of the shortcomings of conventional treatment are what drove him to expand into functional medicine and other modalities.
During dinner, I realized that he was one of the pediatricians I had rotated with in medical school (over 8 years ago). He was working out of a small building with a couple other pediatricians and I ended up spending most of my time there with him. Something about him made me think I had the most to learn from him, and in retrospect I think some of it was his willingness to seek the truth despite the pressure of being harried with a full (over) load of patients and those annoying medical students.
In addition to his regular office visits, he offers HBOT in roomy chambers (that you can rent out) and single-reagent immunizations. His website is www.integrativepediatrics.net.
It's raining lead!
It seems like the cascade of lead in
products on our store shelves never ends: paint, toys from China,
lunch boxes, supplements from China. Now we've got another source
of lead coming from right here in this country: lipstick. Of the
name-brand lipsticks tested over half had significant levels of
lead and a third of the lipsticks had more lead than is currently
allowed to be in candy (I didn't realize they allow lead in
candy...). You can read the full report here.
So, add this to the pile of sources of lead exposure and stir it with the research that came out last year showing that lead exposure at levels way below what was considered toxic increased heart attacks. How many other things does it impact? No one's done the research.
The best thing to do is protect yourself by minimizing your exposure, taking plenty of vitamin C and consider removing what lead there is with proven chelating agents.
So, add this to the pile of sources of lead exposure and stir it with the research that came out last year showing that lead exposure at levels way below what was considered toxic increased heart attacks. How many other things does it impact? No one's done the research.
The best thing to do is protect yourself by minimizing your exposure, taking plenty of vitamin C and consider removing what lead there is with proven chelating agents.
Vitamin D (again) reduces cancer
risk
It's starting to get tedious. In
a recent article in the American Journal of Clinical
Nutrition,
Vitamin D (this time with calcium) reduces the risk of cancer (in a
group of >55 year old Nebraskans) over a 4 year period by 76%
(95% confidence interval 40-91%). At least they gave a useful
amount of vitamin D3 (1100iu/day). Interestingly, even calcium
(1500mg/day) alone showed a substantial lowering of risk, but it
wasn't significant.
Now, the important thing to appreciate is that this study was only 4 years and that your typical cancer will have been growing for several years before it is diagnosed. So, is this a reduction in the incidence of cancers (less cancers starting), slowing of growth (thus fewer showing up over the study), or stopping the cancers that had already begun? Frankly, with such a dramatic improvement, it could be all three.
Now, the important thing to appreciate is that this study was only 4 years and that your typical cancer will have been growing for several years before it is diagnosed. So, is this a reduction in the incidence of cancers (less cancers starting), slowing of growth (thus fewer showing up over the study), or stopping the cancers that had already begun? Frankly, with such a dramatic improvement, it could be all three.
Phthalates, testosterone, air
freshener, and fish
Sunday, October 07, 2007 | Permalink
What do phthalates, testosterone, air
freshener, and fish have in common? They've all been topics in
recent articles coming from the NRDC's senior scientist Gina Soloman. Nice source of information.
The first three all come form the same article: Air Fresheners - How Safe Are They? NRDC tested 14 air fresheners and found 12 contained phthalates, which are endocrine disrupters and alter hormone levels - particularly the testosterone levels in babies. Walgreens, whose air fresheners had the most phthalates, impressively responded by pulling the stuff off the shelf and reformulating it. Here's a page that lists the symptoms many perfume ingredients can cause as well as other things you can use to clean, and this page summarizes the phthalates issue and also tells you what you can do about it.
The other article discusses the conflicting recommendations that just came out about fish intake particularly for pregnant women. She correctly points out that the recommendations to eat fish should include aiming for low-mercury fish. At the end of the article she has several great links about the issues at play.
The first three all come form the same article: Air Fresheners - How Safe Are They? NRDC tested 14 air fresheners and found 12 contained phthalates, which are endocrine disrupters and alter hormone levels - particularly the testosterone levels in babies. Walgreens, whose air fresheners had the most phthalates, impressively responded by pulling the stuff off the shelf and reformulating it. Here's a page that lists the symptoms many perfume ingredients can cause as well as other things you can use to clean, and this page summarizes the phthalates issue and also tells you what you can do about it.
The other article discusses the conflicting recommendations that just came out about fish intake particularly for pregnant women. She correctly points out that the recommendations to eat fish should include aiming for low-mercury fish. At the end of the article she has several great links about the issues at play.
"Pharmacologic Treatment of
Osteopenia Not Usually Indicated"
Monday, September 17, 2007
| Permalink
A recent American Family Physician journal, citing a JAMA article, puts the lie to the idea that people
(particularly women) with osteopenia (low bone density) should be
on medications. With all the evidence that these medications (like
Fosamax or its friends) shouldn't be first-line treatments, why are
doctors still prescribing them so quickly? If your doctor pulls out
the pad for this, ask them when the last time they saw that drug
rep and whether they are pushing the doc to use it as a
preventative. This kind of behavior is occurring more and more, so
let your doctor know that it's getting so obvious and blatant that
even the patients are picking up on it. There are some movement
among conventional docs to limit their exposure to drug
reps, No Free Lunch
for practicing physicians
and Pharmfree for medical students. Sadly, the No
Free Lunch doesn't turn up any drug-rep free primary care
physicians in Ann Arbor (though it does find a pediatrician in
Ypsilanti).
Interestingly, the article points out that the only treatment that has been shown to reduce nonvertebral fracture risk in women with osteopenia is estrogen. Bioidenticals, anyone?
Interestingly, the article points out that the only treatment that has been shown to reduce nonvertebral fracture risk in women with osteopenia is estrogen. Bioidenticals, anyone?
Yield or flavor and nutrition?
Sunday, September 16, 2007
| Permalink
When I was in college, I brought my
grandmother an organic nectarine from the co-op in Champaign. She wasn't interested, saying, "I
don't like nectarines," but finally acquiesced. When she tried it,
her eyes lit up and she said she didn't like the ones in the stores
any more since they were flavorless, but this one tasted like they
did when she was a kid.
