What's the deal with the flu shot recommendations?

The flu season is approaching and people are starting to ask about getting the flu shot. The CDC recommendations came out a couple months ago and claimed that there are 36,000 deaths annually from the flu so everyone should get flu shots. I’ve become a bit skeptical of these recommendations.
Do you remember back in 2004 when one of the factories (Chiron) that made flu shots
had a problem and had to junk its entire output for the year? At that point, there was only enough demand to justify 2 companies making the entire amount for the whole country. One factory can't meet its amount for the year and then suddenly there's not enough and all the "health authorities" go into a tizzy about the lack of flu shots. Fewer people got vaccinated and nothing much in reality changed: no bump in flu deaths or anything.
Now, in order to reduce the risk of this happening again, we need to have more places making it, but in order to get that to happen, there has to be more demand. How do you do that? Expand the criteria for who needs one and then stir up the fear about flu so the people are frothing at the mouth to get a shot. So, rather than shot recommendations based on valid health concerns, the recommendation becomes based on economic concerns.
Frankly, the original recommendations for flu vaccine are the only ones that are supportable: for people for whom a flu would be enough to push them over the edge (frail, nursing homes, etc.) and the people who care for them. Everyone else was gravy for the vaccine makers. Expanding the definition of who needs it to "chronic disease" and huge swaths of ages covers a much bigger chunk of the population and ensures enough of a demand to justify more manufacturers.
As far as the recommendation for children and pregnant women, it's unconscionable to inflict further vaccines onto an already overburdened childhood vaccine schedule when the justification is ensuring a demand for flu shots. Even worse is giving thimerasol-containing vaccine to pregnant women: the developing fetal brain is particularly vulnerable to the ethyl mercury in the vaccine.
Even for the targeted population, the shot is of questionable utility. The virus that the flu shot protects against covers only a small proportion of the things people get sick with and call "the flu", and the match between the vaccinations and the strains that go around every year aren't very good: after the season is over they invariably say "well, it was only a partial match for what actually went around." One study demonstrated that the vaccine only reduced the severity of the flu but slightly increased the incidence of it in the people who got the vaccine.
This article summarizes the data on the effectiveness of the vaccine in adults as only 30% effective in preventing flu-like illness and didn’t affect the hospitalization rate overall nor the amount of time off work. In the elderly (65 and over), this article shows that in the community (most people who would be reading this, as opposed to institutionalized in a nursing home or hospital) the flu vaccine is not significantly effective against the flu, flu-like illness, or pneumonia. However, for people who are institutionalized, there does seem to be a clear benefit.
Now, I know people still like to reduce their risks of getting something that may knock them out for a week or so, so for a couple years I tried to get the vaccine, but I wasn't willing to put mercury into people's bodies to do it. To that end I tried to pre-order "preservative-free" vaccine for the upcoming flu season (buying flu vaccine is like getting rock concert tickets: the sales open and everyone rushes to snatch stuff up), but every time all the preservative-free stock was snatched up leaving only the exact same stuff with thimerasol in it left available (and this is before the stuff has even been made: why can't they just change the supply to meet the demand?). The first year I discovered that at the end of the season there was some preservative-free stuff left over, which I got and made available. I haven't been able to get it since, so I gave up.
So if you are determined to get the vaccination, I would try to get the preservative-free stuff (which Kroger claimed to have last winter). Otherwise, being sure you have enough vitamin D (check a 25-OH vitamin D level and get it well into the normal range, I like to get it to 50 ng/dl or more) and take vit C at least daily.
Am I recommending not to get the vaccine? No, I'm just trying to add some perspective so people can make their own decisions. For most people it isn't a matter of life and death and it comes down to if it will make your life easier. Read the fourth paragraph before this one (especially the last sentence) and make your decision.

