I’ve had a bit of ‘a bee in my bonnet’ this year. I heard that! Ok, arguably it extends a little further back…like my whole career! But if you’ve seen the topics I’ve been speaking on at conferences in recent months, you’ll know exactly the soapbox I’ve climbed up onto. Inter-professional communication & collaboration. My particular focus (naturally 😉 ) has been current issues regarding the sharing of, and access to, pathology results for our shared-care patients. However, in the face of several distinct threats to the practise of both naturopathy and medicine in Australia of late, especially in the form of anti-collaborative rhetoric/push affecting both professions right now (read PHI reforms, promptly followed by proposed MBA review..if you haven’t read this regressive and repressive set of recommendations you seriously must), the question of how to improve collaboration in order to ultimately serve our patients better, has never been more urgent.
Last week, at the ICCMR conference, I outlined the current barriers for naturopaths to accessing patients’ pathology results (current and historical) and the heightened risks that this results in, either because of incomplete information or because of the subsequent direct pathology referring by naturopaths. Yes, bypassing the GP and another set of trained eyes on your patients labs comes with risks. I also spoke to the opportunities that await us if we can overcome this: in terms of improved patient outcomes, reduced risk, more economically responsible public health budget spending etc. etc. need I go on?! In the Q & A following my presentation, a doctor in the audience made two very important contributions, which deserve some additional air…she said:
“Shouldn’t the patient ultimately own their own pathology results? Then it would be a case of them electing who has access to these: their GP, their naturopath, their osteopath. Rather than the other way around – after all, we are all supposed to be members of their health care team, right?”
She said it. Not me. But I applaud her. She’s right of course. Right now, under the current proposed changes, we and integrative health care delivery and patients’ right to choose and self-direct their healthcare and public health budgetary burden…are all under threat of de-evolving. Right at the time when, with the current chronic disease burden and predicted public health budget blowouts, it should be all hands to the pump! Who has ever conducted a cost-benefit analysis of what integrative health care (successful patient sharing between naturopaths and GPs /specialists) saves the government? No one is my guess and when I proposed I do exactly this for my PhD on a particular parameter some years back, I was not so subtly told, that in spite of a great application, given the primary funding of the research group was from government, and a clear conflict of interest with the head researcher who was also a government advisor, ” my proposal was not in line with the current directives”. Yep.
Last week, a dear mentee of mine mentioned that a GP one of her patients sees responded to her respectful correspondence regarding their shared patient with absolute terror, citing possible de-registration if they are seen to be collaborating or interacting with her in any way…assuming the MBA changes go through. This doctor then decided the lesser risk, was to cease communication with this other key member of the patient’s health care team, not refer the patient for any follow up investigations (including those representative of basic duty of care) and certainly not enable access to any pathology results for this patient from the past or in the future. My mentee’s exemplary response to this doctor:
“My apologies for placing you in an uncomfortable position. I do understand the restrictions and guidelines GPs must work within for Medicare and AHPRA and understand that as you are the requesting practitioner you are liable for any pathology referred for. I make this clear to all my patients and that my referrals are on a request base only and it is up to yourself or the requesting GP for the final decision. I only try and request pathology through a GP or other medical practitioner to try and minimise both risks (of only myself viewing these labs) and unnecessary costs to the patient.
…’X’ has currently been seeking medical and alternative treatment for over 2 years and yet has had no change, if not a worsening of his condition and when I saw them 2 weeks ago, it was my understanding that not even basic assessment of full blood count, liver function and other general health markers had been completed. I had advised X that not all pathology may be covered under Medicare, and to come back to me so I could send him privately for those tests not able to be completed under Medicare. My apologies this was not made clear to you at the time of his appointment.
I take pride in my evidence-based approach to nutritional health in my practice, and work frequently with other patients’ medical practitioners in supporting their health. Thank you for your time and I appreciate your thoughts on this matter”
If the patients’ best interests are no longer the primary goal, as decided by bureaucrats, both government and organisational, is it time to ask the actual health professionals to please stand up?! Is it tipi-talk time for practitioners from all disciplines? Growl over.