A nice report just came out that puts together the increase in yield through modern farming with the loss of flavor and nutrients that has been dogging our foods. The bottom line is that while the volume of food per acre has increased, the nutrients per acre has not seen the same increase, so the food is less nutritious. Along with the loss of nutrition comes a loss of flavor (is it because of this that people are thought to lose their sense of taste as they get older?).
There's lots of great info in the full report, but it's 36 pages plus introduction and footnotes, so let me hit a couple important points:
•At least 30% "of the U.S. population ingests inadequate levels [by their estimation of "average requirement"] of magnesium, vitamin C, vitamin E, and vitamin A". This also means "the average American consumes inadequate levels of 2.9 [of the 16 evaluated] essential nutrients each day". This is worse in women and worse with increasing age (women 19-30 years old average 3.78 deficiencies, nearly 1/4 of the nutrients studied). Specifically, vitamin E intake is inadequate in over 97% of adult women, with the average getting only half of what she needs (note that this is vitamin E from food which is more then just the alpha-tocopherol found in most supplements). [p. 8]
•By growing new, high-yield, varieties next to older varieties, they were able to demonstrate that the significant reductions in modern crops stems from the high-yield strains: between strains used in 1873 and 2000, iron dropped by 28%, zinc dropped by 34% and selenium dropped by 36%, in addition to a decrease in the quality of the protein. This means you must eat more food to get the same amounts of nutrients. [p. 14]
•This doesn't only apply to vegetables, but to other foods as well: as milk production per cow increased, the nutrient concentration decreased. [p. 18]
•The increased transit distance of or food (averaging at least 1,500 miles from farm to plate) means most food is picked green and ripened artificially, further diminishing nutrients: ripe blueberries have more than four times the anthocyanins (cancer-protective compounds) that green picked ones do, and picking apples and apricots green leaves them with no vitamin C, which is normally contained in the ripe fruits. [p. 19]
•Increasing carbon dioxide in the atmosphere also leads to further losses in nutrients. [p. 19]
•Organic foods do have higher concentrations of nutrients that conventionally grown crops. [p. 25]
Finally, they point out that due to the higher nutrient density of organic produce, it scores higher in taste than conventional produce. [p. 32]
Score one for my grandmother.
A nice report just came out that puts together the increase in yield through modern farming with the loss of flavor and nutrients that has been dogging our foods. The bottom line is that while the volume of food per acre has increased, the nutrients per acre has not seen the same increase, so the food is less nutritious. Along with the loss of nutrition comes a loss of flavor (is it because of this that people are thought to lose their sense of taste as they get older?).
There's lots of great info in the full report, but it's 36 pages plus introduction and footnotes, so let me hit a couple important points:
•At least 30% "of the U.S. population ingests inadequate levels [by their estimation of "average requirement"] of magnesium, vitamin C, vitamin E, and vitamin A". This also means "the average American consumes inadequate levels of 2.9 [of the 16 evaluated] essential nutrients each day". This is worse in women and worse with increasing age (women 19-30 years old average 3.78 deficiencies, nearly 1/4 of the nutrients studied). Specifically, vitamin E intake is inadequate in over 97% of adult women, with the average getting only half of what she needs (note that this is vitamin E from food which is more then just the alpha-tocopherol found in most supplements). [p. 8]
•By growing new, high-yield, varieties next to older varieties, they were able to demonstrate that the significant reductions in modern crops stems from the high-yield strains: between strains used in 1873 and 2000, iron dropped by 28%, zinc dropped by 34% and selenium dropped by 36%, in addition to a decrease in the quality of the protein. This means you must eat more food to get the same amounts of nutrients. [p. 14]
•This doesn't only apply to vegetables, but to other foods as well: as milk production per cow increased, the nutrient concentration decreased. [p. 18]
•The increased transit distance of or food (averaging at least 1,500 miles from farm to plate) means most food is picked green and ripened artificially, further diminishing nutrients: ripe blueberries have more than four times the anthocyanins (cancer-protective compounds) that green picked ones do, and picking apples and apricots green leaves them with no vitamin C, which is normally contained in the ripe fruits. [p. 19]
•Increasing carbon dioxide in the atmosphere also leads to further losses in nutrients. [p. 19]
•Organic foods do have higher concentrations of nutrients that conventionally grown crops. [p. 25]
Finally, they point out that due to the higher nutrient density of organic produce, it scores higher in taste than conventional produce. [p. 32]
Score one for my grandmother.
Insurance companies reject
bioidentical hormones!
I just got a note from
SaveMyMedicine.org about the latest way that insurance
companies are working to help the drug companies: by refusing to
pay for compounded hormones. You'd think they'd be smart enough to
see that by covering compounded bioidentical hormones they could be
saving themselves drastic amounts of money: Premarin or Prometrium
are about $45 a month each and testosterone gel or patches are
upwards of $200 a month, while compounded estrogen (usually a
combination of estrone, estradiol, and estriol), progesterone, or
testosterone each start at around $25 or so a month (they can go a
little higher at higher doses). Add the additional costs of higher
incidences of breast cancer in women taking Provera and they could
really be making out by supporting
bioidenticals.
Aetna's going to stop on October 1, while BCBS changed their policy back in May (note that BCBS cites an unscientific 2001 FDA study that even the FDA doesn't support).
As the note I got says: If you are an Aetna or BlueCross BlueShield customer, please contact your employer’s HR department and ask them to petition your health insurance company to reinstate coverage of bioidentical hormones and other compounded medicines. Remind them that healthy employees are productive employees and your health depends on these drugs. Your doctor has decided that compounded medicines such as bioidenticals are the best treatment option for you. Both your employer and your insurer have a responsibility to provide you with the medicines you need at a reasonable cost.
Aetna's going to stop on October 1, while BCBS changed their policy back in May (note that BCBS cites an unscientific 2001 FDA study that even the FDA doesn't support).
As the note I got says: If you are an Aetna or BlueCross BlueShield customer, please contact your employer’s HR department and ask them to petition your health insurance company to reinstate coverage of bioidentical hormones and other compounded medicines. Remind them that healthy employees are productive employees and your health depends on these drugs. Your doctor has decided that compounded medicines such as bioidenticals are the best treatment option for you. Both your employer and your insurer have a responsibility to provide you with the medicines you need at a reasonable cost.