If you want some perspective of the risk of death from influenza, it's a little obfuscated by combining it with deaths from pneumonia (which is much deadlier in general than influenza) in the data available from the CDC for 2002
here, but let's do the best we can. Incidentally, this report gives the total number of flu/pneumonia deaths for 2002 as 65,681, so I have to say I'm skeptical of the number of influenza deaths given in the CDC/MMWR report (35,000) and, indeed, looking at the references it cites, it appears the authors misread the article and used the number for chronic disease-related deaths rather than the influenza-related deaths which is less than 1/3 of the number: 8,097. This, then, implies that less than 1/4 (actually only 12.3%) of the flu/pneumonia deaths are actually from the flu, so we'll use this number.
So, in the age 1-4 group (for which universal annual flu vaccination is recommended) the combination for flu and pneumonia accounted for 110 deaths in 2004, while the US population aged 1-4 was nearly 16 million. Thus, assuming _all_ the deaths were from flu, there would be ~150,000 children vaccinated to prevent one death (assuming that vaccinations would be 100% effective in preventing death from the flu, which is unlikely considering the matches generally are 50% or less). Far more likely, less than 25% of the kids' deaths were from the flu and it is less than 50% effective in preventing death from the flu, so we're looking at over 1,200,000 1-4 year olds vaccinated to prevent a single death. To break it down to purely economic terms, that's over $20 million to prevent one death, not a good use of funds when there are more cost-effective ways to prevent deaths for children aged 1-4. Then, consider the incidence of side-effects of the vaccinations: is the incidence less than 1 in 1,200,000? The vaccine adverse event reporting system is designed to minimize the reporting of these events as being vaccine related, and with the data available
here we can calculate that with 62 million flu doses distributed and 1400 adverse events, there's about 1 adverse event per 45,000 doses. This means that in order to save that 1 life we have to tolerate 27 adverse events on the way. Yes, most adverse events aren't life threatening, but (overall for all vaccines since the data isn't broken down by vaccine) 15.8% were in 2001, so we're looking at 4 additional hospitalizations or deaths on the way to maybe preventing one death. Even this article demonstrated that there is “little evidence” of benefit of vaccination in children under 2.
For the next recommended universal vaccination group >50, some segments have vanishingly small amounts of flu deaths: it's not in the top 10 causes of death for 55-64 y.o. americans and not in the 45-54s either, so we can safely assume that it's a minor risk (<0.4% of deaths) for the entire 50-64 age range. There's 45 million people who won't significantly impact their risk of death with a flu shot.
FInally, we're getting to the age range who shows some risk: 65 and older. 3.2% of deaths (59,000) are in the flu/pneumonia category, so a drastically smaller amount of over 65s, perhaps 15,000 died of flu in 2002. But remember that when you die, you have to die of something, so in some of these cases, flu was merely the last straw. So, with a population of 35.5 million over 65s in 2002, there's less than 1 in 2000 dying of the flu, and with the vaccine being less than 50% effective that's over 4000 vaccines (>$80,000) to prevent 1 death.
However, 4000 vaccines to prevent 1 death isn't that bad, but realizing that the flu is much more likely to kill someone who is already on the edge (among over 65s, those 85 and older were 16 times more likely to die of influenza, says
JAMA), it would be much easier and more cost effective to target those people and vaccinate them and their caregivers. Which brings us back to the original recommendation for the vaccine: those likely to die from catching the flu and the people who take care of them.
So, why all the recommendations for more vaccinations? 16 million 1-4 year olds and 45 million 50-64s means the they are recommending 60 million vaccinations that aren't remotely supported by the data. It's got to be to ensure an adequate market for the vaccine. Either that or someone's making a good profit off it.

Tempus fugit: BHRT Summit 2 and Pain Release book bonuses

Two interesting opportunities to Learn Useful Things About Health (something I quite enjoy doing and highly recommend) are coming in the next couple days: an opportunity to get a pile of free stuff just for buying what should be a good book (provided you do it on November 8 at Barnes & Noble), and the second BHRT World summit.