Want to ensure you are writing professionally to other health care practitioners? Then our recording and resource Dear Doctor, is for you!
In this 45min podcast Rachel succinctly covers the serious Do’s and Don’ts for your professional letter writing. Rachel gives step-by-step instructions and examples for key phrasing and clear medical justifications, what terms to use when in order to come across respectfully, and how to present urgent red flags without sensationalising. This podcast is will help your professional letters improve collaboration for you and your patients need.
Let’s talk turkey about our pharmaceutical Pet Hates, mine are Proton Pump Inhibitors (PPIs). They irk me more than any other drug class. It’s not entirely rational. Let’s face it, they have some stiff competition but for some reason, in my mind, they almost always win: helping so little & at such a high cost to patients. What fuels my fire of course is their over-prescription, followed closely by the complete disregard for the prescribing guidelines which state:
“When clinically indicated, PPIs should be used for the shortest duration necessary and chronic use is not recommended except for treatment of pathological hypersecretory conditions including Zollinger-Ellison syndrome and maintenance healing of erosive oesophagitis.”
Sorry…did I hear you correctly? Chronic use is not recommended – yet this is one of the drugs most commonly on ‘set and forget mode’ in general practice. To boot, their chronic use has been associated with a number of serious concerns, which I’ve touched on before, from osteoporosis to increased rates of GIT infections. not to mention just the little ol’ detail of malabsorption of multiple nutrients! But this week, yet another health concern has popped up and into my inbox…and well..I found myself shouting at the medical newsfeed on my screen…[again] 🙁
“In their analysis, more than 42,500 adverse events reported to the US Food and Drug Administration by patients on PPI monotherapy were compared with more than 8300 reports from patients on histamine-2 receptor antagonists (H2RAs)….Patients on PPIs alone were 28 times more likely to report chronic kidney disease than those taking H2RAs, while the frequency of acute kidney injury reports was around four times higher…Reports of end-stage renal disease were 35-fold higher among PPI users, while reports of renal nephrolithiasis were three times higher”
To be clear, while these increased rates are TERRIBLE and unacceptable in the context of the ‘set and forget’ prescribing that seems it be rife in most countries, they still only effect a small % of patients e.g. approx 5% of patients had adverse renal effects on PPIs Vs 1% on the older generation H2 blockers for reflux but it’s yet another reason (like we needed more?!) to think twice before our patients are initiated on these meds, which are presented to patients as being benign. Typically with drug development, the older drugs in a class are superseded by newer ones that are ‘cleaner’, and therefore more effective with less adverse effects but this is one situation where if one of my patients really did need a med, I would say out with the new and in with the old!
One scenario where PPIs in combo with multiple antibiotics get routinely rolled out is of course H.pylori infections. But does this make sense??
For a bacteria identified just a few decades ago as being a cause of chronic gastritis, atrophic gastritis and gastric carcinoma, the escalation of number of antibiotics used to eradicate it (4 at last count + PPI) has been nothing short of breathtaking. A management approach more consistent with both integrative medicine and with an improved understanding of the delicate microbiome focuses on changing the gastric environment to ‘remove the welcome mat’. What do we know about how to do this successfully? It turns out…quite a lot. You can find out here with our previous UU30: H.pylori- Eradicate or Rehabilitate?
So you’ve gone to all the effort. Be that writing referral letters suggesting some pathology investigations might be warranted or you’ve coached your patients endlessly to get copies of ones done elsewhere so that you may be privy to their findings. Worse still, you’ve directly requested the pathology, with your patient paying out of pocket for the tests. Then the results come in and they look…well wrong. You, as the conscientious clinician, typically do 3 things:
Step 1 Spend hours pouring over & over the labs and back over the case notes
Step 2 Worry about the new differential diagnoses that are now suddenly seemingly a possibility in your patient. It doesn’t look good.
Step 3 Doubt your own pathology reading ability, ‘Hey maybe I just don’t understand these bloods like I thought I did’
But (often)…it’s not you, it’s them.
