Thursday, January 28, 2010

Integrative Medicine: A New Way of Looking At Health

Photo by D Sharon Pruitt, via Flickr, used under the Creative Common's License.

A new year, new opportunities... or maybe repeat opportunities. How to choose which challenges to take, or which challenges to build upon from earlier steps. The decisions of a new year.

And as this year begins, I find many great opportunities to spread the word about naturopathic medicine, in new ways, to a new group of health care providers. In my community, a number of heart and vascular guys have recently come together and formed a new group, and in the process have decided that they want to broaden their approach to health care. They want to look at serving patients beyond performing procedures and dispensing pharmaceuticals, but practice from a more integrated place. As we all know, however, liking an idea and implementing it are not often an easy step. But these guys are asking some good questions, and that is very encouraging. Not just asking who should be involved, but the how, the when, the where, and the big question, the why. Seems simple, but there is so much education involved in answering the why.

For the our purposes here, I’ll keep to just our profession of naturopathic medicine and not approach the questions of the why for all the other health care practices considered, such as acupuncture, hypnotherapy, exercise therapeutics, mind-body work . . . simply, why do these patients need naturopathic care? I am certain that we can each give 50 reasons in less than 5 minutes, and it would seem like a relatively mindless effort. The question, however, is really about the why when the answer involves two things: the ability to change, and the dollar. The conversation begins with the discomfort that the idea of having to change how we think and how we behave brings to so many of us. The discussion then moves on to the bare facts of economics – simply, that many patients can’t afford to continue taking pharmaceuticals due to the ongoing costs of those pharmaceuticals, let alone adding the cost of another provider or the cost of their recommendations. Their insurance pays for the procedures, but not the maintenance meds. How do we imagine we can get them to an appointment with an ND, and then, to pay for supplements. But what about the fact that Americans are spending billions of dollars on complementary and alternative therapies? What patients are going to those providers and paying their hard earned cash for those appointments? How do we get these patients, who are not thinking about what they can do to change their lifestyle habits, to consider doing so? These heart and vascular guys are asking these questions. How do we know which direction to send the patients? Which of the providers that are involved in this program will best serve which patients? How do we know? How can we help patients to see the value?

So begins the development of a program. Not the logistics of bringing all these folks these to the table, looking at credentials, nor finding out where and how we can serve patients under one roof or two. It’s about providers learning from one another, what we do, how we think, how we approach health care that is distinct, yet can be integrative and whole. Communicating, respecting one another’s approach to health care, keeping the patient in the center. This is the work that is the challenge, for which none of us ever took a class, for which there is yet no curriculum. An integrative clinic such as this is one way to work out some of these issues, not unlike the immersion approach to learning a language. And life’s lessons of how to get along and play well together should prepare us to some degree, but there is so much more. And this seems to be where the work is – no matter how many stories I hear, no matter what the location or who the group members are, the challenge is how to work together, well. I think that asking the right questions is a great place to start.

Tuesday, January 26, 2010

Massachusetts - Planting the seeds of revolution?

Guest post by Carol Rainville, N.D.

After the Seachange
Photo by occam via Flickr, used under the Creative Common's license.

Itʼs been several days now and I am still trying to wrap my mind around the fact that conservative Republican Scott Brown won the senate race in Massachusetts. I was hoping for some kind of voting irregularities to surface but, alas, such is not the case.

A recent Washington Post poll says health care was the most important issue driving the results. I didnʼt really need a poll to figure that one out. One candidate vowed to vote for it and the winner vowed to vote against it. The poll also said that the majority of voters support the Massachusetts universal health care plan. In my own little poll, my selfemployed friends have expressed far greater fear, frustration and anger with the state mandate than the friends with employer-provided health care plans.

