How Low Can You Go…With Cortisol?

Assessing Adrenals can be hit and miss, especially given that even more so than other labs, timing is everything.  That’s why endocrinologists typically won’t look at anything less than a 24hr urine collection. If the total output is deemed to be high = Cushing’s and if it’s low = Addison’s. Sounds simple right?  But to say only values outside of this reference range flag a problem might just be a case of throwing the baby out with the bathwater (or urine in this case!). Especially given it has been established that humans frequently fail at correct & complete 24hr urine collection! Alternatively we can use saliva or blood assays and capture the cortisol at any given time point, comparing that to expectations based on diurnal rhythm – but again, how are the reference ranges for these ascertained and is there such as thing as low normal. high normal results for cortisol, that actually warrant follow up investigation?  I’m so glad you asked.

I see a number of patients who present with possible indications of flagging adrenals: from some distinguishing, but far from definitive features, in the clinical picture, to secondary lab markers. However, when they ‘limp’ over the line with their morning blood cortisol result I am often left talking to myself in an echo chamber about the need for more follow up.

But with the RCPA a.m. reference range of 200-650 nmol/L (Some seriously wide goalposts!) and some labs even going down to 150 with their minimum acceptable level for morning cortisol…are we right to still flag hypocortisolism (for any reason) as a differential in patients with low normal results?

Well Medscape yet again delivered Christmas 🤶 early last week with the largest study to date of blood cortisol, that has narrowed what’s ‘normal’ significantly…at least in terms of how low you can go before warranting further investigation.  In this study they tested blood cortisol in the morning and afternoon, in over 1200 individuals presenting at an endocrinology clinic to determine in real world terms how low is too low (and associated with an increased likelihood of genuine adrenal insufficiency). They then gave this new ‘minimum cortisol’ a bit of test-run in 2 other large cohorts of patients to check it really did work as an effective cut off and wham bang…we now have a fully validated bare minimum… and guess what…it’s 275 nmol/L in the morning and 250 nmol/L in the afternoon! 

Let’s be clear, their cut-off has what’s called a low ‘positive predictive value’ – which means most people (approx 2/3) with cortisol under this cut-off, upon further investigation (typically the ACTH stimulation test) will be found to be fine.  BUT the point of this study was to ensure we don’t miss patients with adrenal problems just because they have ‘within range’ cortisol…and this new cut-off delivers on that.

This is big helpful news actually.  Previously with patients who had am cortisol between 150- 275 we tended to find ourselves in ‘no man’s land’ – unable to provide enough of an argument about why adrenal insufficiency should still be on the differential list but unable to abandon that suspicion entirely.  Thanks Medscape!  Now if all the labs, RCPA and the referring physicians can just read this study and shift their goal posts…🙄

Our Group Mentoring 2020 Doors are just…about…to…close! 

TODAY!

So if you love labs (or want to learn to love them more), desire to be a better diagnostic detective than you already are and want truly independent mentoring in a collegiate and structured environment for next year and you haven’t applied yet…best shove your foot to hold that door open right now! We offer a range of different levels & types of special interest groups: from New Graduates & the Mental Health Primer group (for those wanting to upskill and focus on this area), from rotating case presentations in our regular groups which are a mix of funky similarly skilled clinicians, to our pure GP group…take our pick!  But get in quick by emailing us right this very second: admin@rachelarthur.com.au

Group Mentoring…What’s it all about?

 

For all those Mentoring Virgins 😇 out there wanting a clearer understanding of what it’s really like to be part of my group mentoring, this video is a little snippet from a session with one of my groups. This year has flown by and I have thoroughly enjoyed working with each fabulous group of dedicated ‘life-long learners’.

OH YES!!…and the real announcement is…..(drum roll)…
It’s that time of the year….Applications open next week for GROUP MENTORING in 2020! 

As a result of the generous feedback and insights from our current Mentees, we are always fine tuning our program & level of service. Yep…it just keeps getting better and better every year!! We are keeping everything that so many practitioners have told us they love from the past 7 years (wow….have I been doing it for that long?!) and simply improving the already incredibly popular formula, with some great new features for 2020.

