“Two great speakers – inspirational in the first half and bang on in the second – I now know how much I don’t know”
Just out now in time for Christmas…no seriously though… this year I had the good fortune to team up with Biomedica and in particular Rachel McDonald and we delivered a 3 hour seminar called Mental Health in Holistic Practice. The intention behind this collaboration was to shift the education focus for practitioners from a prescription based approach, to one really about the clinical reality of managing mental health clients. Probably most of you will agree that the ‘treatment’ counts for only a portion of the positive outcomes in your patients and this is particularly true in clients challenged with mental health issues. After more than 20 years in practice working in this area, I’m keen to share what I’ve learned so other practitioners can get there much much faster! (more…)
Apologies for having a one-track mind currently but yes I’m still banging on about the thyroid this week. You see, this year in my own clinic I connected up some dots I hadn’t connected before via a series of young female patients. Each of these women presented with some hypothyroid features, most notably, low basal body temperatures, fatigue and weight gain and while their thyroid hormones (TSH, T4 and T3) were all technically ‘within range’, their T3 levels were very low (low 3s) and the TSH seemed to sit low as well (<1.5). Normally of course, when T3 levels drop we expect TSH secretion from the pituitary to rise in response, as a means to correcting this dip, however, this part of regulation appeared ‘blunted’ or even ‘broken’ in these women.
So why would their pituitary be sleeping on the job, allowing them effectively to experience long term suboptimal thyroid function?(more…)
Just been speaking on the thyroid at ACNEM last week and am finding that practitioners across the board are getting more and more curly thyroid cases. One scenario that we increasingly see is something that might be described as ‘T3 resistance’, when your patient’s T3 value looks healthy but they continue to manifest the signs and symptoms of hypothyroidism. There are several differentials to consider of course (more…)
I’ve learned a lot (!) and as always that learning has principally driven by my clients – their pathology, the diagnostic investigations we’ve employed to better understand the drivers behind their conditions, their response to various treatment approaches & of course a million other subtle thing we’re learning along the way. The other teachers are the many practitioners I interact with on a daily basis as part of our individual or group mentoring sessions – whether it’s some curly question or problem they bring that throws me into the scientific literature searching for answers or a fabulous bit of wisdom they bring to the table themselves, it’s a great reciprocal learning environment. You know, the most common thing I hear from naturopaths is the frustration they feel at the limitations of their under-graduate education and how it is only since graduating that they’re ‘learning all this stuff” but in reality, as with most health professions, the bulk of the learning has to happen on the ground.
I’ve been in practice for about 20yrs (ouch!) and I don’t think my rate of learning has slowed at all. It’s great if we can view this as the eternal fountain of inspiration that keeps us motivated and engaged in our profession…no not every minute of every day…let’s be realistic now…but overall it’s a strength not a weakness 🙂
Over the next month I’m being let loose on the major capital cities thanks to Nutrition Care to for a series of evenings of case study discussions – bringing together quick teaching points from all the things my clients have taught me this calendar year. Whether it’s from a diagnostic or treatment & management perspective I’ve got some juicy morsels to share! I hope you can come along and we can learn from each other yet again as a nice way to reflect on the year and our ever –growing profession…. If you’re interested in attending contact your local Nutrition Care representative for more information or call them on (03) 9769 0811
I’ve been re-reading lots of studies for a talk I’m delivering at ACNEM in Melbourne, investigating the relationship between selenium and a myriad of thyroid pathologies: from hypo- to hyperthyroidism and from subclinical thyroiditis to cancer. The sheer number of trials is overwhelming & increasing, in fact I think there’s more every time I go back and look (!) and the bulk of the findings keep telling us yes! yes! yes!…selenium plays a pivotal protective & corrective role unmatched by any other nutrient. Whether it’s buffering the oxidative stress that comes with high TPO antibodies or lowering antibody titres, preventing or minimising the orbitopathy associated with Grave’s or simply maintaining a better level of T3 in euthyroid individuals, there are numerous potential positive effects from selenium supplementation …in the right patient… and therefore this is the bit we need to be clear about: while the majority of both epidemiological and interventional studies all concur that low selenium levels equate with a greater risk of thyroid issues in all our patients & poorer outcomes in patients with already established thyroid disease, the big question ishow low are we talking?? (more…)
When I grow up I’d like to be a few different things, forget any ballerina or astronaut aspirations, my list includes a clinical psychologist, an integrative psychiatrist and last but by no means least, an endocrinologist. I’m fascinated by hormones, their regulation & incredible interconnectedness and the longer I’m in practice and the more patients I see with hormonal issues, the deeper I dive into the endocrinology texts (Endocrinology by Greenspan & Baxter is an absolute favourite of mine and you can now purchase this as a download to your computer which is super handy). I think (more…)
