When I was studying my under-graduate I imagined my clinic was going to be full of them: well patients wanting to maintain or even improve upon their wellness. Turns out…not so much…all the really really sick people have taken their spots and the former has been listed as an endangered species. But I do catch glimpses of them, as I am sure we all do, in their natural habitat, with over-flowing baskets at the organic grocery store or farmer’s market, routinely up the front of the pilates class and also sometimes in our clinics. So now that naturopathy, by consumer demand, not practitioner intent, has transitioned so much into the ‘unwellness space’, do we know anymore what to do with the well ones??
I heard some great talks at the NHAA conference recently. One, in particular, was by my stellar colleague, Liza Oates, who observed that contemporary naturopaths tend to respond to these clients in 1 of 2 ways:
a) Unaccustomed to a patient who eats, exercises, sleeps and balances their work & non-work worlds better than themselves…PANIC…
b) Dig deep back through the dusty archives of their personal & family medical history until they FIND A PROBLEM THEY CAN TREAT!!! such as, ‘Once I was constipated for a couple of days’ or, ‘Once I took a course of antibiotics’.
I know…we’re hilarious…we have to laugh at ourselves 😉 Liza offered up some great ideas about how to approach our consults with these patients. Many of her tips, however, could be applied to the rest of our patients as well to gather some really valuable insights. And it’s always great to hear from someone who has been seeing patients over decades…there’s so much to be gained from those who’ve gone before us (or alongside us…in my case!) and can speak to these firsthand lessons. Here are just a few of her pearls
The ‘not stressed’ patient
We encounter a lot of people who can misreport their stress levels, not because they are trying to lead us astray but that’s that slippery slope of self-reporting & the possibility that someone has normalised their ‘load’. Liza says she likes to step away from that potential trigger word, ‘stress’ and instead ask, ” What are your tell-tale signs when the demands exceed your capacity?”
This is not so that we can fulfil option b) mentioned at the beginning…digging desperately to find some unwellness to treat – but rather as an aid for both practitioner and patient alike to understand better that individual’s response to their psychosocial environment.
Ask them to design their own health retreat
If they reply, “I would start every day with a little meditation and yoga, a chai and then a healthy hot meal”, then these can be translated into little goals we can set to bring some of their ‘best self ‘ into their every day. It also helps to better understand their values, individualised self-soothing and self-care & great prescriptions to begin with, given they’re telling you they are already at contemplation in terms of their readiness for behavioural change. They’re not going to require too much convincing – they’re already converts they just need permission and support to implement.
And if you’re sitting there reading this and thinking, ‘Hey! These are exactly the patients I want my clinic full of”…then to hear more of Liza & Greg Connolly’s commentary and insights about how the wellness space has been hijacked by others and how naturopathy needs to move centre-stage in this increasingly popular trend, take a listen to this interview they recorded at the conference.
Want to Improve Your Patients’ Compliance?
This UU30 recording from our back catalogue on the behavioural change model and how it impacts patients’ response to our advice is a key element in developing a professional approach that actually works. Unless practitioners are aware of the way that patients approach changing their dietary behaviour or exercise regimes, they the mystery of non-compliance will never be solved!
Oh no, it’s her again 🙁 I mean the chick in the photostock image not the other ‘her’, me. I know. It’s the end of another mammoth year, you’re tired, worn out, used-up all your brain-power quota (a little projection?) and I can hear you begging for mercy when I start a sentence with…”So you think you know….” followed by, “blah blah blah Iron,” but hear me out.
Correctly identifying & managing iron issues is a bread & butter part of our business, right?
With Iron deficiency affecting an estimated 1 in 5 women and Iron excess almost another 1 in 5 – patients with one form of iron imbalance or another tend to be over-represented in waiting rooms.