Dr. Dan Benor, MD, (a doc I’ve been familiar with for a few years and who seems to know what he’s doing) has a book out about a simple and rapid method of releasing both physical and emotional pain,
7 Minutes to Natural Pain Release. The urgent part is that if you buy the book at Barnes & Noble on November 8, 2008, you can then use the receipt to get a pile of free bonuses: interviews with the author, audio seminars and classes on a variety of health topics, and a pile of e-books (including “Caring, Housing and Health of Your Dog”, which is what tipped me into deciding to get it on Saturday). The book is only $18, though if you decide to forego the bonuses or miss November 8th you can get it as an e-book for only $10. You can follow the link or click on the picture to see the bonuses.
image

The other upcoming opportunity is the second
BHRT World Summit, starting November 10 and continuing through November 25 with interviews with 10 health experts about bio-idential hormones and other therapies. The interviews are aimed at the general public to educate you about some more holistic approaches to improving our health. There are 3 options for taking part: $29 to get the interviews on the days they are broadcast only, $49 to listen to them whenever you want, or $120 to listen anytime and get a transcript of all the interviews and downloadable files of all the talks so you can listen away from your computer. I got the complete package last time and, while there were a couple small points where I disagreed with the doctors, was glad I got it and even I learned a lot from the talks. You could learn a lot, too. Follow the link or click on the banner to sign up. There’s a few bonuses with this, too, so check it out.
BHRT2

Sample treatment outline

When I had a layover thursday on the way to the ACAM convention, I ran into a woman who’s had multiple medical issues and was walking around with a backpack full of medications. She’s been going to a variety of specialists and overall her problems have been dealt with using a variety of medications. As we got to talking, she shared some of her diagnoses with me and I mentioned some other avenues she may want to investigate.
Now, I will probably never see her again, but she stayed on my mind as she’s a complex medical case. With the variety of problems, most doctors get frustrated and throw up their arms in frustration or try the couple therapies they have at their disposal then reject the patient if they don’t work. This doesn’t help the patient.
So, perhaps she will have a chance to read this and be able to take advantage of some of these therapies (I’m only including the diagnoses and avoiding any personal details so she’ll be the only one who can identify herself from this information). For everyone else, you’ll get a chance to see the approach that I take.
Her problem list includes (I wasn’t taking notes, so this relies on my memory and may have some errors): thyroid cancer in the past (eventually had entire thyroid removed) but doing well until last winter when she had sudden onset of attacks or episodes of (I don’t remember the details) fatigue and palpitations. Since then she has been diagnosed with multiple sclerosis (can only tolerate one MS drug), bone loss, massive iron deficiency anemia, massive vitamin D deficiency (I think she said she needed 60,000iu weekly just to bring her to perceptible levels, Ehlers-Dahnlos (not type 4), autonomic dysfunction, mast cell instability, hypoglycemia, orthostatic hypotension, some muscle/tendon shortening from limited use, and probably a few other things. She has tried an elimination diet in the past, eating nearly exclusively chicken and rice and felt weaker and lost weight during that time.

In terms of going after some of her current diagnoses directly, here are some things that she could try (you’ll notice some things come up more than once):
History of thyroid cancer and now completely without a thyroid: with her other problems, she may not be converting T4 (in synthroid, what is usually prescribed) to T3 (the active thyroid hormone), sometimes lab tests can help but sometimes you just have to do a trial of the different forms (Armour thyroid, cytomel, or compounded thyroid hormones) and see where the patient feels the best.
For her MS: Estriol (one of the estrogens, this is the weakest estrogen and least inflammatory) ~6 mg daily (this is the estrogen that is most elevated in pregnancy which is one time women with MS have fewer symptoms, a trial of estriol showed reduced white matter lesions in women with MS on estriol) applied transmucosally (this avoids the first pass liver metabolism that gives more metabolites from taking pills); vitamin D, enough to get her blood levels up to 60 ng/ml (plenty of data showing a connection between low vitamin D and MS); low dose naltrexone 3-4.5 mg before bed (learn more about it from
this website); it’d be good to check her stomach acid production as it’s typically low in people with MS (I had a patient the other day who took nearly 2 hours to reacidify her stomach, normal should be under a half hour, so this means food isn’t getting digested).
Bone loss: she’s already taking calcium and magnesium, but extra magnesium may be warranted and the form of calcium certainly matters in someone who’s likely low in stomach acid (and another reason to check her stomach acid); enough vitamin D is essential for calcium metabolism so we’ll make sure she’s over 60 ng/ml;
estrogen can help keep her bones strong and we already have another indication for using estriol and progesterone can help to encourage growth of the bones while testosterone (bringing back up to normal levels only) is also important for keeping bones strong; weight bearing exercise; maybe some additional supplements to support her bones.
Iron deficiency anemia: she can’t tolerate regular iron (ferrous sulfate), so while some IV iron may get her levels up right away, she should take a more gentle iron like bis-glycinate or some other chelated iron and take it with vitamin C to increase absorption; also, resistant iron deficiency anemia is a red flag for gluten intolerance or helicobacter pylori infection, so those need to be ruled out.
Ehlers-dahnlos: this is a connective tissue disorder that is typically genetic, so without knowing what the genes in her situation are coding for (they code for enzymes and other proteins so knowing where the defect it you can sometimes get around it) I would at least recommend a decent amount of vitamin C since it is essential for collagen formation and making strong tissues.
Mast cell instability: quercetin is a bioflavanoid that stabilizes mast cells and may be more effective than the cromolyn that she’s taking now (see
this book).
Orthostatic hypotension: licorice can help retain sodium and may help her get her blood pressure up, though she may well have adrenal problems so a thorough evaluation of them would be warranted.
Autonomic dysfunction: once again, adrenal problems here, too, though this is a shoe-in for the environmental illness work-up below.
Hypoglycemia: small frequent meals is the mainstay of treatment here, but using more protein and fat can stabilize things a bit; sometimes food allergies can be an issue here.