And that’s what I often explain to practitioners who contact me (step 4). You see sometimes what they’re losing sleep over are what I call, Bad Bloods. Occasionally, the fault of the pathology company…but way way way more often the fault of the patient and the referring practitioner, who has not educated the patient correctly about what to do and not do prior to blood collection for certain tests. I am excited to see how many practitioners are competent with pathology reading these days and building their skills and confidence all the time, that’s why it is so so disheartening for the practitioners (and for me as a mother hen mentor) when they lose time (& sleep) getting to Step 3 when they should be able to spot ‘Bad Bloods’ fast. There are 7 classic give-away patterns.
Will are unlikely to know every quirk of every blood test our patients will ever have done, but knowing what constitutes the ideal time and conditions for the most commonly performed ones, can go a long way to minimising any future Bad Bloods between you and patient as well. This includes things like exercise, alcohol intake, duration fasting and even sexual intimacy…yup!
This month’s Update in Under 30 installment Beware of Bad Bloods teaches you the 7 patterns to watch for and provides you with a great resource stipulating the best collection conditions for the most common blood tests. Don’t let Bad Blood come between you and your patient, the right diagnosis & management or just some well-deserved sleep!
Good practitioners are being led to bad conclusions by some patients’ pathology results. Not because they can’t interpret them or the testing has no merit but because they just don’t know when to discard a set because they are ‘bad’. Occasionally, the fault of the pathology company but much more often the fault of the patient and the referring practitioner, who has not educated the patient correctly about what to do and not do prior to blood collection for certain tests. This recording clearly describes the 7 classic give-away patterns of ‘Bad Bloods’ which will enable you to spot them fast in the future. In addition to this. while we are unlikely to know the idiosyncrasies of very lab our patients will ever have done, knowing the ideal collection times and conditions for the most common ones assists you and your patients to avoid any in the future – handy clinic resource included.
Hear all about it by listening to my latest Update in Under 30: Beware of Bad Bloods.
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.
Never say never, right. Back in my old uni teaching days, I scorned the very notion of treating someone with ‘actual melatonin’. Always in favour of upstream approaches over downstream, I was keen instead to give patients the ‘ingredients & cofactors’ so they could whip the right amount up themselves. Well fast forward another decade in clinical experience, and research too, and while I refuse to give in with many other ‘replacement remedies’, melatonin, has snuck well and truly into my list of treatment considerations for some very specific presentations such as silent reflux, treatment refractory GORD and Barrett’s oesophagus, buoyed by some amazing clinical successes. So much so…that in fact I’ve embraced this replacement approach, whose results in this setting especially, can’t be replicated by treating with ingredients and cofactors. Turns out of course I am not alone – melatonin has won a lot of fans over the last decade.
A recent Australian article from 6 minutes revealed a significant increase in GPs prescribing melatonin for sleeping issues in children and then of course, there is its substantial use in cancer and typically at mega-doses that will make your toes curl.
But always in the back of my mind is the old me. Whispering things like, ‘ but melatonin isn’t a nutrient, nor a herb, so it’s not naturopathic’ – hence we can’t even prescribe it, needing to refer patients to others for access and yet more pressing, ‘what do we really know about the full implications of replacing such a potent and ubiquitous neurotransmitter?’ I know. This old me, she’s annoying, right.
But she’s also important.
So absolutely perfect timing then to hear about a homegrown (2 Aussie Naturopaths in fact) systematic review on the adverse effects & safety of melatonin which is full of important and surprising info and I think ….everyone…single…one…of…us needs to read it:
“While this review reveals a high degree of safety for melatonin with few adverse events that cannot be easily avoided or managed in most populations, it also reveals lack of clarity regarding melatonin’s relationship to endocrine processes, and its effect on hypertensive patients and potential drug interactions in this population.”
But the devil is in the detail.