Anyone can spot overt iron deficiency anaemia or full-blown haemochromatosis but many health professionals find the ‘in-betweens’ confusing and fail to recognise some key patterns we see over and over again, that spell out clearly your patient’s current relationship-status with this essential mineral. This often results in giving iron when it wasn’t needed and missing it when it was. If you’re imagining someone else, i.e. the person who ordered the Iron Studies for your patient, will step in and accurately interpret the more curly results can I just say D-O-N’-T...they’re often as perplexed or even more so than you. After starting this conversation a year ago with So you think you know how to Treat Iron Deficiency, & its baby sister, So you think know the best Iron Supplements, our (imaginary) switchboard went crazy. While practitioners got the message loud and clear about how to improve the likelihood of treatment success in iron deficient patients, hot on the heels of this came email, after fax, after carrier pigeon, with examples of patients’ Iron Studies, the ‘somewhere in between ones’, accompanied by the equivalent of a dog head tilt…aka ‘I don’t get it’.
And this is to be expected.
What were you taught about reading Iron Studies? Was it made out to be all about ferritin? And TSH is a solid stand-alone marker of thyroid health, right? 😉
Were you introduced to the other essential parameters included in Iron Studies, explained how they contribute to your diagnosis and reveal important details about the patient’s ability to regulate this mineral or not? About when to dose and when to hold your fire?
Nah…I didn’t think so. But it’s up to us, people, to hone our skills in Iron Study interpretation…because individualised nutrition is our ‘thang’ and more than any other nutritional assessment, this collection of markers, actually allows us to go beyond the ‘one size fits all’ model…everyone must have X of this and Z of that in their blood tests…and see each patient’s actual individualised need and relationship with this mineral. In the latest Update in Under 30, I introduce you to 3 key players in iron assessment and the insights each offers become so clear, you’ll be able to read any combination or permutation of iron results that walk through your door. To boot, I’ve included a wizz-bang cheat-sheet of those iron patterns that are frequently seen and rarely recognised, including one totally novel one that I’ve never talked about before…to make your job even easier and put you well and truly ahead of the pack in understanding iron nutrition. It’s Christmas…and as the mantra goes…we can always fit just a little more in at Christmas time, right? 😉
Overt Iron Deficiency Anaemia or Haemochromatosis aside…do you understand the critical insights markers like transferrin and its saturation reveal about your patients iron status? Most practitioners don’t and as a result give iron when they shouldn’t and fail to sometimes when they should. This audio complete with an amazing cheat sheet for interpreting your patients Iron Study results will sharpen your skills around iron assessment, enabling you to recognise the real story of your patients’ relationship with iron.
Hear all about it by listening by my latest Update in Under 30: So You Think You Know How To Read Iron Studies? For all Update in Under 30 Subscribers, it’s now available in your online account and if you are not a subscriber you can purchase this individually here.
As Britney so famously put it, ‘Oops, I did it again!’ I remember the actions on my to do list but not the intended recipients! D.O.H. I was talking with a practitioner the other day who lamented that she had never really learnt about stats nor how to assess the quality of research in her undergraduate and could I point her in the right direction towards a resource that simply explains this increasingly important basic skill-set…well I would if I could remember who you were!! Anyhoo, I followed through in my usually dogged way to the bottom of my actions list and with the help of a lovely past-intern, got directed to these free BMJ resources on how to read research…G.O.L.D.
Papers that go beyond numbers (qualitative research) Trisha Greenhalgh, Rod Taylor
Papers that summarise other papers (systematic reviews and meta-analyses) Trisha Greenhalgh
Papers that tell you what things cost (economic analyses) Trisha Greenhalgh
Papers that report diagnostic or screening tests Trisha Greenhalgh
Papers that report drug trials Trisha Greenhalgh
Statistics for the non-statistician. II: “Significant” relations and their pitfalls Trisha Greenhalgh
Statistics for the non-statistician Trisha Greenhalgh
Assessing the methodological quality of published papers Trisha Greenhalgh
Getting your bearings (deciding what the paper is about) Trisha Greenhalgh
Anyway…while I continue to ponder who this was actually intended for… it dawned on me how many people would just LOVE these & benefit from them immensely in the meantime. Couldn’t most of us do with a little more research literacy? So I thought I’d share. Don’t you love it when we work as a team. Now…who can help me find my keys?! 😉
It’s starting to feel a lot like…that Update in Under 30 time of the month!