The HBOT that just won't stop
Alright, new there's even more stuff
I've found on hyperbarics and I hate to keep it to myself.
HBOTreatment.com carries a variety of mountains of info
on the utility of HBO, including this article (in PDF format) on HBO for multiple
sclerosis. In fact, this
page is a
catalog of articles on using HBO in a variety of disorders.
The AAHA (American Association for Hyperbaric Awareness) is seeking to advance the understanding of HBOT. Their website is worth a look (just be ready for the audio "Welcome!" when the page loads). The Hyperbaric Healing Institute has a few notes on using HBO for various disorders.
The AAHA (American Association for Hyperbaric Awareness) is seeking to advance the understanding of HBOT. Their website is worth a look (just be ready for the audio "Welcome!" when the page loads). The Hyperbaric Healing Institute has a few notes on using HBO for various disorders.
Carpet in!
I finally got the new carpet installed
into the front and it looks pretty good. I was finally able (with
the help of a patient) able to track down recycled, environmentally-friendly carpet tiles from Flor and find people who knew how to install
it.
So, now the front desk is in the other room and (9 months on... hmm...) nearing completion of the remodeling.
So, now the front desk is in the other room and (9 months on... hmm...) nearing completion of the remodeling.
Even more on HBOT!
Would you believe I got an email last
night about using hyperbaric oxygen in the military for al the
brain injured veterans we're getting these days? It's from
the American Association
for Health Freedom, who are supporting the
International Hyperbaric Medical Association
in seeking funding for treatment for 400
veterans.
In the background info for the
campaign, they
include this video of a 17 year old who suffered traumatic
brain injury in a high speed motor vehicle accident. After he was
discharged from a rehab canter for for failure to improve, he
underwent 90 HBOT sessions and made remarkable improvements. An
interesting thing to note in this video is that after the first 40
treatments he only makes minimal progression, but then things start
improving more quickly.
More on Hyperbarics
Every time I read more on the utility
of hyperbaric oxygen (HBOT), I'm more annoyed that it isn't being
used more frequently to treat some of the things it's really good
at: neurovascular diseases (MS, alzheimer's, etc.), ischemic
conditions (stroke, heart attack, sickle cell exacerbations). In
addition to the article I
mentioned last november, I've come across a couple
more: a
journal article about the successes of HBOT (and the politics holding it back)
and an article
about the unrelenting attacks on a physician who is using it to
successfully treat patients, as well as an article about the American Heart Association's
demonstration that HBOT is an effective treatment for heart
attack.
In fact, here's 13 benefits to the heart from HBOT (from that last article, please see it for the references):
1. Hyperbaric oxygen therapy applied to the heart during critical loss of oxygen exerts a remarkable defibrillating effect so that tremulous, rapid, ineffectual contractions are prevented; total death of the heart muscle cells is avoided; and abnormal dilation of the blood vessels with subsequent complications is controlled.1
2. Using HBOT in conjunction with various drugs enhances the effectiveness of both the oxygen and the drugs.2,3,4,5
3. Combining HBOT with drugs completely arrests or considerably reduces angina attacks in patients otherwise resistant to prolonged drug treatment.6,7,8.9
4. Patients with cardiac pain from ischemic heart disease experience total relief, along with disappearance of dyspnea (difficulty breathing), when they receive HBOT.10,11
5. Administering HBOT lowered elevated blood cholesterol in all 220 patients cited in a study conducted by the Russian internist Dr. S.A. Borukhov and her colleagues.12
6. HBOT normalized electrocardiograms in all patients in that same Soviet study.13
7. For diminished muscular power of the heart, HBO exerts long-term normalizing effects for circulating blood through the body.14
8. HBOT exerts antiarrhythmic action on the heart.15,16,17
9. HBOT increases heart patients' tolerance to hard work and taking on physical loads.18,19
10. HBO taken at three atmospheres of pressure (a pressure rarely used in the United States) protects any individual's heart from damages due to lack of oxygen.20
11. One's entire heart conduction system functions better from receiving HBO treatment (even when prophylactically administered).21
12. Without taking drugs of any kind, breathing oxygen under pressure stabilizes impaired fat metabolism and improves liver function for someone with ischemic heart disease.22
13. Due to its characteristic of mollifying stress and distress, HBO has long-term and short-term protective effects for a person with a heart problem.23
Finally, I just came across a virtual font of articles on HBOT written by Dr. R. A. Neubauer MD, including 2 articles specifically about the etiology of multiple sclerosis and the treatment of MS with HBOT (1, 2).
In fact, here's 13 benefits to the heart from HBOT (from that last article, please see it for the references):
1. Hyperbaric oxygen therapy applied to the heart during critical loss of oxygen exerts a remarkable defibrillating effect so that tremulous, rapid, ineffectual contractions are prevented; total death of the heart muscle cells is avoided; and abnormal dilation of the blood vessels with subsequent complications is controlled.1
2. Using HBOT in conjunction with various drugs enhances the effectiveness of both the oxygen and the drugs.2,3,4,5
3. Combining HBOT with drugs completely arrests or considerably reduces angina attacks in patients otherwise resistant to prolonged drug treatment.6,7,8.9
4. Patients with cardiac pain from ischemic heart disease experience total relief, along with disappearance of dyspnea (difficulty breathing), when they receive HBOT.10,11
5. Administering HBOT lowered elevated blood cholesterol in all 220 patients cited in a study conducted by the Russian internist Dr. S.A. Borukhov and her colleagues.12
6. HBOT normalized electrocardiograms in all patients in that same Soviet study.13
7. For diminished muscular power of the heart, HBO exerts long-term normalizing effects for circulating blood through the body.14
8. HBOT exerts antiarrhythmic action on the heart.15,16,17
9. HBOT increases heart patients' tolerance to hard work and taking on physical loads.18,19
10. HBO taken at three atmospheres of pressure (a pressure rarely used in the United States) protects any individual's heart from damages due to lack of oxygen.20
11. One's entire heart conduction system functions better from receiving HBO treatment (even when prophylactically administered).21
12. Without taking drugs of any kind, breathing oxygen under pressure stabilizes impaired fat metabolism and improves liver function for someone with ischemic heart disease.22
13. Due to its characteristic of mollifying stress and distress, HBO has long-term and short-term protective effects for a person with a heart problem.23
Finally, I just came across a virtual font of articles on HBOT written by Dr. R. A. Neubauer MD, including 2 articles specifically about the etiology of multiple sclerosis and the treatment of MS with HBOT (1, 2).