  • New 15min Follow up with one on one with me! via Zoom for those cases that have been presented in our group mentoring sessions.  This is a brand new format to follow up on how your client is going after the session – what’s working, and what’s happening now, what should you do next? Rachel will spend 15 mins with you on Zoom 1-2 months after you presented your client case.  The recording will then be uploaded to Basecamp so the whole group can catch up on the progress and extend our learning opportunities again.
  • We’ve expanded our mentees 30% discount to ALL Rachel Arthur Nutrition products on our website for 2020. When you join the Group Mentoring Program, you will receive a discount code that you can use for any and all purchases on Rachel’s website throughout 2020 – the Update in Under 30 subscriptions, Audio and Video recordings, Packages on Pathology, Thyroid, Iron.
  • Certificate for CPE Hours – we’ve done this for the last 2 years and will continue to do so to make your CPE easier at your end
  • General and Specialist Groups – we’ve had a great response to our specialist groups this year, and we are offering these again in 2020, so you can choose from:
    • General Group Mentoring –our regular case presentation groups, with practitioners taking turns to present a case, or just listen in. Yes, this ‘fly on the wall option’ which we’ve come to learn is preferred by some praccies (due to a lack of time, good cases or confidence) is finally getting formalised for 2020!
    • GP dedicated Group  – this depends on our final numbers of applicants for 2020.  This year we had a combined group of GPs and naturopaths with advanced standing, which has worked well.  Either way, we have a good track record in catering to the needs of doctors, medical specialists and dual qualified naturopaths (osteo, psychology etc).
    • New Graduate Groups –  great opportunity for New Grads to build confidence as they leap from student to practitioner, or for practitioners wanting to refresh their core clinical skills such as MindMaps, Pathology, Improved Case Taking etc.
    • Mental Health Primer Group –  topic based to build on your knowledge in the role of naturopathic medicine in Mental Health – from screening tools to key management issues, specialist diagnostics and beyond.
    • Mental Health General Group Mentoring – practitioners presenting their client cases with a focus on primarily Mental Health presentations.
“I believe the mentoring you are offering is allowing me to develop myself into the type of practitioner that I want to be.
I really aim to provide evidence based treatments, and wish to utilise pathology testing results as one of the major diagnostics in my practice. I can see that every mentoring session with you brings me closer to that, filling my knowledge gaps every time. You and your knowledge base is so inspiring, and I only hope that one day I will know close to some of what you know!” – Andrea Robertson

And don’t forget some of the offerings our Group Mentoring consistently delivers as part of your program – the opportunity to learn every month via high level applied knowledge not theoretical and to see it in action with tracking and updates on patient progress, our incredible online resource sharing platform for communication and support between sessions and the opportunity for sharing of pearls of knowledge from my 20+ years of experience and research together with the collective wisdom and know-how of each unique group.

“I am one of Rachel’s New Grad mentees. My first year out has been pretty overwhelming and I wanted to let Rachel know that I have been watching the zoom sessions and have learned so much to take my clinical confidence and practice to the next level.  She has an amazing gift of nailing the important aspects of practice and giving useful usable information that brings together the fuzz of everything you have learned and ties it all up with a neat bow with her pearls of wisdom every month. I plan to be a mentee again next year (and for many years I suspect)”  – Bek Di Mauro

 

REGISTRATIONS OPEN 14 October!

 To read more about the program click here.
Information on how to apply will be released on 14 October. Join the waiting list now so you won’t miss out by sending us an email on admin@rachelarthur.com.au.

 

Get Plugged Into The Brain’s Trust…

Forehead USB not required. Phew.  All that is required, is a real thirst for new knowledge, rapid development of your diagnostic skills and a willingness to commit an hour every month to tap into your new Brain’s Trust: Rachel and a collection of colleagues with a shared desire (general practice or mental health-focused) and similar level of experience to you – new graduate, medical, naturopathic or dual qualification.  And take one great leap forward closer to being the practitioner you want to be.

The Rachel Arthur Group Mentoring Program has the longest (7 years and counting!!) and most impressive track record of practitioner satisfaction for value for money and meeting clinician’s key learning outcomes.