So here’s a newsflash for you – 4 human studies found melatonin had negative effects on key aspects of reproduction, like sperm counts and ovulation and not at mega-doses my friends, no…at 2mg/d over several months. We shouldn’t be surprised, right, melatonin is critical to fertility cycles in all other animals…but how many health professionals know this, or not just know it…but make our recommendations with this in mind? Other studies reported fascinating impacts on insulin sensitivity (5mg) and amazingly, (or not being the king of all things circadian), opposing effects depending on the time of administration. Then there’s the drug interaction with anti-hypertensives…a negative one, I must add. No information still unfortunately about the impact of long-term replacement on our own endogenous production. Anyway…enough spoilers… READ THE ARTICLE. This hasn’t wiped melatonin off my list of potential recommendations all together but it has given me some serious food for thought and much greater clarity about in whom this suggestion should be off the menu.
‘Melatonin – Misunderstandings and Mistakes’ – this important 2017 clinical update about what we are getting right and wrong with Melatonin answers in particular, one of the most common sources of fascination & frustration for clinicians, the reasons behind the Melatonin non-responder. We’ve all encountered patients who have taken Melatonin for sleep problems and reported no benefit, or initially responded and then lost efficacy quickly, or even patients who experienced insomnia after taking. What does this tell you about your patient and what should you do to resolve this and better still, prevent it? This UU30 from 2017 reveals all!
Finally a systematic review puts paid to the nonsense that ‘withdrawal from antidepressants’ is problematic only for a few, is ‘mild’ & ‘lasts only 1-2 weeks’ with no treatment necessary other than reassurance, which is still being perpetuated by current prescribing guidelines both here and overseas. In fact their review found that 56% of patients experienced problems with stopping antidepressants and the majority of these rated these as ‘severe’. Back in the good/bad old days when I worked for a pharmaceutical company who made psych meds the phenomenon of an ‘initiation phase’ during which time suicidal risk was heightened, was acknowledged and freely discussed…in-house at least. However, the concept of a ‘withdrawal syndrome’ was less clear. Anyone who has witnessed patients coming off ‘even the cleanest’ SSRIs will speak to a potential myriad of worrisome experiences including…
“Typical AD withdrawal reactions include increased anxiety, flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal. Dizziness, electric shock-like sensations, brain zaps, diarrhoea, headaches, muscle spasms and tremors, agitation, hallucinations, confusion, malaise, sweating and irritability are also reported (Warner, Bobo, Warner, Reid, & Rachal, 2006, Healy, 2012). Although the aforementioned symptoms are the most common physical symptoms, there is also evidence that AD withdrawal can induce mania and hypomania, (Goldstein et al., 1999; Naryan & Haddad, 2011) emotional blunting and an inability to cry, (Holguin-Lew & Bell, 2013) long-term or even permanent sexual dysfunction (Csoka & Shipko, 2006).”
Previously termed ‘discontinuation syndrome’ by expert panels – to distinguish these inconvenient effects from the more seriously viewed (read nasty) benzo-associated discontinuation problems – was an act of smoke and mirrors, according to this scathing and insightful review by Davies and Read, who argue strongly this is a clear cut withdrawal picture and it deserves as much consideration and concern. In particular they point out that of course, patients can experience these symptoms even without ‘discontinuation’ – but simply as a result of a delayed or skipped dose, an intentional dose reduction etc. And they provide the alarming context that one third of people in the U.K. (and likely similar developed countries) who take antidepressants for more than two years have no evidence-based clinical indications for continuing to take them. But wait..I’m just getting to the worst bit, this is the part that gets me personally…having been a peddler in the past of these meds and in certain patients still spruiking their benefits, I am in no disagreement about them being necessary, helpful & even life-savers in some patients…yes I have seen this too many times to ignore it…BUT…and now this is where I start raising my voice a tad….
Patients need to make informed choices, and having a clear understanding of what you are likely to experience on any given medication has been shown to improve outcomes but according to the 2 largest surveys conducted to date,< 2% of antidepressant users are being told any of this. Do you know why? Well, let’s start with the misleading guidelines… if the RACGP says it isn’t so…then can we expect their GP to know or say any differently?