Who woulda thought? Folic acid is
effective.
After the incessant drumbeat coming out
of the pharma-pumped media disparaging nutrition, a refreshing
article came out the other day: "Folic Acid May Lower Stroke Risk."
One of the key findings is
that there are greater improvements in risk in the people who took
it longer. This is, of course, obvious, since you can't expect to
starve yourself for months then have a good meal and be right back
to normal.
Of course, in order not to lose her professorship, dr. Carlsson (who is quoted in the article) has to say that it is premature to recommend a benign and inexpensive nutrient to prevent strokes in the population that shows the greatest reduction in stroke risk from folic acid supplementation (people who've never had strokes, "primary prevention").
Dr. Wang (one of the researchers) suggests that "people in the U.S. who eat healthy diets probably get enough folic acid in the foods they eat." Any guesses what fraction of the population would fall in to that category?
Of course, in order not to lose her professorship, dr. Carlsson (who is quoted in the article) has to say that it is premature to recommend a benign and inexpensive nutrient to prevent strokes in the population that shows the greatest reduction in stroke risk from folic acid supplementation (people who've never had strokes, "primary prevention").
Dr. Wang (one of the researchers) suggests that "people in the U.S. who eat healthy diets probably get enough folic acid in the foods they eat." Any guesses what fraction of the population would fall in to that category?
Most Americans obese by 2015?
Epidemiologic Reviews just came out with news that not only are an alarming number of
Americans overweight and obese now, over half the American
population will be by 2015. They're actually predicting 75% of
adults and 24% of children will be overweight or obese.
What can you do to avoid becoming one of them or to leave their ranks? Diet and exercise are simple to say, but not so simple to do. It helps to have support and that why I've started offering First Line Therapy in my office. First Line Therapy is a research based lifestyle program to improve all your risk factors for chronic diseases (including obesity, heart disease, diabetes and more).
Call the office and find out how you can join our First Line Therapy program. We are enrolling more people starting in August.
What can you do to avoid becoming one of them or to leave their ranks? Diet and exercise are simple to say, but not so simple to do. It helps to have support and that why I've started offering First Line Therapy in my office. First Line Therapy is a research based lifestyle program to improve all your risk factors for chronic diseases (including obesity, heart disease, diabetes and more).
Call the office and find out how you can join our First Line Therapy program. We are enrolling more people starting in August.
Catching up with vitamin D
A recent (June 29, 2007)
article points out that even in Hawaii, 11.1
hours/week of total body skin exposure (on average) is inadequate
to get 51% of the participants to have an adequate amount of
vitamin D (which they define as a level of 30 ng/ml, lower than I
like). As the lead author states, "This implies that the common
clinical recommendation to allow sun exposure to the hands and face
for 15 minutes may not ensure vitamin D sufficiency."
This echoes nicely what I've been telling patients for some time based on my own experience of having pale skin, walking to work and taking supplements with 400 iu of vitamin D3 daily and still having a level of only 23: "15 minutes of sun exposure to hands and face daily adequate? A lie. 400 iu daily adequate? A lie."
The article ends with a conservative recommendation of "treating vitamin D deficiency with vitamin D supplementation, "it seems prudent" to aim for a serum 25-hydroxyvitamin D concentration no greater than the maximum produced by natural UV exposure; i.e., approximately 60 ng/mL."
They don't mention that it commonly takes 2,000-4,000 iu daily of D3 to get anywhere near that level, a dose that will give doctors with no nutritional background fecal incontinence. This dose will not get anyone near the lowest toxicity level seen of 150.
So, this article adds to the stack of journal articles supporting higher levels of vitamin D, but will it catch on among conventional docs? Not unless there are vitamin D reps coming in with donuts and pens that say "Vitamin D3" on them. If we're lucky, however, I'm wrong and every doc will start checking vitamin D levels, then recommending adequate vitamin D supplementation (for pennies a day) and cut the rates of cancer and degenerative diseases by huge amounts (some estimates say 50% reduction in cancer with adequate vitamin D).
If you want to learn more about the benefits of vitamin D, the Vitamin D council (.com or .org) is a good resource.
This echoes nicely what I've been telling patients for some time based on my own experience of having pale skin, walking to work and taking supplements with 400 iu of vitamin D3 daily and still having a level of only 23: "15 minutes of sun exposure to hands and face daily adequate? A lie. 400 iu daily adequate? A lie."
The article ends with a conservative recommendation of "treating vitamin D deficiency with vitamin D supplementation, "it seems prudent" to aim for a serum 25-hydroxyvitamin D concentration no greater than the maximum produced by natural UV exposure; i.e., approximately 60 ng/mL."
They don't mention that it commonly takes 2,000-4,000 iu daily of D3 to get anywhere near that level, a dose that will give doctors with no nutritional background fecal incontinence. This dose will not get anyone near the lowest toxicity level seen of 150.
So, this article adds to the stack of journal articles supporting higher levels of vitamin D, but will it catch on among conventional docs? Not unless there are vitamin D reps coming in with donuts and pens that say "Vitamin D3" on them. If we're lucky, however, I'm wrong and every doc will start checking vitamin D levels, then recommending adequate vitamin D supplementation (for pennies a day) and cut the rates of cancer and degenerative diseases by huge amounts (some estimates say 50% reduction in cancer with adequate vitamin D).
If you want to learn more about the benefits of vitamin D, the Vitamin D council (.com or .org) is a good resource.
Challenge to mammography screening
before 50.