And the long-awaited good news is…we will offer our New Graduate Program, which debuted this year to much critical acclaim, again in 2020!

Being part of the 12-month group program allows you to connect to a community of like-minded, similarly-skilled practitioners in a structured teaching environment either via case-based presentations (regular groups) or via an interactive curriculum (New Graduates, Mental Health Introduction). You’ll be plugged into 11 other practitioners and together with Rachel’s brain, you’ll receive the knowledge and confidence to assess, investigate and manage no matter who and what walks through the door. Our profession thrives when we thrive as individuals and central to this is building networks of ‘similar others’ in order to find your tribe and benefit from the ‘collective’.

“Rachel is a wealth of information, she has such a knack for breaking down cases. All case presentations no matter how complex are nicely deconstructed into bite sized bits of information that’s easy to digest and take away and put into practice. This mentorship program is worth its weight in gold, it shows you how to deconstruct cases, develop knowledge, gain greater clinical insights and you’ve got a fabulous base of other knowledge practitioners you can ask questions. Can’t wait for the rest of the cases! And you can count me in as a second year mentee next year.” – Megan

In Group Mentoring you’ll be learning core clinical skills that you can apply in realtime to your practice and be able to ask questions along the way. The most valued aspect of the mentoring is the ability to discuss practice experiences with the mentor and to hear and learn from all the group members, sharing experiences, knowledge and learning as we go during the sessions.The bonus of these sessions is you’ll find your tribe, gain support and radically build your toolkit.

I love witnessing every practitioner’s growth, I want everyone to find mentors to support them in their career in integrative health. – Rachel

“Having the group session each month, as well as having Basecamp to bounce ideas around in, is a reassuring connection to know is there if I need it. Having just started practice this year and working in an environment without other Nat’s around, I have noticed the occasional feeling of isolation. So having the monthly catch up keeps me feeling connected to other clinicians and gives me exposure to other cases and perspectives that I wouldn’t have otherwise had.” – Georgie

 

Going by the landslide of registrations for 2019, Group Mentoring is fast becoming a popular choice and could be an integrative part of your practice & your career progression.

So if being part of the community excites you and if the thought of learning and benefiting from a collective knowledge base that is strong and pulls on expertise outside of our own, now’s the time to join the conversation through Group Mentoring.

2020 Group Mentoring Program Applications Open in October!

Read all about it here or email admin@rachelarthur.com.au to let us know you are interested.

When the Body Attacks the Mind

 

Following an important weekend of discussing mental health from a more balanced perspective (that’s my new less provocative term for ‘integrative’ or dare I even mumble…holistic) in Perth for ACNEM, I remain alert but not alarmed of how much is still to be revealed in this area.   Recently, for example, in our mental health dedicated mentoring group, we discussed a case of a somewhat atypical schizophrenia presentation in a middle-age female migrant.  Fortunately, I co-chair these sessions with an incredible clinical psychologist who was quick to pick up that no CNS auto-antibodies had been tested, and given the peculiarities of the case they should have. This is a relatively new area, in terms of more mainstream acceptance of this as a differential in some psychiatric presentations and provision of these tests now through mainstream labs, but it would appear it is far from common knowledge.   Then I read this brilliant article and…well I think we all need to read it.  Here are some snippets…

Scientists had previously noted that certain autoimmune diseases, such as lupus, were associated with psychosis. And they’d begun to suspect that some infections might, by activating the immune system, contribute to psychiatric conditions. But Dalmau provided meticulous proof that the immune system could attack the brain. The development of a test for the disorder, and the fact that very sick patients could recover with treatment, prompted a wave of interest in autoimmune conditions of the central nervous system. In total, scientists have identified about two dozen others—including dementia-like conditions, epilepsies, and a Parkinson’s-like “stiff person” syndrome—and many experts suspect that more exist…

Robert Yolken, a scientist at Johns Hopkins University, estimates that about one-third of schizophrenics show signs of immune activation (though he adds that this could be related to other factors, such as smoking and obesity). And autoimmune diseases are more common among schizophrenics and their immediate families than among the general population, which could hint at a shared genetic vulnerability.”