More global solutions (we’re trying to find the root cause so she doesn’t need to be taking all this stuff) since when someone has all these problems there’s often something behind it:
More thorough allergy evaluation and repair of the gut may be warranted, perhaps she’s allergic to chicken and that’s whey she did so poorly.
Heavy metal testing: sometimes heavy metals can trigger all these weird symptoms, and remember that chicken is often loaded with arsenic.
Environmental illness: toxic mold (were there some water leakage problems in her house?) or some other environmental stressor can lead to this seemingly hopeless array of problems, so a work-up by
someone who knows about environmental medicine is warranted.
Yeast: sometimes candida can become systemic and cause lots of weird symptoms, but I don’t recall her having much of an antibiotic history so it depends on the history and presentation.
Other infectious cause: lyme disease can sometimes cause a host of strange problems, and conventional testing isn’t fantastic, so even a trial of therapy could be warranted.

So, perhaps this short list of possible approaches just off the top of my head (I’m away at a conference on integrative treatment of cancer right now so don’t have access to my references) will be helpful for people to understand how I approach things and perhaps they will help this person if she happens upon my website.

Featured on Fox 2 news

I was featured in the Fox 2 morning news yesterday for being the “centerfold” of Hour Detroit’s “Top Docs” issue. You can see my 3:40 of fame on Fox Detroit’s website.

Top Docs issue!

This October’s Hour Detroit magazine is their 9th annual Top Docs issue, and I’m not only in it (the first and only holistic doctor), but there’s a two-page spread about me. Go and read the article here (where you can leave comments), or get the ready-to-print (and ad-free) version here. You can bet I’m sending a copy to my parents.

Keep on top of new articles!

We had a little problem with spammers hacking our mail page to send spams, so I’ve had to upgrade the program that makes this website. With any luck, it doesn’t look too much different, but it does have the ability to allow you to subscribe to an RSS feed of this news page so you can find out about new entries more easily. You can find the link to the feed at the bottom of the sidebar on the left of the page. Depending on how your browser is set up, clicking on that link could give you a cool page or a bunch of intimidating-looking code. The simplest explanation for how to use RSS I’ve seen is the video at this page.
Another new feature on this page is the “tags” near the bottom of the sidebar (they have a dot in front of them). These let me put up a link to all the articles that include a particular subject. So, if you’d like to see all the articles I wrote about hyperbaric oxygen, you can just click on the “
Hyperbarics” link and you’ll see them all.
Finally, I’ve written enough articles here that you don’t want them all to load at once, so they are archived by year. Use the links just above the tags to browse the entries by year.