The American College of Physicians
noticed that all those mammograms in younger women may not be a
good idea. This article doesn't mention the downsides like
compression possibly rupturing tumor capsules or high radiation
exposure from mammograms (which increase the risk of breast cancer, particularly in
women at high risk). They did also admit that mammograms cannot prevent most
breast cancer deaths. So, the final recommendation is that women 40-49 should discuss it
with their doctors. If only more doctors knew about alternatives
like thermography.
Thermography web site up!
After a month of tinkering and slaving
away, I finally have a workable website for Ann Arbor Thermography. Please stop by http://aathermography.com and check it out. There's a
contact page there where you can tell me what you
think. I also have 2 other domain names that point to the same
place: http://a2thermography.com and http://annarborthermography.com. Use whichever is easiest for
you.
BCBS limiting prescriptions?
I got the Blue Cross "Physician Update"
the other day and noticed something alarming. In their quest to
reduce expenditures, they are trying to limit what they are
spending on prescriptions. Some of the things they are doing are
reasonable (using generics where reasonable), but one is
disturbing: "Enforcement to Exclude Off-Label Coverage", which
"Helps curb prescription drug misuse."
"Off-label use" means using a drug for something other than what the FDA approved it. Keflex (cephalexin) is an antibiotic that has an approved use (the manufacturer did studies to show a benefit for) bacterial infections. There is a common off-label use for preventing bacterial cardiac infections in people who could get them from dental procedures (it is used for this in people who are allergic to penicillin, the usual medication for this).
In addition to the incredibly common off-label prescribing all physicians do, alternative doctors are prone to use things for off-label uses that aren't so common: Omacor (fish oil) for reducing joint pain, Clomid (clomiphene) for increasing low testosterone in men, low-dose naltrexone (LDN) as an immune stimulant in all kinds of diseases (MS, pancreatic cancer, rheumatoid arthritis...), etc. Indeed, it is the innovative use of current medications that drives progress and benefits patients without increasing costs.
Now BCBS seems to be saying that they will know better then the doctor what is appropriate for the patient. Maybe they are the ones practicing medicine without a license?
If you combine this with their threatening to take me off their PPO for "over-utilizing" (spending more than the average 6-15 min appt with patients and getting thorough testing on people), they're not my favorite insurance company right now.
"Off-label use" means using a drug for something other than what the FDA approved it. Keflex (cephalexin) is an antibiotic that has an approved use (the manufacturer did studies to show a benefit for) bacterial infections. There is a common off-label use for preventing bacterial cardiac infections in people who could get them from dental procedures (it is used for this in people who are allergic to penicillin, the usual medication for this).
In addition to the incredibly common off-label prescribing all physicians do, alternative doctors are prone to use things for off-label uses that aren't so common: Omacor (fish oil) for reducing joint pain, Clomid (clomiphene) for increasing low testosterone in men, low-dose naltrexone (LDN) as an immune stimulant in all kinds of diseases (MS, pancreatic cancer, rheumatoid arthritis...), etc. Indeed, it is the innovative use of current medications that drives progress and benefits patients without increasing costs.
Now BCBS seems to be saying that they will know better then the doctor what is appropriate for the patient. Maybe they are the ones practicing medicine without a license?
If you combine this with their threatening to take me off their PPO for "over-utilizing" (spending more than the average 6-15 min appt with patients and getting thorough testing on people), they're not my favorite insurance company right now.
Thermography is here!
Last weekend we went out to pick up and
get trained on our new thermography equipment. I was floored by how
sensitive it can be. I now have all the equipment up and running,
so you can call and set up your appointments. We'll start only
doing thermography on Fridays until we need to add more days. The
number to call for thermography is 734-332-6290, which is still
answered by the same people and you'll still come to the same
office.
If you're wondering what screening thermography can do, it is a great way to do non-invasive breast cancer screening (more info here) (preferably in addition to mammography, but also for people who don't tolerate mammography or for whom mammography otherwise isn't a good idea), find the source of pain and look for other irregularities. You can learn more here (yes, it's in New Zealand, but it's a great compendium of quality information) until I get my own information pages set up.
If you're wondering what screening thermography can do, it is a great way to do non-invasive breast cancer screening (more info here) (preferably in addition to mammography, but also for people who don't tolerate mammography or for whom mammography otherwise isn't a good idea), find the source of pain and look for other irregularities. You can learn more here (yes, it's in New Zealand, but it's a great compendium of quality information) until I get my own information pages set up.
Wait times for new appointments
Monday, April 09, 2007 | Permalink
"The only ones who can claim to be above suspicion are those who are so much sought after that their cured patients are immediately replaced by fresh ones." -George Bernard Shaw, in the preface to The Doctor's Dilemma
Mr. Shaw was no fan of physicians. Would he have come to see me? Tough to say, but if the wait for a new patient appointment is anything to go by I should have satisfied his concern. The wait for new patients can be a few months, but give me a call regardless.
Drug Reps
Sunday, March 25, 2007 | Permalink
I've always been uncomfortable with
drug reps: they're only there to get doctors to sell their stuff. I
caught drug reps misrepresenting stuff in residency: not stuff they
could have done by accident. As you may expect, I'm not a big fan
of them.
I stumbled across a recent book, Confessions of an Rx Drug Pusher today and thought I'd share, especially since the posted chapter is pretty damning. Read that chapter here (I linked to the beginning of the chapter, skip all the stuff previous to it). The author is a 15-year veteran of drug sales. The story pretty much speaks for itself.
I stumbled across a recent book, Confessions of an Rx Drug Pusher today and thought I'd share, especially since the posted chapter is pretty damning. Read that chapter here (I linked to the beginning of the chapter, skip all the stuff previous to it). The author is a 15-year veteran of drug sales. The story pretty much speaks for itself.
Hormones and cardiovascular
risk
Sometimes I'm disappointed by the
journals. Circulation recently had an article on reducing women's
risk of cardiovascular risk, in which hormone replacement was
listed as class III (not useful/effective, may cause harm). A
summary of the article in Medscape breaks down the variation in
risk:
So, there is risk in the standard hormone treatment of oral estrogen and progestins (synthetic progesterone-like molecules): each raises the risk of a clot 4-fold. However, it also shows that transdermal estrogen doesn't increase the risk and may lower it and that progesterone similarly doesn't raise the risk. Using bioidentical hormones in a smart manner, then doesn't raise the risk and likely lowers it going from this article.