There are some potent practical take-homes in this article embedded especially within the story of an 11-year-old boy who was admitted to hospital with profound psychiatric features – initially misdiagnosed and managed as BPAD and later found to have autoimmune encephalitis.  First and foremost: psychiatric conditions develop gradually.  When there is an acute onset in the absence of an acute trauma – the possibility of a biological (esp autoimmune) driver should be elevated in your differentials. And the mother of this boy, now aged 21 and having undergone 5 relapses and recoveries in between, virtually echoes the thoughts and findings of Carl Pfeiffer half a century ago, when she says, “Too often, psychosis is seen as the disease itself but psychosis is like a fever, it’s a symptom of a lot of different illnesses.” Important for thought.

Milk Madness – Is it a thing?

Could dairy intake in susceptible individuals be a risk promoter for mental health problems?  In addition to evidence of the exorphin derivatives from certain caseins interacting with our endogenous opiate system discussed in part 1, we now look at the evidence in support of other milk madness mechanisms.  Specifically, the IgG and IgA antibodies about what this tells us about the patient sitting in front of us about their gut generally and about their mental health risks, specifically.  The literature in this area dates back to the 1970s but the findings of more recent and more rigorous research are compelling. Find out more here.

Secret Weapons for Integrative Practitioners

 

 

What makes integrative health professionals stand out is that we take the time and have the attention to detail to capture the ‘whole health story’ of each patient.  As a result, however, we  tend to end up with vast amounts of information for every client: detailed medical histories, broad systems-reviews, condition specific validated screening surveys, in-house physical assessment data, not to mention a pile of past pathology results…and that’s before we start our own investigative path!

So as you sit at your desk with a plethora of information in front of you, you’re probably thinking, ‘Great, so much valuable information – Oh dear…so much valuable information!’ and struggling to separate the critical narrative from the noise. 

Plagued by circular questions:  ‘Where do I start?’, ‘What needs to come first?’, ‘Which treatment objectives will pack the most punch for this patient right now?’, ‘What really requires further investigation and what can wait?’  … your thoughts jump around, from one shiny thing to the next…you can ‘see’ so many of the connections… but can you see them all, the whole interconnectedness, and therefore the prescription, laid out in front of you like a road map to follow?

Introducing the two essential tools (aka secret weapons)…

MindMapping & Timelines

… the actual practice of gathering vast amount of a patients case onto one piece of paper.
Yes, that’s what I said ONE PIECE of paper!

Sounds too good to be true?? Well, they don’t quite give you super powers but they will help you write the patient prescription for you and not just one prescription but typically, for the next 12 months.  These tools can turn good clinicians into great ones and, once you master them, save enormous amount of your time on your patient work-ups.  Relevant to all health professionals who use an integrated approach, the utilisation of these tools, will also reveal to you much about what you know, but didn’t immediately realise (e.g. the means by which gut dysbiosis contributes to impaired oestrogen detoxification), and just as importantly, highlight your knowledge gaps & therefore opportunities for further growth along the way (e.g. how do inflamed joints disrupt GIT tight junctions?).

As ‘whole picture people’ we bite off a lot!  It’s these systems, timelines and MindMapping, that Rachel has found help her, and so many other clinicians, truly ‘digest’ the case, optimising our understanding and management.

“I loved this session and think it’s very relevant. I have used these tools before, but never mastered them or used them regularly. I have mostly used mind maps for study, so I love this application and with practice, think I will get used to using them for every case.”

“AMAZING!!! Fantastic health links that I did not know and really consolidated my knowledge on how to produce a Mindmap and how to be better at it! Fabulous session. Thank you”

“Most difficult is challenging existing patterns of thinking around mindmaps and training my brain to approach it more effectively (plus getting faster).  This will come with practice.  Most satisfying is seeing how useful they can be when done well at the start in terms of time saving in the overall case (across years) and getting to the core (s) of the case. Great session!”

MindMaps & Timelines – Effective Integrated Patient Work-Up

In the Part 1 Video, Rachel teaches you how to effectively perform a case work-up that does justice to the holistic framework and model. At the end of this presentation there is a practice run for you to create a MindMap and Timeline. PDF sample case notes, MindMap and timelines are included.