Since the universal health insurance law went into effect here in 2007, premium costs have skyrocketed. If you donʼt have “credible” health insurance coverage, you will be fined. Since January 2009, credible means, in addition to the basic coverage prescribed by law (catastrophic insurance alone isnʼt enough), you must also pay for prescription drug coverage whether you need it or not. We are seeing double digit annual increases in our premiums. Blue Cross was planning increases of up to 47% for some small businesses for 2010, claiming costs have increased that much in the span of one year!

I had high hopes for health care reform when President Obama took office. The original ideas looked like real reform. It now looks like the Massachusetts plan gone national and I believe that is the message the voters here were sending. They are outraged and they donʼt want more of the same. I share the outrage. As a self employed individual I pay well over $8000 per year just in premiums, plus co-pays and the cost of membership in a chamber of commerce to get that special group rate. I rarely use prescription drugs and the ones I have used were not covered by my insurance. Itʼs not hard to see who the winners are here.

For a lot of reasons, though, Scott Brown was not my candidate of choice. My thinking was that if Congress did pass this legislation, with the same results we have seen here, the national outrage would drive real reform. Senator-elect Brown is an intellectual lightweight and once he casts his vote against the health care bill, his 15 minutes of fame will be over. However, that vote may well be “the shot heard round the world.”

I do believe things happen for a reason. Massachusetts has sent a strong message to Washington because the citizens of this state and this country, however naively, still believe in government of the people, by the people, for the people. There is an incredible opportunity here. President Obama and Congress can grab it and regain the peopleʼs trust or they can let it pass them by. If the latter happens, I sense a revolution sprouting. Cake anyone? (Apparently, Marie Antoinette never really said “Let them eat cake” but the symbolism remains.)

Wednesday, January 20, 2010

Hitting the Ground Running

By Carl Hangee-Bauer, ND, LAc
AANP President

Running Guy
Photo by aarmono via Flickr, used under the Creative Commons' License.

Greetings and Happy New Year/ New Decade! After the trials, tribulations and struggles of the first decade of the new millenium, I think we are all looking forward to 2010 and the coming years with optimism that better things lie ahead.

This is my first message to you as incoming President of the AANP. As I write this, we have already hit the ground running in 2010 as we prepare for the first Board meeting of the year taking place January 16-17th in San Francisco. Last month Dr. Lise Alschuler thanked our exiting Board members Dr. Chad Aschtgen, Dr. Vanessa Esteves, and Dr. Steven Bailey for their service to the AANP and to the profession. I echo her comments and add that they will be missed and their contributions are greatly appreciated.

For all of us, I want to thank Dr. Alschuler for her service as AANP President over the past two-years. Her steady hand, grasp of the complexities of the issues facing the AANP, inspiring words and ability to see the big picture and guide this organization are unsurpassed. Believe me, she's a very tough act to follow and is a role model for me as I begin my term. Thank you so much, Lise!
This is a time of turnover on the Board with newly elected members coming onboard for their 2-year terms. I want to take a few moments to welcome and introduce our new members.

Dr. Helen Healy joins the Board in her dual position as Chairperson of the House of Delegates. She is a long time leader in the naturopathic profession and her pioneering work in Minnesota led to the recognition of NDs in that state. I might add that Helen and I served together on the first Board of the AANP in 1986, both of us the new kids in the room in awe of Dr. Sensenig and the other leaders of the AANP. It will be great to work with her again.

Last year, the House of Delegates passed a bylaws change adding a representative from the American Association of Naturopathic Medical Colleges (AANMC) to the AANP Board of Directors. Dr. Guru Sandesh Khalsa, Dean of the naturopathic program at Bridgeport University, joins the board in this capacity.

Dr. Corey Resnick, a past Treasurer of the AANP, rejoins the board as our newly elected Treasurer, bringing his past AANP experience as well as his proven business savvy to this position.

Dr. Michael Reece, past president of the Pennsylvania Association of Naturopathic Physicians, brings his years of experience and leadership to the AANP Board. Besides his impeccable naturopathic credentials, you may know Michael for his skills on the drums at our convention dances.