Sadly, they also list folic acid and antioxidants in the same class that says "may cause harm". Clearly, no one has died from antioxidants or folic acid. There has been a limited number of studies showing some increase in risk with fractionated antioxidants (beta-carotene or alpha-tocopherol alone) in certain circumstances, so it is important to get use full-spectrum antioxidants when using higher doses (mixed carotenoids with selenium or mixed tocopherols).
Sadly, newspapers often pick up these articles without any background and trumpet it as fact. It pays to read in more depth, and be cautious about people who paint all hormone replacement with the same brush: there are clear differences in risk between approaches, and this is why I do not use oral estrogen at all.
Researchers found that "route, type, and dose" of hormone therapy matters, in the Estrogen and Thromboembolism and Risk Study (ESTHER), a multicenter study conducted in 8 hospitals in France that included 271 cases and 610 controls. Compared with nonusers, oral estrogen users had an odds ratio of 4.2 (95% confidence interval [CI], 1.5 - 11.6) and 0.09 [this is probably a typo and the risk should be 0.9] (95% CI, 0.4 - 2.3) for transdermal estrogen. Norpregnane derivatives were linked to a 4-fold increase in venous thromboembolism; but there was no risk for venous thromboembolism with micronized progesterone and pregnane derivatives in the study.
So, there is risk in the standard hormone treatment of oral estrogen and progestins (synthetic progesterone-like molecules): each raises the risk of a clot 4-fold. However, it also shows that transdermal estrogen doesn't increase the risk and may lower it and that progesterone similarly doesn't raise the risk. Using bioidentical hormones in a smart manner, then doesn't raise the risk and likely lowers it going from this article.
Sadly, they also list folic acid and antioxidants in the same class that says "may cause harm". Clearly, no one has died from antioxidants or folic acid. There has been a limited number of studies showing some increase in risk with fractionated antioxidants (beta-carotene or alpha-tocopherol alone) in certain circumstances, so it is important to get use full-spectrum antioxidants when using higher doses (mixed carotenoids with selenium or mixed tocopherols).
Sadly, newspapers often pick up these articles without any background and trumpet it as fact. It pays to read in more depth, and be cautious about people who paint all hormone replacement with the same brush: there are clear differences in risk between approaches, and this is why I do not use oral estrogen at all.
Wrong about echinacea
It looks like I was wrong about
echinacea. I had been saying that it is an effective anti-viral and
immune-stimulatory herb hat should only be used for 2 weeks at a
time. Now, after reading some more definitive research, I see that it is not only OK to take
echinacea on a continual basis, but it actually is beneficial to
take it this way. Therefore, my old adage that any company that
puts echinacea into a daily vitamin doesn't know what they're doing
and should be regarded with suspicion is wrong. This is a perfectly
reasonable thing to include in a multivitamin, and (as demonstrated
in the article on echinacea) may well extend life-spans. The
research on mice showed a increase in survival in mice at any age,
increasing with the age of the mice.
However, this doesn't mean that any old kind of echinacea will do the trick: other research shows that it is the alkylamides that are responsible for the anti-inflammatory effects and the polysaccharides and glycoproteins are responsible for the immune-stimulating effects, while the echinacosides and other things that OTC echinacea products are typically standardized for don't seem to have much activity, though the phenolic compounds do seem to help keep the alkylamides from degrading. Also, the dried plant materials lose potency quickly, so good echinacea doesn't come in a powder (unless you take massive amounts).
Also, I finally found the answer for which part of the echinacea (E. Augustifolia seems like the best, and E. Purpurea may be close, but E. Palladia isn't very good) to use when:
Roots harvested in the fall have the anti-inflammatory effects that are good for colds (typically the body will have already eliminated the virus before you start showing symptoms, so the inflammation is just part of the mopping-up process and there is no role for antibiotics at this point especially since colds are caused by a virus which wouldn't be affected by antibiotics even if they were still present despite your doctor having given you antibiotics in the past for a cold - this is an example of bad medicine from listening to too many drug reps and not reading any research or even just about any current literature on treatment of the common cold, but forgive my digression).
When the flowers are in early maturity, the aerial parts contain the immune-strengthening compounds that are good for keeping infections from starting in the first place.
So, I apologize to all the companies I had maligned for putting echinacea in their multivitamins (though they'd better check to see they're putting the right things in there) and especially to everyone who had heard my talks and also had it stuck in their heads the wrong way. It is for them that I am putting this in plain text so we call all get it straight once and for all.
However, this doesn't mean that any old kind of echinacea will do the trick: other research shows that it is the alkylamides that are responsible for the anti-inflammatory effects and the polysaccharides and glycoproteins are responsible for the immune-stimulating effects, while the echinacosides and other things that OTC echinacea products are typically standardized for don't seem to have much activity, though the phenolic compounds do seem to help keep the alkylamides from degrading. Also, the dried plant materials lose potency quickly, so good echinacea doesn't come in a powder (unless you take massive amounts).
Also, I finally found the answer for which part of the echinacea (E. Augustifolia seems like the best, and E. Purpurea may be close, but E. Palladia isn't very good) to use when:
Roots harvested in the fall have the anti-inflammatory effects that are good for colds (typically the body will have already eliminated the virus before you start showing symptoms, so the inflammation is just part of the mopping-up process and there is no role for antibiotics at this point especially since colds are caused by a virus which wouldn't be affected by antibiotics even if they were still present despite your doctor having given you antibiotics in the past for a cold - this is an example of bad medicine from listening to too many drug reps and not reading any research or even just about any current literature on treatment of the common cold, but forgive my digression).
When the flowers are in early maturity, the aerial parts contain the immune-strengthening compounds that are good for keeping infections from starting in the first place.
So, I apologize to all the companies I had maligned for putting echinacea in their multivitamins (though they'd better check to see they're putting the right things in there) and especially to everyone who had heard my talks and also had it stuck in their heads the wrong way. It is for them that I am putting this in plain text so we call all get it straight once and for all.