Grrrrrrrr…. yes that’s me…not a wild animal in the room with you.
Because you know what happens in the absence of this?! And let me say I have also seen this too many times to ignore as well, people feel compelled to stay on them & this is truly heartbreaking to witness. The experience of a reduced dose or a period without is so terrifyingly disconcerting to that poor unsuspecting individual, and without explanation, is misinterpreted by them (and according to this review often by their doctor as well!!) as being either a sign of their inherent mental instability and need for ongoing medication, or misdiagnosed as a separate condition. Ok…apologies, this is over a decade of pent up frustration…resurfacing as a result of reading this incredibly important and disturbing review. I think I need a little lie down now 🙁
Helping patients off anti-depressants is a challenging and important function that must be initiated by the patient with the full support of the prescribing practitioner, however there’s a role for complementary medicine here too. Rachel walks you through a range of strategies and when you might consider each. Listen to the free sample here from the Update in Under 30 from 2013 – Leaving Anti-depressants Behind. Or perhaps you’re interested in all things Mental Health and should find out more about our specialist mentoring group running in 2019.
As an avid reader of medical news I face a barrage of headlines both domestic & international everyday. I feel this is important for many reasons – not just so that I know what’s being said about their medicine but what they’re saying about ours as well! Anyone see the jaw-dropping headline last week: Could Probiotics be bad for your gut? Yep.
Now how many of you didn’t make it past the headline? It’s hard isn’t it.
There’s almost a reflexive shutdown for many of us to dismiss such a proposition as simply ‘ridiculous’, surely on par with our response to an article from a climate skeptic…as we shake our heads with ‘you gotta be joking right?’… but unless we read on, we’ll never know. (more…)
Not long ago, Kathryn Simpson and I were sharing a hotel room on yet another work trip to somewhere. The lights were out, it was way past our bedtime and we were just gasbagging incessantly like a couple of teens, when a thought pops into my head:
“Hey Kathryn, back when you were my student, did you ever imagine this scenario in the future – you know us being colleagues and friends and having slumber parties full of laughing?”, she replied, “Well no, but you know what I REALLY never could have imagined in my wildest dreams…the Australian Naturopathic Summit and you inviting me to be a co-founder of something that’s had such a big impact! That one I just didn’t see coming!”
Well to be honest, neither did I but sometimes I just have an idea that won’t leave me alone and is too important and too promising to ignore. Three years ago when I shared one of these, the vision of a national naturopathic conference by naturopaths for naturopaths, that would lift us all professionally, offer collaboration over competition and provide us the highest level of non-biased education, with Nirala Jacobi, turned out she’d been visited by the same thought bubble. Then I approached Kathryn, who was working for me at the time and pretty fresh out of uni but full of passion and drive about building a better ‘new’ naturopathic career path, one that supported rather than splintered those emerging out of great courses into a harsh, challenging professional space.
Time-travel forward to now, we are just 10 weeks(ish) out from erecting the chai tent, marquees and lanterns, for the second inception of this extraordinary thing called the Australian Naturopathic Summit 24-26th August at Lennox Head.
This is the culmination of 3 years of work from us, one paid project manager and the exceptional generosity of over 25 of our naturopathic idols, thought leaders and torch bearers who are donating their time to present plenaries, workshops, case studies, panel discussions… because they believe so strongly in the cause and the need for such an event.
If you think I am running out of breath between all these words..I am. This thing…has taken on a shape and life much greater than even we had envisioned.
If you follow the work I do – you’ll know that I am passionate about collaboration over competition. I could never have come to this place in my career without the input of many (some who remain on speed dial even now!) and through my mentoring programs, the infamous RAN internship and hopefully times we’ve come across each other…I’ve encouraged you to do the same and by doing so, grow bigger together. So just imagine the value of collaborating face-to-face…over 3 days…at a festival in Lennox Heads… ? And not just for 1 hour, but for 3 full days with 100’s of other practitioners from all areas, specialities and locations. Oh and if you’re thinking you’ll just have to wait ’til the next one’…SPOILER…there is no guarantee of a next one! Being a passion project that we 3 donate our time to, for you, it requires your support to keep it going.