Update in Under 30 are dynamic power-packed podcasts that will help you keep abreast of the latest must-knows in integrative medicine. Focused on one key issue at a time, Rachel details all the salient points so that you don’t have to trawl through all the primary evidence yourself. All topics are aimed at clinicians and cover a range of areas from patient assessment to management, from condition based issues to the latest nutritional research. Most importantly, each podcast represents unbiased education that can contribute to your CPE points, so if you haven’t subscribed yet…what are you waiting for??!! 🙂
That’s me…always questioning the ‘status quo’ and Iodine is the perfect example! The interview I did on this important subject with Andrew Whitfield-Cook from FxMedicine, covers a lot of key areas of confusion & underscores why it’s so critical all health practitioners get clarity on this topic. ‘It’s just a matter of geography’.
You know, I say to people, we can make vitamins ourselves, we can get all sorts of other organisms including animals, bacteria and plants to make vitamins for us, and then eat those…but minerals…our source of minerals…well it all comes down to the rocks and the soil our food itself is grown or fed on. And iodine is profoundly influenced by these factors. (more…)
I had the privilege of presenting at the Integria GIT Symposium last weekend. For those of you who attended, you’ve gone back to your clinic with a bunch of new ideas and inspiration I hope…oh and a new respect, terror and watchfulness for threadworm thanks to me! In my presentation I outlined the many presentations of this infestation, what to watch for and the risk of chronic recurrence due,in particular, to a reduced ability for some individuals to produce chondroitin sulfate which renders the GIT environment hostile to worms.
Chronic threadworm is a huge & grossly under-recognised issue in paediatrics, often presenting as behavioural & cognitive disorders (and these can be severe), bruxism, enuresis etc. of course, but another presentation typically missed is vulvovaginitis, vulval pain or UTI like sx in young girls. (more…)
Ever wondered where on earth (or Mars?!) I came from? As much as I can’t keep quiet on some topics, my personal journey to here has been a bit of closed book to many. Recently during an interview with Andrew Whitfield-Cook from FxMedicine, which was supposed to be strictly about postgraduate education paths and the desperate need for mentoring, internships etc for naturopaths, the sneaky devil got me to spill the beans on a whole lot more!
Having been involved in so many aspects of naturopathic and integrative health care education over the past 15 years, of course I do have a lot of ideas about how practitioners can best accelerate their learning and development, the need for more independent education and the importance of fostering critical thinking.
I think you already know that I feel passionately about this but do you know the whole story? Who I have been mentored by and how I continue to tread the path of the ‘student’? (more…)
Setting: Local cafe
Scenario: Run into friends of friends who join us in the sunshine for a cuppa & we’re discussing the finer details of chai (western version V the real streets of Delhi stuff), tumeric lattes etc etc. as you do. I comment on how unpleasantly strong I found the cow’s milk in those downtown Delhi chais we had when we were there.
50 something man: Oh I LOVE that – I just LOVE cow’s milk. I drink loads of the stuff. I used to drink 2L a day but now it’s more like 1L a day.
50 something man: Absolutely. Then there’s the cheese as well – I would eat at least 1kg of that a week. But it’s good for my bones, right? I have that thing, you know, before osteoporosis…brittle bones. (more…)
I am frequently asked what scientific journals I subscribe to and often by the same practitioners over and over, because they can’t reconcile my answer: “None”. Yet I constantly have my head in the scientific literature, right? The two are not mutually exclusive, it’s just about knowing which free scientific and medical news-feeds are worth their weight in gold! If you really are digging into the itty-bitty detail of things these won’t answer all your questions on all your topics but they do a great job of 1) keeping you up to date with the big headlines in general medicine, or, with the use of alert systems and filters, just the areas of health you’re particularly interested in and 2) offering you a huge highly credible resource database that is easily searchable.