The future of the back
What will the construction bring?
Four new rooms in the back, a lab, a lounge for patients getting IVs, more windows and ventilation, eco- and allergy-friendly flooring, breathing room for everyone.
We'll see what we can do with the four rooms once we see how much it all costs. At a minimum, the IV Prep will return to the back in a real room with a sink and counter, storage will go to the back, and eventually my office will move back one room and the front desk will move into the front room, leaving more room for a family to sit in the front. The hyperbaric chamber may end up with its own room, too.
Some of the color choices are tricky when the place isn't built yet, but I hope they'll work out.
Four new rooms in the back, a lab, a lounge for patients getting IVs, more windows and ventilation, eco- and allergy-friendly flooring, breathing room for everyone.
We'll see what we can do with the four rooms once we see how much it all costs. At a minimum, the IV Prep will return to the back in a real room with a sink and counter, storage will go to the back, and eventually my office will move back one room and the front desk will move into the front room, leaving more room for a family to sit in the front. The hyperbaric chamber may end up with its own room, too.
Some of the color choices are tricky when the place isn't built yet, but I hope they'll work out.
Construction begins, Dr. Alspector
moves
Construction on the back of my office
has begun. We spent last week cleaning out the back of the office
and moving it into the second room, so the back will become
respectable space for our office.
In order to pack up this room, Dr. Alspector (who used to occupy it) has moved across the parking lot (to 190 Little Lake drive #5), and has graciously let us house our hyperbaric chamber over there until we have space for it once again. It is still usable, so call for an appointment.
During visits at our office, you may hear sounds of the construction in the back, but don't worry, they're not about to drill through the wall during your visit (though it may sound like it).
In order to pack up this room, Dr. Alspector (who used to occupy it) has moved across the parking lot (to 190 Little Lake drive #5), and has graciously let us house our hyperbaric chamber over there until we have space for it once again. It is still usable, so call for an appointment.
During visits at our office, you may hear sounds of the construction in the back, but don't worry, they're not about to drill through the wall during your visit (though it may sound like it).
Directions fixed
Thanks to an alert reader, I discovered
that Mapquest's map for my location places me up the road
and across the street from where I really am, so I removed it from
the directions page so no one else gets wrong directions. I also
noticed and cleaned up some links to extinct pages in the
directions page
Hyperbaric Oxygen and the "noncovered
conditions"
Hyperbaric Oxygen Therapy (HBOT) is
quite useful for a number of conditions, though the medicare laws
have a curious and unusual statement about HBOT: a non-covered
conditions list. Most therapies' entries in the medicare laws don't
even list covered conditions, so why does this specifically name 22
conditions as being "non-covered"? This is especially interesting
because the 22 conditions are all clearly effectively treated by
HBOT.
The last issue of Hyperbaric Medicine Today has an interesting article about how this happened. You can go read it yourself at http://www.hbomedtoday.com/PDF/HBOMT_8.pdf The article starts on page 7, you'll have to scroll down to it in the acrobat file yourself. Interesting reading.
If you'd like to read some information about HBOT by physicians who use it, try here. You can read a (relatively) short bibliography of research on HBOT here.
Here is the medicaid list of noncovered conditions:
1. Cutaneous, decubitus, and stasis ulcers
2. Chronic peripheral vascular insufficiency
3. Anaerobic septicemia and infection other than clostridial
4. Skin burns (thermal)
5. Senility
6. Myocardial infarction
7. Cardiogenic shock
8. Sickle cell anemia
9. Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency
10. Acute or chronic cerebral vascular insufficiency
11. Hepatic necrosis
12. Aerobic septicemia
13. Nonvascular causes of chronic brain syndrome (Pick's disease, Alzheimer's disease, Korsakoff's disease)
14. Tetanus
15. Systemic aerobic infection
16. Organ transplantation.
17. Organ storage.
18. Pulmonary emphysema
19. Exceptional blood loss anemia
20. Multiple Sclerosis
21. Arthritic Diseases
22. Acute cerebral edema
As the author of the "noncovered conditions" list points out, there is no law against using HBOT for these conditions, they are merely off-label uses for HBOT. There are also articles about using HBOT for migraine and Lyme disease (which medicare presumably won't cover either, nor, by extension, would insurance companies). And since I have a special interest in MS, I dug up this page which is the beginning of a discussion on HBOT for MS.
Why do I take this interest in HBOT? I managed to get my hands on a modest chamber and have been looking into using it therapeutically.
The last issue of Hyperbaric Medicine Today has an interesting article about how this happened. You can go read it yourself at http://www.hbomedtoday.com/PDF/HBOMT_8.pdf The article starts on page 7, you'll have to scroll down to it in the acrobat file yourself. Interesting reading.
If you'd like to read some information about HBOT by physicians who use it, try here. You can read a (relatively) short bibliography of research on HBOT here.
Here is the medicaid list of noncovered conditions:
1. Cutaneous, decubitus, and stasis ulcers
2. Chronic peripheral vascular insufficiency
3. Anaerobic septicemia and infection other than clostridial
4. Skin burns (thermal)
5. Senility
6. Myocardial infarction
7. Cardiogenic shock
8. Sickle cell anemia
9. Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency
10. Acute or chronic cerebral vascular insufficiency
11. Hepatic necrosis
12. Aerobic septicemia
13. Nonvascular causes of chronic brain syndrome (Pick's disease, Alzheimer's disease, Korsakoff's disease)
14. Tetanus
15. Systemic aerobic infection
16. Organ transplantation.
17. Organ storage.
18. Pulmonary emphysema
19. Exceptional blood loss anemia
20. Multiple Sclerosis
21. Arthritic Diseases
22. Acute cerebral edema
As the author of the "noncovered conditions" list points out, there is no law against using HBOT for these conditions, they are merely off-label uses for HBOT. There are also articles about using HBOT for migraine and Lyme disease (which medicare presumably won't cover either, nor, by extension, would insurance companies). And since I have a special interest in MS, I dug up this page which is the beginning of a discussion on HBOT for MS.