So with saying all that…..(cajon roll…that’s a drum for you non-hippies)….It is with great excitement and enthusiasm that today I can announce a special deal for RAN subscribers. Yes….that’s you! Just like myself you all see a need to grow and build skills, knowledge, competence and confidence in the practice of naturopathic medicine. Come join the very best of your profession and take up this special offer to attend the second independent Australian Naturopathic Summit held in Lennox Head on 24-26 August.
To get 15% off a full 3 day pass enter Festival at the checkout
Book your tickets before they run out at www.australiannaturopathicsummit.com.au.
For information or questions about this special email email@example.com.
This summit is unprecedented in Australia for the following reasons:
- It is free from commercial bias
- It is about professional development, improving our practices and career paths, not products
- The primary objective is to support the Australian Naturopathic community, celebrating our diversity and creating a platform for our own Naturopathic torch-bearers in various areas (Practice, Research, Herbal Manufacture, Corporate Health, Entrepreneurship etc.) to help light the way for the broader professional community
This year our theme for ANS 2018 is ‘Coming Together On Common Ground’
Naturopathy has many different practices and paths,
but we all work for the same purpose, guided by the same principles.
The ANS 2018 program has three distinct themes across the 3 days…
- Friday 24 August: Custodians of the Vital Force
- Saturday 25 August: Upskilling Your Clinical Practice
- Sunday 26 August: The Business of Business Development
The morning of each day consists of plenary sessions followed by a lengthy lunch break that allows for networking, beach walking, guided outdoor meditation, perusing the vendor village, or simply enjoying the festival atmosphere in the beautiful outdoor location that our summit is surrounded by OR for those die-hards some amazing case studies presented by the likes of Jason Hawrelak, Dawn Whitten and Sandra Villella. Afternoon sessions are workshop-style, designed to be more interactive. There are plenty of workshops to choose from to keep you riveted and inspired.
We have created a jam-packed program to do just that.
Download your copy of the full program here!
ANS 2018 – come join the very best of your profession.
Book your tickets before they run out at www.australiannaturopathicsummit.com.au.
To get 15% off a full 3 day pass enter Festival at the checkout.
For information or questions about this special email firstname.lastname@example.org
Quite the month for it, I hear. My inbox has run hot with practitioners deeply concerned about some serious finger pointing that’s been going on.
The fingers in these instances have belonged to medical practitioners and the direction they’re all pointing, is seemingly at any complementary medicine their shared patient is taking.
Here’s a couple of good examples: “Your high blood pressure is the result of the combined mineral formula you’re taking!” These were the words of a GP to a 50 something female patient when he discovered she was taking a calcium, magnesium, potassium containing formula. The patient was hypertensive at the initial appointment, at which time the naturopath encouraged her to actually seek review, assessment and prescription of an anti-hypertensive, however the patient declined. The nutritional prescription was recommended in response to high acidity (raised anion gap) and prematurely low GFR (impaired renal function). Patient’s HBP continued to be problematic so the next doctor she sees, points the finger and says, it must be this product!
Would anyone like to explain that to me? In fact, that was my advice back to this very concerned and understandably rattled practitioner…just to cordially request the GP to outline the mechanism by which this might occur. (more…)
I was just reading the results of a spot Facebook poll of GPs asking what the most wonderful medications ever invented are. Once everyone got the customary “caffeine” gag out of the way, the rest of the nominations and auspicious award winners unfolded like a who’s who of the modern medicine prescription pad. Naturally, Penicillin took out first prize (no surprises there unless you’ve been living under a rock…a very clean sterilised one at that that!), one vaccine made the top 10 but I thought there were a few unexpecteds in here:
1. Penicillin “Because of it, entire nations can now afford to worry more about diseases of old age rather than infection. Penicillin’s success ushered in the era of modern pharmacology. To be fair, alongside antibiotics were profound improvements in housing and sanitation.”