Point 1, Exhibit A 😉 :
Here’s just a few examples from the last month that popped into my inbox from Medscape that got my pulse racing:
Most practitioners are pretty knowledgeable about Zinc and are quick to recognise a deficiency and the opportunities for zinc supplementation as an effective therapy and those same practitioners are often plagued by nagging questions that come up, in spite of loads of clinical experience, like:
- Are plasma and serum zinc levels interchangeable?
- What does zinc adequacy look like? Is it just a single number on a page or do we always have to factor in copper levels and get the ratio right as well?
- What can I expect from zinc supplementation in terms of changes to the patient’s plasma zinc?
- What should I do when a patient’s zinc marker is refractory to the intervention?
- Is there really a significant difference between the different supplemental forms available?
I like to fancy myself as a bit of Supplement Sleuth! I love working with herbs, nutrients and nutraceuticals rather than pharmaceuticals but I am not blinded to the fact that manufacturers and suppliers, whatever their form of medicine, are large competitive businesses that ultimately need to sell product and want to sell more. Often practitioners & patients are surprised when I say things like, ‘It’s vitamin C not something sophisticated – go buy something cheap as long as it ticks these boxes…”. In contrast, there are some nutrients and nutraceuticals at the other end of the spectrum, that evoke my compete attention around form, delivery method etc. and I would never send my patient out the door to get these anywhere else.
A few times recently, I’ve been asked by praccies, ‘What’s the deal with CoQ10 and ubiquinol V ubiquinone/ubidecarenone forms?’ and I can hear in their tone that they posses a healthy skepticism when being sold the latest and greatest supplement! ‘Should all my patients be using the ubiquinol form or just some?’, ‘Is it really worth the premium price?’. Great questions all of them 🙂 (more…)
Cheesy I know! 😉 However, recently the issue of knowing when to use Withania somnifera & when not to, came up again in mentoring so I thought it’s probably a good one to share. Withania, aka Aswagandha or Indian Ginseng, has become a favourite adaptogenic prescription for many practitioners, myself included. I remember learning specifically (about a million years ago!!) that this herb is ‘warming’ & ‘nourishing’, thanks in part to its iron content. In a traditional medicine context, it’s used for those particularly vulnerable populations such as children, the pregnant, the elderly and the malnourished, boiled in milk as a tonic. These ideas always stayed with me, and lead me to only use Withania in similar patients and presentations with good results. (more…)
Have you ever wondered what is the best way to grow your business? Not a cardboard cut-out, off-the-shelf kind of business that every business coach talks to, or somebody else’s business, your business? Business advice like naturopathy, according to Rachel, is about taking an individualised approach.
The traditional model of a naturopath was based on a one on one clinical practice model, while potentially still a path to success and satisfaction, this requires a totally fresh and contemporary perspective on what works today. In addition to this, many naturopaths feel a need to diversify their revenue stream in order to work smarter not harder. The naturopathic path is not always conventional and rarely the same for any two practitioners depending on personality, location, skill sets (including non-naturopathic), passion etc.
Rachel gets it. (more…)
It’s taken a little while for me to collect my thoughts on this one. Initially there was a little flash of anger, frustration and a good deal of huffing and puffing when I heard about the RACGP guidelines recommending GPs say no to any requests from naturopaths for further investigation of their shared patients… but I’m over that now. In an interview on 702 ABC Sydney radio last week, Stephen Eddy, the vice president of ATMS, responded to these guidelines by suggesting that a blanket directive for GPs to ignore all requests from all naturopaths about all testing didn’t really sound sensible or appropriate. Here here! Surely, in the pursuit of evidence based medicine and discerning practice decisions, each case should be considered on an individual basis. I think Stephen Eddy gives GPs more credit for being able to make these judgements than their own association! (more…)
Most of us know that measuring a fasting blood glucose to assess how well someone is managing their glucose levels is about as crude and insensitive as waiting for the smoke detector alarm to tell you your dinner is cooked! If we wait to see an abnormal result here we’ve missed a prime opportunity for patient education and prevention long ago. Much the same story if you’re looking at HbA1c results.