Why do I take this interest in HBOT? I managed to get my hands on a modest chamber and have been looking into using it therapeutically.
Bad reporting on flawed studies
Thorne Research came out with
an
editorial that
nicely summarizes the problems with some of the recent, well
publicized, studies that can be construed to show that supplements
are ineffective. However, looking at the actual studies clearly
shows they do work. For the full story, read the
article.
Perchlorate/thyroid and
lead/circulation connections
Nice articles further substantiating
the environmental connections to thyroid and heart disease/stroke
came out recently. I added the links in the "useful health
resources" section of the Links page.
New links
While writing an email on a list for
med students I came across some interesting links that I added to
the Links page.
Updated framework
I just updated the program this is
designed on, which meant I had to also update the theme I modified
for it. With any luck, this all went off without a hitch and I can
get back to getting other things done (like updating this more
frequently and paying the bills).
If you find any technical problems, please let me know.
If you find any technical problems, please let me know.
Fall workshops up
I've put up the info on the fall
workshops. There's starting to be some reruns, but that's a good
thing: less whipping together a brand-new presentation at the last
minute and just some fixing-up for new information. Check 'em out
on the Upcoming Events
page.
Adding pages and links
I'm adding a page of
links (at the bottom of the sidebar),
including to some great resources for health freedom. Please take
some time to read the information and support these places that are
working to allow us to maintain our health.
I've also started using a fun little extension to make the information on some pages more manageable, so check out the Upcoming Events and Links pages.
I've also started using a fun little extension to make the information on some pages more manageable, so check out the Upcoming Events and Links pages.
Fixed bug in Internet Explorer 6
rendering
I've finally fixed the problem that was
making the website look terrible in IE6. Without an easy way to get
my hands on IE6, it was a little tricky, but Dr. Alspector let me borrow her computer for an
evening. So, with that fixed, I've removed the extra links on the
bottom of the page and all should be well. Please let me know if there are any further problems. Of
course, if you can't use the links, you can't get to this page, so
it's a bit moot.
Hmmm... now IE 5.2 is making it look a little funny. Everything works, however. Since almost no one uses IE 5.2 anymore, I'll spend my time on more pressing issues.
Hmmm... now IE 5.2 is making it look a little funny. Everything works, however. Since almost no one uses IE 5.2 anymore, I'll spend my time on more pressing issues.
On the cover of Crazy Wisdom
Journal
Three local holistic doctors and I are
on the cover of the Crazy Wisdom Journal that came out last month
(May-August 2006, #33). The article is called, "Interviews with the
Next Generation of Holistic Physicians," but it isn't available
online. You can see the cover picture at the
Crazy Wisdom Journal's front page. There should still be copies of the
journal at Crazy Wisdom, but I've run out long ago at my
office.
-update- I found the article online, but who knows how long it will remain. Get at here: http://www.crazywisdom.net/interviewpdf/holisticdocs.pdf
-update- I found the article online, but who knows how long it will remain. Get at here: http://www.crazywisdom.net/interviewpdf/holisticdocs.pdf
ACAM Convention this weekend
This weekend is the ACAM convention, so the office will be closed thursday
and friday (May 4-5) and I may not be able to return any messages
until monday. The good news is that I'll come back chock-full of
new therapies to help everyone! I'm attending a workshop on IV
therapies so we may eventually get to the point of being able to
give good doses of vitamin C when needed.
Front Desk Staff
I've hired two great people to staff
the front desk. They're answering the phones and calling back all
the messages people have left for me.
So, you should be able to get a live person most of the time when you call, and if not a call back within a day. They've called back most of the old messages (except for things I specifically need to deal with), so if you haven't gotten a call back it must have gotten lost in the transition so give us another call.
I've also set up some more talks for the Summer, so check the events page for the updated listings.
Finally, with my being in the office 5 days a week now, I have appointments available in a much closer time frame, so no more month-long waits for new patients (at this point).
So, you should be able to get a live person most of the time when you call, and if not a call back within a day. They've called back most of the old messages (except for things I specifically need to deal with), so if you haven't gotten a call back it must have gotten lost in the transition so give us another call.
I've also set up some more talks for the Summer, so check the events page for the updated listings.
Finally, with my being in the office 5 days a week now, I have appointments available in a much closer time frame, so no more month-long waits for new patients (at this point).
Lots of changes
I've been making lots of changes
recently: I'm changing the website (should look similar, but makes
it much easier to keep up), my office (the closet is no more), and
my work (I have been going up to Flint twice a week to help out at
a clinic up there, but I've gotten too busy to continue doing that,
and will cut that back starting in April).
The goal of all this is to improve the care I'm giving patients:
An easier website makes it more likely to be up to date.
A more open office is nicer and makes room for a reception station. The reception station means I'll be hiring some help to take some of the work off my shoulders (I can't answer the phone while I'm seeing patients, but if I'm booked solid the whole day, I get no time to check messages or schedule new patients, leading to absurdly long waits for people to get calls back).
Less time in Flint means more time at my office, so I'll finally have some openings to schedule the new patients who have been leaving me messages (I've been getting them, but haven't had openings to put new patients in).
Things are still hectic, but should be settling down soon (at least in geological time).
So, the take home message is that is you've tried to contact me and haven't gotten a response, I'm working on it and haven't forgotten you. Do realize, however, that I'm currently booking for a month from now.
The goal of all this is to improve the care I'm giving patients:
An easier website makes it more likely to be up to date.
A more open office is nicer and makes room for a reception station. The reception station means I'll be hiring some help to take some of the work off my shoulders (I can't answer the phone while I'm seeing patients, but if I'm booked solid the whole day, I get no time to check messages or schedule new patients, leading to absurdly long waits for people to get calls back).
Less time in Flint means more time at my office, so I'll finally have some openings to schedule the new patients who have been leaving me messages (I've been getting them, but haven't had openings to put new patients in).
Things are still hectic, but should be settling down soon (at least in geological time).
So, the take home message is that is you've tried to contact me and haven't gotten a response, I'm working on it and haven't forgotten you. Do realize, however, that I'm currently booking for a month from now.