2. Smallpox vaccine according to the author of this poll Dr. Justin Coleman,”was a triumph of research, pharmaceuticals, human cooperation and public health planning.”
3. Contraceptive pill for changing the lives of women all around the world. True but BOY does it change it for the worse in some!! (more…)
If you receive the free Medical Observer newsfeeds you’ll know what I’m talking about. Here are some recent headlines:
I stand accused of rorting Medicare. This is what it’s like
A GP is sued after doing everything right — except her notes
After-hours funding shakeup
‘We’re becoming unviable,’ says GP hit with $22K e-PIP repayment
This Christmas I wish for doctors to feel valued again
So the answer is, probably. Tales direct from the trenches that I hear from GPs, suggest it is increasingly difficult to make a living without adhering to a crazy volume of <10min appts, without being sued (too often) or dragged in front of AMA or APRHA. I hear them and know that the increased pressure is coming from multiple angles and I think it is very sad that previously such a respected and valued role in society appears to be ‘losing its value’. Don’t get me wrong, I don’t agree with the old ‘Doctor as God’ model and think it ‘s very unhealthy actually for patients, but I feel like GPs with all their extensive training, knowledge and expertise are in urgent need of an Oprahesque ‘new dawn’! (more…)
No this is not a joke. The room they enter happens to be the clinic space of a practitioner I mentor. The older women are friends, both originally from the UK and they sit in on one another’s consultations sharing many of the same experiences: grief over loved ones lost, memories, laughter and both describe waking in the morning with a sense of dread, because they’re tired, feel they’ve lost their oomph, their motivation, their chutzpah…that’s mostly why they’ve come today.
But know what else these two have in common? (more…)
May was the month of teenage girls presenting with severe digestive problems, especially ‘food intolerances’, leading to avoidance of specific foods and at times significantly reduced food intake overall. As integrative health practitioners, validating and creating insight for clients on the nature and source of their food reactions is our bread and butter, right? Is it wheat? Dairy? Gluten? FODMAPs? Salicylates? Oxalates? We are not surprised by how many ‘sick’ patients we see in spite of a theoretically ‘healthy diet’ – healthy for others perhaps but not for the individual in front of you, right? But what if I told you that each of these teenage girls had a BMI < 18 kg/m2, does that change your opinion about your role? Would you assess, monitor and manage these teenage girls differently? You should.
Take the example of one of my clients: 14yo female with a BMI 16.3, who had her first confirmed food reaction under 2yo with failure to thrive, which was attributed by a paediatrician & dietitian at the time to severe salicylate sensitivity. She underwent jejunal biopsy at 3yo for suspected coeliac disease, due to ongoing concerns and a primary relative with CD but it was NAD. In the 11 years since, there have been a couple of other digestive diagnoses based on solid evidence, such as mainstream stool PCR testing. So surely, the fact that she is underweight & that she skips lunch at school due to digestive discomfort is proportionate and explained by her organic digestive issues. Or is it? (more…)
Just back from a truly wonderful Australasian Integrative Medical Association (AIMA) conference in NZ. I don’t know what it is about the land of the long white cloud but they seem to produce some of the loveliest, most earnest health practitioners and this conference reflects this, setting itself apart each year as a result of its very organic mix of speakers (general practitioners, naturopaths, nurses, specialists) who are all equally embraced and lauded. To boot we had medical students invited to attend this year and guess what, these 20 or so med students…they stayed for the full weekend much to everyone’s surprise(!), loved it and want more. Really. At the AIMA NZ conference, on the two occasions I have spoken, I feel a sense of coming home…no I don’t mean I am about to move there (too cold!!) but I mean coming home to integrative medicine. (more…)
Often we assume our patients know at least the basics about health – especially about things soooo seemingly basic…that we fear mentioning them would offend and make us look like someone trying to teach grandma anything! But there are some instances where I’ve found I have simply assumed too much.
I think the issue of what I affectionately call ‘Vag Care’, is right up there as an example.