The price of success

One of the problems with getting people better is that once word spreads and more people schedule appointments, the wait for a new appointment can get a bit long. While having people booked 2-3 months in advance can be reassuring to me, it does pose some problems:
  • People looking for appointments can get frustrated by the wait. Fortunately, we have Gaia who can see patients sooner. We also keep a wait list for people who want to get in earlier than the appointment they schedule.
  • When an appointment is months away, people often forget when the appointment is or that they ever made the appointment. So, we end up with new patient appointments with no patient. This is a problem for us (it’s hard to pay the bills when we’re not seeing patients) and it’s unfair to the other people trying to get in to see us.
So, in an effort to minimize this problem, we’re requiring deposits before making an appointment. We’ll take a credit card over the phone, or send in a check (with your name, address and phone number) and we’ll call you when it arrives. The deposits are fully refundable if a person cancels an appointment 5 business days before the appointment, and the deposit can be used to pay for visit, co-pay, and supplements once the appointment is kept.

Made it back alive

Despite the long gap since my last post, I have not died from my trip to rural Honduras. Things at the office have been quite busy and I don’t get so many chances to write here.
A bunch of college students and a few doctors and other health professionals all got together and brought all the medications and supplies we could. We lived in a hacienda in bunk rooms and rode a bus 1-2 hours to the sites where the locals lined up to get help. Despite the long bumpy and dusty rides, heat, and other hardships (of which the flight back was probably the worst when a delayed flight made us lose all our connectors), we all kept good spirits and played soccer with the local kids (who were kind enough not to embarrass us).
Waiting for patientsA bunch of uswaiting to the the doctorsMountain viewsMountain viewsmountain views

Gone on Medical Brigade in Honduras

I'm going on a medical brigade in Honduras the week of august 18: http://www.hondurasmedical.org/
We're going to have to reschedule everyone from that week and I won't be around for the week. Sorry about the short notice, the plans just came together.

Many faces of wheat allergies

The other day I had three patients independently and spontaneously tell me they had discovered they are allergic to wheat.
I've seen a lot of people make huge improvements by removing foods that bother them, and frequently suggest allergy testing or an elimination diet to root out these problems. The interesting thing on this day was the diversity of the symptoms that resolved with removing wheat from these people's diets.
One patient found that when he went off wheat, his thinking became much clearer (he's been diagnosed with bipolar disorder and attention deficit) and he stopped using the lithium he had been prescribed since he didn't need it any more. In addition, his chronic runny nose and reflux symptoms went away, problems he was having with dry skin on his face resolved, he lost weight and he's performing much better at work. Upon re-challenge with wheat, he started getting a dry rash on his face which resolved with avoiding wheat again.
Another patient found that his chronic eczema and hives improved when he stopped eating wheat.
The third patient eliminated wheat and this was the only thing that improved her intense sugar cravings that had originally brought her in. She also found an improvement in her energy levels and that re-challenge with wheat makes her feel terrible and gives her a runny nose, canker sores and fatigue.
Unfortunately, I don't have consistent testing between these three people due to individual circumstances and finances. Gliadin antibodies (from conventional labs) on all three were negative (gliadin is one part of the gluten protein that can trigger gut reactions). IgG and IgE antibodies (through a conventional lab) on one patient showed moderate IgE antibodies to wheat (this is characteristic of eczema) and very low IgG antibodies to wheat. One patient had a combined IgE/IgG4 antibody test through a specialty lab that did show high levels of antibodies to wheat and gluten. I have had other patients who didn't turn up any positives to conventional IgG/IgE testing despite profound symptoms that improved with removing wheat.
On the heels of this, an article came out in
American Family Physician (a journal for family docs) that maintains the doctrine that only IgE mediated reactions (which can be elicited with skin-prick testing) are food allergies and that most things that are called food allergies aren't. While that may satisfy allergists (for whom skin-prick testing is a significant part of their office income), it does little for the patients who have sensitivities to foods that don't show up on skin testing, and they are often dismissed by physicians who don't know that there is more to it than just IgE reactions. Some of the early work on food allergies was done by allergists, but the specialty has veered over to simple skin testing (which rarely shows food allergies) as the standard for allergy testing, leaving all the patients who don't show up with it out in the cold.

Why, oh why, Wyeth?