Dr. Trevor Holly Cates is also joining the board in 2010. Dr. Cates is the first woman in California to receive a license as a Naturopathic Doctor and was appointed by Governor Schwarzenegger to the Bureau of Naturopathic Medicine Advisory Council.

We round out our list of new members with Dr. Kasra Pournadeali. He is a past president of the Washington Association of Naturopathic Physicians, and an appointed board member for the Washington State Medical Association (WSMA)-accredited Foundation for Care Management.

All told, the AANP Board consists of 13 members. As you can see, almost half of the board consists of new members, joining myself and Dr. Alschuler, Dr. Michael Cronin, Dr. Tabatha Parker, Dr. Sara Thyr, Dr. Bill Benda and Dr, Michelle Clark. All of these Board members bring a great deal of experience and leadership to the AANP and will help this organization meet its goals now and in the future.

In the coming months, one of my goals is to keep you informed of the work the AANP is doing and and the issues we are facing, both as an organization and as a profession. 2010 promises to be an exciting and challenging year. As most of you know, the AANP is celebrating its 25th anniversary this year and we are already planning for the convention in Portland in August. This is a convention not to be missed as we look back on the first 25 years of the AANP and forward to the future.

Externally, as health care reform takes shape in Washington, we will be watching as well as educating legislators and staff so naturopathic medicine is represented and more people will have access to naturopathic care. President Obama promised change and we are going to get it; the challenge is guiding this change to improve the health of all Americans. Naturopathic medicine is an important piece of true health care reform, and our board and staff are working diligently on this issue.

Lastly, I want to remind you that the AANP is a member-driven organization. The membership elects its leaders to represent them and our common interests. From the perspective of the Board, you are our bosses. Everything we do we do in the interest of furthering our common goals, helping NDs be more successful and advancing the naturopathic profession. One of the basic goals of the AANP is best expressed in what we call our "Global End Statement: "People will experience optimal health and wellness through the principles and practices of naturopathic medicine, and actions towards this End will not exceed the operating budget of the Association."

Give us your feedback. Tell us your goals and dreams. Let us know what we're doing right and where we could improve. Make sure your voice is heard.

Till next month,

Carl Hangee-Bauer, ND, LAc
AANP President

Tuesday, January 12, 2010

Paradigm Shifts in Cancer Care

By Jacob Schor, ND FABNO

Small cell carcinoma, CAM 5.2 immunostain (400x)
Photo by euthman, via flickr, used under the Creative Commons License.

A big change is occurring in the way scientists view cancer and we need to keep up. Perhaps we may need to update our terminology. Or perhaps go back to some older phrases from years ago.

My ruminations are triggered by an article Gina Kolata wrote that appeared December 29 in the New York Times titled, “Old ideas spur new approaches in cancer fight.”

In her article, Ms. Kolata describes the work of Mina Bissell, Bert Vogelstein, Barnett Kramer and other researchers who are reshaping the way cancer is seen. The current view is that cancer is the result of genetic damage allowing malfunctions to accumulate. The blame is laid on individual cells that become cancerous and pass on their dysfunction to their offspring. The new paradigm that Kolata describes is different: “Gene mutations are part of the process of cancer, but mutations alone are not enough. Cancer involves an interaction between rogue cells and surrounding tissue.”

Early ideas on cancer once dismissed, such as that, “… a blow to the breast might spur cancer, an infection might fuel cancer cells, a weak immune system might let cancer spread…” are being reconsidered. The rapid decrease in breast cancer rates seen after hormone replacement therapy went out of favor is a prime example of why the old explanations are inadequate. Because breast cancer rates dropped too rapidly to be explained by genetic changes, Kolata offers us a more plausible explanation, “…that the hormone treatment somehow changed the environment of naturally occurring cancer cells…”

This isn’t that different from the ‘fertile field’ debate that modern medicine thought ended with Louis Pasteur several centuries ago. On the one side are those who favor a simple causative explanation for disease as in, ‘Germs cause illness.’ Our profession has favored, or at least given credibility to, the ‘Fertile Field’ concept, that ‘Germs won’t grow unless they find a suitable host, a fertile field.’ The changing views Kolata points out in her article run parallel to this idea. Cancer won’t grow unless it finds itself in a suitable environment.