To explain this I always use the analogy of a duck. A duck will always be able to swim but the question is how much effort does it have to exert to swim the same distance? If your blood glucose is within range after an overnight fast that’s as good as saying, ‘this duck can swim the length of the pond’. What it doesn’t tell you is how fast its little legs are paddling in order to achieve that. Measuring a fasting insulin at the same time, however, tells us some additional important information. It tells you how fast the duck’s legs are paddling just to keep its head above water! The more insulin you’re having to secrete to just maintain normal blood glucose levels, the more alarmed we should be! (more…)
Howdy hard working praccies 🙂 well I received a very interesting email this week from someone asking me if I thought her urinary iodine result was accurate or if, as I have written about previously (https://rachelarthur.com.au/concentrating-concentration-getting-urinary-iodine-right/), it needed to be corrected for the creatinine content of her urine. Her raw iodine result was 24ug/L which suggests severe iodine deficiency. Her referring doctor however had also asked for creatinine and applied the creatinine correction formula I have previously described:
Iodine (mcg) ÷ Creatinine (mmol) X 8.85 = Corrected Iodine – which changed her result to 265 mcg/gCR which suggests she is NOT iodine deficient at all
She then asked another doctor to review the result who had told her 24ug/L was correct in the first place as ‘pathology companies automatically correct for the concentration of the urine’. Naturally the individual found the difference in opinions and results absolutely striking and ultimately disconcerting so she thought she’d ask me.
It was good to get this email because it made me go and check my facts, get in touch with all the major mainstream pathology companies we deal with and ask their labs ‘Do you or do you not automatically correct for creatinine when you report urinary iodine results?’ I was worried I had given you guys some bad advice 🙁 …here’s what I found out: (more…)
No matter how long I am in practise there is always a group of patients for whom ‘vaginal thrush’ is a major problem. Most of us have some fabulous tricks up our sleeves to help resolve these issues & reduce their susceptibility – intravaginal lactulose is one of mine thanks to Jason Hawrelak. And then you come across those clients who vigilantly do every thing you ask them to and yet you fail to completely resolve the issue. Doh!
One of the most important things to do with all clients presenting with ‘thrush’ sooner rather than later is send them STAT (!) for a vaginal swab.
Not only does this clarify if it is in fact actually thrush (2/3 of self-diagnosed women get it wrong according to research!) but better again it names the actual culprit. It may come as a surprise but not all vulvovaginitis is due to Candida albicans – increasingly they are the result of other Candida species and this is something you absolutely need to know.
During a recent mentoring session, a practitioner wanted to better understand why she had a group of patients whose thrush seemed so resistant to her usually successful treatment. Here’s my initial response in a nutshell… (more…)
I am frequently asked by practitioners about where I find research and whether I subscribe to journals. I always tell people to look for information that is available for free first. Google has recently released a new web browser plug-in making accessing free, independent, full text research articles even easier! Pretty groovy huh?
As my last post suggested not relying on information provided just by company reps (if you missed it check it out here) is essential to being an informed practitioner. So here’s an introduction to Google Scholar button for your web browser to help you do just that!
What is it?
The Google Scholar button is a plug-in that you can install on your web browser (currently available for Chrome, Firefox and Safari) so that you can find the source article of referenced information via the title or take your web searches straight to Scholar. Google Scholar will show free and fee-based article in its results.
How does it work?