In the Part 2 Video, Rachel demonstrates in detail how to put a MindMap together from case notes. You’ll be able to see ‘in action’ how to apply all the information from Video 1 and have all your questions answered. PDF’s of both slideshows are included.

and watch this presentation now in your online account.

 

One Direction Is So Last Decade…

With many of the mentoring sessions I run, I suspect there’s often a misperception that the learning is one way. Part of what thrills me about being a mentor is all the learning opportunities I am personally presented with.

Recently, I had an exceptional example. You see, I am privileged to have a colleague, Sonya Cacciotti, in one of my groups. She has worked for over a decade in tandem with an extraordinary doctor up here in Ballina, and they have had a particular long-standing interest in sleep quality, assessment and management. Consequently, her knowledge in this area is exceptional, particularly with regard to not just obstructive sleep apnoea (OSA) but the much more and often missed, upper airways resistance syndrome, that is especially common in women.  She’s been in my ear on numerous occasions and during group sessions saying, Watch out for this Rachel, it’s more common than we all realise and could be behind many people’s problems‘.

As luck would have it, I have seen a series of cases now within quick succession that all look suspiciously like undiagnosed apnoea or airways resistance. I was listening all along but now Sonya’s wise words and these conditions have my full attention. (more…)

Don’t get me started …

 

Screen Shot 2017-09-21 at 10.03.10 am

 

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…)

Is This You?

RAN Internship
When I was studying my undergraduate I sat at the front of the class, especially for the medical sciences.  My chemistry lecturer tried to talk me into transferring to chemistry.  My biochemistry lecturer tried to convince me to become a biochemist.  But what I loved was the union of the two: medical sciences and naturopathy.  As a student I hogged all Q and A opportunities and I am confident I annoyed many many people.  If this sounds familiar, not because you were a classmate and I still annoy you (!), but because you could also be labelled a ‘lab lover’, a ‘pathology perv’ and an EBM evangelist…then this might just be for you.  You can find out by answering these Qs…
(more…)

Finding YOUR point of difference

odd one out

I really enjoy mentoring practitioners in business – it’s a real privilege to be able to hear about each practitioners’ aspirations and challenges.  A few weeks back I had the good fortune to speak with a fresh one!  A practitioner who has only been in business for a short period of time.  As always before our session,  I looked over all aspects of her online presence from her website, to her practice newsletters, Facebook presence etc. Goodness how things have changed from when I graduated and you literally just hung out your shingle!!  As much as the online world has created incredible opportunities for people working in integrative health and the public who use our services, I think it has also of course brought the ‘competition closer’.

 

(more…)

Business Breakthrough Sessions with Rachel

Business Mentoring Breakthrough Session

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…)

What Do You Do For Post-Partum Hashimoto’s Thyroiditis?

 

Like all thyroid disease, post-partum thyroid conditions seem to be on the rise – and often they rewrite the rule book when it comes to thyroid pathology & its management. Therefore for many of us it can add an extra element of uncertainty about how to help these clients.

One of our graduate practitioners has a great example of this, a 33yo female who developed late gestational diabetes and is now struggling with a new baby and an autoimmune thyroid disease!  What would you do?  Does post-partum thyroiditis have unique triggers/drivers that require specific treatment? What can you/should you be doing differently because she is still breastfeeding?  What’s the likely progression/prognosis?

This is your invitation to come along and find out the answers to these questions and more.  During our live graduate mentoring session on Monday 15th June at 3.30pm AEST we’ll work through all aspects of the case, from history to presentation and from looking for clues in her pathology results to where to start with treatment. (more…)

Is This Your Month to Start Mentoring?

We’re ready to begin another year of group mentoring from this Tuesday and we’ve got just 6 spots in total still available across all our time slots! Maybe you’ve heard the buzz about the sessions from some of our mentees over the past few years & are tempted but have been holding back or deliberating…now’s the perfect time to join in, while we’re all coming back from a break and the groups are reforming and settling.  To boot we’re offering newcomers, a special 6 month package to get you started: attend yourself (or if necessary receive an audio recording when you’re unable to) all sessions from January to June at a reduced price https://rachelarthur.com.au/product/special-6mth-group-mentoring-package/ (more…)