I admit to having fallen under the sway of this ‘genetic damage’ model of cancer. Many of the therapies and supplements we have suggested to patients have focused on attacking cancer on this level; supplements that encourage DNA repair or that trigger apoptosis (cellular suicide). Both of these processes have been aimed at the cancer cells rather than on the ‘cancer environment’ in the patient’s body.

In recent years though, more and more, my thoughts and those of my colleagues who specialize in naturopathic oncology have shifted. Rather than thinking of a ‘fertile field’ in which a germ can take root and grow, I find myself using analogous terms like, ‘weather, climate and season,’ that can be either favorable or unfavorable for cancer growth.

We have been paying increasing attention to the effects on cancer of various hormones, growth factors and inflammatory markers. Goals like changing levels of insulin-like growth factor 1 (IGF-1), transforming growth factor Beta-1 (TGFB-1), or NFKappaBeta (nfKappaB) have become the focus of our therapeutic choices. We are trying to understand the effect mast cells have on tumor growth, the consequences of chronic inflammation and the chemicals this triggers. Fluctuations in these chemicals mark the daily ‘weather’ in the body. As TGFB-1 increases, single breast cells find it easier to metastasize. As IGF-1 increases, tumor cells grow as if fertilized. The long-term overproduction of these chemicals and others may be a barometer to gauge the body’s climate.

If we stretch this analogy one step further, might we say that vitamin D marks off the seasons in the body’s internal calendar? Certainly it is in the winter when vitamin D levels drop to their lowest point that cancer finds the most favorable environment to grow.

How different the clinical approaches these different result in was brought home to me last week. Nathan Seppa writing in the January 2, 2010 issue of Science News described a recent report on vitamin D’s effect on lymphoma: “Sunshine vitamin may play protective role against common form of the blood cancer.”

In the article, Seppa describes a presentation by Matthew Drake of the Mayo Clinic at the annual meeting of the American Society of Hematology. [Vitamin D deficiency is associated with inferior event-free and overall survival in diffuse large B-cell lymphoma. Abstract # 1953, American Society of Hematology 51st Annual Meeting, New Orleans, Dec. 5–8.] Preliminary abstract available online here.

Seppa writes,

“From 2002 to 2008, the researchers analyzed blood samples from 374 newly diagnosed patients with diffuse large B-cell lymphoma, …..

“The blood tests revealed that half were deficient in vitamin D at the start of treatment, having less than 25 nanograms per milliliter of blood.

“….. patients who were deficient in vitamin D were twice as likely to die, compared with patients who had adequate vitamin D blood levels at the outset. Patients with low vitamin D concentrations were also about 50 percent more likely than the others to have their cancer worsen….”
This information comes as no surprise. In the last dozen years, close to 6,000 papers have been published in the medical literature on vitamin D’s positive effects against cancer. Low vitamin D levels are now well established to be a component in the ‘climate’ that allows cancer to flourish.

Shortly after reading Seppa’s article, I received a phone message from a patient, at her oncologist’s office for chemotherapy. Her oncologist didn’t think it necessary to measure her vitamin D levels, a test that we had suggested she ask him to do. Measuring vitamin D levels and supplementing as needed to assure patients are not deficient is routine these days in naturopathic oncology. It apparently is still not routine in medical oncology.

This juxtaposition of medical paradigms could not have been clearer. Our goal is to create an internal environment in the patient so that cancer will not flourish. The oncologist’s goal is to destroy cancer cells using the tools at his disposal. The problem, as we are beginning to see it, is that these tools can be harsh and create an environment in which cancer flourishes. During and after standard oncology treatment, the various chemical factors that we use to measure the internal ‘weather’ describe a ‘climate’ conducive to cancer growth. To use the older phrase, chemotherapy and radiation creates a ‘fertile field’ in which cancer grows.