When I started studying naturopathy I quickly became full to over-flowing with inspiration that everyone could achieve wellness simply by making better choices with their diet, their lifestyle, activity levels and perhaps some slippery elm thrown in. As a senior student and then later again as lecturer, I played ‘spot the first year student’ – they were always the ones biting into a whole capsicum like an apple at lunch time or drinking copious amounts of green pond scum, obviously infected with the same fervor that I’d experienced. During my studies, I certainly didn’t foresee myself prescribing the amount of supplements I do in my practice today. So what happened to my grass root ideals? Did I go wrong somewhere to end up being so prescription heavy now? (more…)
Recently in our group & individual mentoring sessions we’ve been looking at lots of patients’ urinary iodine results. Many of you will know that I’m a bit of a fan of doing spot urinary iodine testing to gain some understanding about patients’ iodine, in spite of several well-documented limitations of the test. The first thing to remember is that urinary iodine has a diurnal rhythm, parallel to the rhythm seen with the thyroid hormones, so urinary values will fluctuate throughout the day. We can get around this by always asking patients to collect the sample at the same time – preferably a fasting early morning urination, which represents the lowest iodine concentration in a day. That way we know we’re always comparing apples with apples. The second limitation and frequent cause for misinterpretation of results is not allowing for the concentration/dilution factor of the urine sample.(more…)
Globulins…ever thought much about them? Me neither really unless they were clearly below range which made me consider immune impairment but recently Dr. Michael Hayter, who I am co-presenting the Diagnostics Master Class (Health Masters Live) with, inspired me to take a closer look! Globulins are typically reported in your patients’ E/LFTs or standard chemistry and they refer to a big group of molecules including CRP, transferrin, lipoproteins and yes all the immunoglobulins/antibodies. (more…)
As most of you know, I’m a big fan of establishing good communication with the other practitioners (GPs, psychologists, osteopaths, specialists etc.) also caring for my patients and what began as occasional letters that I found exasperatingly difficult & time consuming to write has become second nature. That’s not to say every letter I write now hits the spot & evokes the desired response but I think I’ve got a pretty good run rate. So I put together some tips that I thought might help you either get started or get SMARRRTer at it!
S – Service
M – Medical language & conventions
A – Accuracy
R – Reasonable
R – Rationale
R – Respectful
T – Time-conscious
Service
A summary of the most important medical aspects of the case is a great time saver for other health professionals & assists them in making better informed clinical decisions
Summarise key points of reference
e.g. Betty Smith (BMI 36kg/m2, Waist 92cm)
e.g. Depression (diagnosed 2010, Zoloft 100mg/d)
Pick out the salient features of the case
What are the absolute must-knows in the case?
Medical language & conventions
Only use medically accepted terms & diagnoses
e.g. avoid naturopathic speak such as dysbiosis, adrenal fatigue etc.
Quantify EVERYTHING relevant
e.g. weight loss/gain (7kg in 3mo), DASS scores, stool Bristol type & frequency
Include all units of measurement
e.g. 4.6 mmol/L, 129/84 mmHg
Summarise medical hx in table form for easy reference
Accuracy
Clarify which details you have first-hand Vs second hand – be careful not to be part of Chinese whispers
e.g. patient reports being diagnosed with lactose intolerance
When including patients’ own words – use quotation marks
e.g. patient reports feeling “dizzy & vague with brain fog most days”
Clarify if some things have been self-prescribed – otherwise the assumption will be that you gave/recommended it to them
Reasonable
Don’t use a scatter gun approach when suggesting investigations
Try not to ask for subsidised testing that the GP is simply unable to do under subsidy
e.g. Full thyroid function test can’t be subsidised without a prior diagnosis of thyroid disease or TSH outside of reference range…WEIRD BUT TRUE
Rationale
Present a brief, clear justification for any requests
e.g. Iron studies (vegetarian diet)
Include appropriate references when the justification is likely to be beyond expected knowledge
e.g. as a deficiency of this vitamin has Vitamin D – both 25 (OH)D & 1,25(OH)2 D, been implicated in a large number of autoimmune conditions assessment of both forms is recommended (Smieth et al. Vitamin D in Autoimmunity. Am J Clin Nutr. 2013)
Respectful
Ask for their assistance/insight/review/guidance
Don’t forget – you want & need it!
Keep in mind also how the relationship your patient shares with this practitioner may be positively or negatively impacted by the respect & tone of your letter
Time-conscious
How far in advance should the GP receive your letter in order to give him/her adequate time to read & digest the content?
e.g. too close to consult – GP might understandably feel ambushed/rushed/unprepared
How much time does a GP or other professional have to spend with each patient?
In summary the less words the better – look for ways to reduce your word count, cut to the chase and ideally get most letters down to 1 page