Simply install the plug-in on your browser (‘How-to’ install and use Google Scholar Button is detailed California Digital Library here) and use the button in the tool bar to search Google Scholar or copy and paste the title of the article you wish to find.
How will it help you?
This tool enables users to find the full text article from just the article title, or to search for full text scholarly articles and books. These may be free or fee based, but the point being it enables you to find free ones.
Get it here!
Download the plug-in right now for Chrome here and Firefox here.
Recently a practitioner lamented that because of her clinic location she didn’t see company reps very often & felt this was a barrier to her staying current with her clinical knowledge. Of course, I had to beg to differ.
We’re quick to judge the medical profession for their reliance on commercial sources of CPD, overwhelmingly provided of course by the ‘drug reps’ but it seems we’re less fazed or concerned about ourselves being equally reliant, unduly influenced and misguided (might I add) by the people employed by the CAM manufacturers expressly to encourage us to sell more of their products! How does that make sense?
I go back to my very repetitive mantra: always be mindful of who delivers you the message/information etc. and what their agenda is.
By promoting their company’s products to us, focusing on the products’ strengths, ignoring or simply not making it a priority to know the limitations or weaknesses of the products or the evidence, ignoring or again simply not making it their business to know when superior products are being produced by competitors or when new evidence comes to light that puts into question their products, reps are only doing what they’re employed to do. But is it helpful and is it ok? (more…)
About a decade ago there was a lot of excitement about using fish oils in the management of mental health, so much so even the American Psychiatric Association developed recommendations suggesting that people with mood, impulse control & psychotic disorders should all consume 1g EPA + DHA per day… but then what happened?
Ask most health professionals (GPs, psychiatrists, naturopaths & nutritionists alike) today whether fish oils are their first choice in mental health nutritional interventions and you’ll frequently get a, ‘No’ and I include myself in that.
Let’s retrace our steps to find out how we got here. The epidemiological evidence linking low omega 3 intake to myriad mental health problems in terms of susceptibility, incidence and severity is almost overwhelming. For example, depression rates are 10 times higher in countries with limited seafood intake and post-partum depression 10-50 times higher (Kendall-Tackett, 2010).
Noaghiul & Hibbeln postulated that countries where individuals consumed less than ≈ 450-680g of seafood per person per week demonstrated the highest rates of affective disorders (2003). One study of 33 000 women with low omega-3 intake were found to have an increased risk of psychotic symptoms (Goren & Tewksbury 2011) and it goes on. Then, we have other evidence also pointing in the direction of fish oils, such as the general consensus that excess unchecked inflammation is evident in many mental health conditions (Maes et al 2013). Numerous intervention studies using fish oils as stand-alone or adjunctive treatments have been published. Interventions have included high dose omega 3 (no specific EPA/DHA breakdown), EPA alone, ethyl-EPA, high DHA, blends with high DHA:EPA ratio, flaxseed oil etc. etc. (more…)
We had a great case in one of our graduate mentoring sessions the other day (thanks Kate 😉 ) , about a 40 something mum of 3 who reported to have cyclical mood and depression. Further investigation of the case, however, revealed that some of the key characteristics of the mood disorder were actually anger, aggression, irritability, hyperactivity, vivid nightmares etc. This particularly came to light with her responses to a mood survey that the practitioner had asked her to complete. I think validated tools like this (esp. DASS), when used appropriately, can give us enormous insight – often revealing things we might not have thought to ask about or that the client might not have voluntarily offered up, particularly if they are not socially accepted or attractive qualities.
If you practice anything like me, then Vitex is an absolute reflex response (think the very funny reflex paper ad – that’s me in my clinic!) & godsend for most cyclical mood issues. However, apart from the fact that this woman’s key period of mood aggravation, although clearly related to her menstrual cycle, was day 5-14 rather than during the late luteal phase, there was another stand out reason for me why I definitely wouldn’t use Vitex. (more…)