Researchers are ahead of the clinicians and we must strive to keep up with their advancing knowledge and paradigms in order to best serve out patients. Though our past ambition to help destroy cancer cells remain valid, we must expand our vision and think in terms of the internal environment that allowed cancer to take root in the first place and the climate left by chemotherapy and radiation treatments that aid cancer to grow.

This is a paradigm shift that comes easy to naturopathic doctors. In a way, it is how we’ve always approached disease.

Tuesday, January 5, 2010

Academia Translated into Plain English

By Bill Benda, MD

Hippocrates Statue and Dooley Hospital Door
Photo by taberandrew via Flickr, used under the Creative Commons License.

Ah, research. The bastion of Truth, the harbinger of new therapies, the gospel according to NCCAM, the Holy Grail of healthcare. Our research departments are at the heart of every medical center, pumping veracity through the veins of academia and bringing lifeblood to the marketing agencies.

But wait just one evidence-based minute. This particular journalist was actually a researcher for a few short years, a certified NCCAM principal investigator probing the effects of hippotherapy (physical therapy on horseback) on children with spastic cerebral palsy, resulting in two publications in peer-reviewed journals. And I am figuratively here to tell you that our collective, integrative research data is not holy, but in fact full of holes. Despite our truest of intentions, my fellow investigators and I walked into the studies brimming with bias (children and animals, for gosh sakes), and emerged no less partisan given our positive results. This does not mean the therapy did not benefit the kids; it simply means we found benefit despite our blinkered perspective.

Now please don’t get me wrong – as imperfect as it is, research is still one of our best tools in determining what arrows to place in our therapeutic quiver. But its conclusions are not the Truth, but simply one more finger pointing in the general direction of the Truth. And to help you, the clinician, to comprehend our particularly pedagogical dialect within the covers of your favorite journal, I have compiled a list of commonly utilized research phrases along with their more accessible vernacular to help in translating the next study you peruse in your living or other room. Plus, as an extra bonus and in the spirit of journalistic integrity, I am going to openly admit that I have plagiarized the following from an anonymous source within the pages of my monthly Funny Times subscription.

So without further ado, here is a translation of common academic phrases into plain old English:

  • “It has long been known” . . . I didn’t look up the original reference.
  • “A definite trend is evident” . . . These data are practically meaningless.
  • “While it has not been possible to provide definite answers to the questions” . . . An unsuccessful experiment but I still hope to get it published.
  • “Three of the samples were chosen for detailed study” . . . The other results didn’t make any sense.
  • “Typical results are shown” . . . This is the prettiest graph.
  • “These results will be in a subsequent report” . . . I might get around to this sometime, if pushed/funded.
  • “In my experience” . . . Once.
  • “In case after case” . . . Twice.
  • “In a series of cases” . . . Thrice.
  • “It is believed that” . . . I think.
  • “It is generally believed that” . . . A couple of others think so, too.
  • “Correct within an order of magnitude” . . . Wrong. Wrong. Wrong.
  • “According to statistical analysis” . . . Rumor has it.
  • “A statistically oriented projection of the significance of these findings” . . . A really wild guess.
  • “A careful analysis of obtainable data” . . . Three pages of notes were obliterated when I knocked over a beer glass.
  • “It is clear that much additional work will be required before a complete understanding of this phenomenon occurs” . . . I don’t understand it, and I never will.
  • “After additional study by my colleagues” . . . They don’t understand it either.
  • “A highly significant area for exploratory study” . . . A totally useless topic selected by my committee.
  • “It is hoped that this study will stimulate further investigation in this field” . . . I am pleased to feed you this B.S., and hope you will give me more funding.

So, future researchers, I hope this thesaurus will assist you in your lofty goal of saving humanity. Go get ‘em!