Fireworks tomorrow, 31 days early!
In case you haven't heard, Wyeth, the maker of Premarin and Prempro (Premarin + Provera), has been plotting to maintain their marketshare by restricting women's freedom to choose safer medications for themselves. Ever since the Women's Health Initiative revealed in 2002 that Prempro increased the risk of stroke, breast cancer, heart attacks, and blood clots (a finding that I, in residency at the time, thought was obvious since Provera was well known to increase the risk of clots), Wyeth has been struggling to maintain its sales of these patent medicines.
Wyeth has managed to keep a monopoly on PREgnant MARe urINe (PREMARIN, get it?) products in the US since it was introduced in 1942 by
dubious legal and political maneuvers including using at least seven women's advocacy groups it funded to influence congressional hearings in 1995. By maintaining this stranglehold on relief of menopausal symptoms, Wyeth has extended its dominion well past the 20 year patent protection and in 2001 had over 11 million women using its hormone medications and over $2 billion in sales of those medications. Following the revelations of the Women's Health Initiative, sales of Premarin and Prempro drop and by 2006 sales are half of 2001 levels (though they had dipped even lower before Wyeth made lower strength versions and pushed for more prescribing).
As women flock to safer treatments like bioidentical hormone replacement (using hormones identical to the ones originally in the women's body), Wyeth decides to protect its profits at the expense of women seeking relief of menopausal symptoms and preventing other changes related to loss of estrogen like osteoporosis and memory loss. In 2005, Wyeth files a "citizen's petition" with the FDA that pushes the FDA to ban estriol, an estrogen naturally produced by women, as an unapproved new drug. Within 70 days, 11 organizations, mostly funded by Wyeth (in a stunning repeat of their tactics 63 years earlier), submit letters of support for this petition. Again, May 19, 2008, members of congress received a letter (coordinated by Wyeth) from 14 organizations (all with major funding from Wyeth) supporting the FDA's actions.
Besides estriol having a 50 year history of use and listing in the US Pharmacopeia, it was in the precursor to Premarin (that was made from pregnant women's urine- but it proved too difficult to collect), and is used by Wyeth itself in products sold overseas. Recent research has shown estriol may reduce the risk of breast cancer and be beneficial in treating multiple sclerosis.
This year, in response to Wyeth's petition, the FDA bans the use of estriol (though the FDA does not have jurisdiction over compounding pharmacies, so this is also a power grab by the FDA) despite admitting that there have been no reports of adverse events associated with its use ever. Somehow, the FDA has managed to put an import restriction on estriol as well, so even though compounding pharmacies shouldn't be subject to the FDA's decrees they are having trouble getting supplies of estriol. Under the FDA's plan, it would require a physician to file an Investigational New Drug form (with the associated $50,000 fee to the FDA) to order estriol for patients.
In the end,
women are losing their options so Wyeth can make more profits.
So, what's with the fireworks? Well, Tuesday, June 3, is the day that hundreds of compounding pharmacists will descend on capitol hill to support H. Con. Res. 342 at the same time the
AAHF is delivering independent letters of support, and a full page ad will appear in Roll Call.
Learn more about this issue
here, and learn more about estriol specifically here.
Corporations will only be able to get away with this as long as we remain quiet, so speak up for this and get active in politics: corporations pay big money to bend the laws in the direction of increased profits whatever the human cost, so the humans have to speak up. It's time.

Dr. Wright joins the fray!

Yikes! I just found out that Dr. Jonathan Wright has joined up as the 11th speaker for the BHRT World Summit that starts tomorrow. Now there's no excuse not to listen in! Also, they've relaxed the listening constraints for the $10 option so you have more flexibility about when you listen.

Bioidentical Hormone Replacement Therapy World Summit

I just found out there's an interesting series of audio conferences coming up: the BHRT World Summit. It starts May 14 and runs through June 2. Lots of doctors who use bio-identical hormones are lined up for this, though I've only heard of a few of them. Sadly, my favorite BHRT guru, Jonathan Wright MD, isn't on the slate.
It does look promising. I'll check it out myself, too, even though it's aimed at regular people. They'll let you listen in each evening for only $10 for the whole series. They also have additional options to listen to the interviews, either by listening on your own schedule or even getting CDs and text from the interviews.
BHRT World Summit
Yes, I know the banner says it ends May 29, but they've added more interviews, so it's an even better deal.

Crohn's costs

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.

Announcing our nurse practitioner!

Gaia Kile
Please welcome Gaia Kile, our family nurse-practitioner. He will be seeing patients and run our FirstLine Therapy program.
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.

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.

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 to the 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.

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.

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.