Soapy water? Female deodorisers, daily panty liners, re-enacting bad movie scenes with soapy suds sex…what the??? It’s been my astonishing discovery that women of all ages, but especially a frightening majority of younger females (<30 yo), in this time of increasingly unreal ideas about sex and sexuality, feel inclined or pressured to adopt these practices in order to erase all trace of natural odour and healthy discharge. The abnormal has become normalised. (more…)
I became interested in working in mental health not entirely of my own free will. I guess you could say, it had made it’s way into my world via family members and friends as well as my own problems when I was younger. So when I was at uni and I came across any information about mental illness, whether it was pathology or prescription, it was when I undoubtedly resonated most strongly with what I was learning. I’ve had some great opportunities throughout my career to feed my interest, met some wonderful mentors and some other powerful teachers who were often my patients. It’s now become a running joke among my teenage children that all my friends are either psychologists or have some sort of mental health diagnosis, ‘…and what does that say about you?’ they love to add teasingly. Well it says a lot probably: that I enjoy people who are comfortable talking about the psychology of our lives and ourselves, that I deeply appreciate that to be human is to suffer and we all suffer it’s just a question of degrees and the bravest of us share that with others. Lastly, I think it tells you that I live in the real world with real people 🙂 (more…)
Ok here’s a gripe I’m having currently. I have a number of patients who are taking anti-epileptic drugs (AEDs) and most of these are children who require them for seizure control. Naturally, working alongside such serious pathology and these critical medications requires a conservative and evidence based approach to ensure the safety of any added intervention. Fortunately, this is something I would like to think is one of my strengths. When these patients present seeking nutritional support, I typically refer them for investigations that can help to clarify what, if any, nutrients are imbalanced because of their long-term AED use or perhaps because of other independent reasons that may compromise they’re overall wellbeing. I feel that in such a vulnerable population I need to confirm nutritional deficiencies to check my assumptions, prove a need for supplementation and prevent against any excess or creation of further imbalance…and by doing so, I can adhere to my motto of least medicine, is best medicine.
The fact is AEDs are notoriously associated with a long list of potential negative nutrient interactions and the evidence to support this is extensive, this includes but is not limited to: folate, B12, B3, B6, zinc & vitamin D and the deficiencies potentially produced by the AEDs can be quite severe depending on a range of individual factors. For many of these nutrients, the research goes further and has shown that correction of the deficiency leads to better drug efficacy – therefore adjunctive nutritional monitoring and correction would seem like a real ‘win win’ situation.
(Stargrove,MB. et al. Herb, Nutrient & Drug Interactions – Clinical Implications & Therapeutic Strategies. 2008) (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…)
Lots of great conversations with practitioners following my recent post on the need to specialise – really thought provoking & clarifying ones which makes me think it’s been a good conversation starter. Key things that have come up for people are:
- How do I choose my area of speciality…e.g. is a spin the bottle approach required?
- Is specialisation sensible when you’re only just starting out or should you be taking everyone and anyone to begin with?
- Is specialising even naturopathic given we have a holistic approach to health?? …e.g. I might say, I only do gut but for my IBS patients there’s a whole lot of stress management & mental health stuff that needs addressing along the way
Great questions 🙂 Now remember, all I’m offering here is my opinion, I don’t think there is a definitive answer to these but I think we should keep the conversation going as a way of keeping us thinking about the way we choose to practice rather than assuming there’s only one way to be a naturopath in clinic. (more…)
I was chatting with a colleague today about a complicated & interesting case of hers, severe hypothyroidism coupled with overt hypercortisolemia (salivary cortisol up to 230!). This is a distance patient & she’s sharing care with a couple of other health professionals with conflicting ideas…tricky!!
So when my friend received an email last week to the tune of… “things are bad, everything is terrible if not worse”, then naturally she starts worrying: What has she missed? What’s gone wrong? What more could/should she have done? Is this some sort of aggravation to the treatment she’s recommended?
This is the place our minds naturally go when faced with these scenarios however one of the things I have really learned over years in clinic is that patients, like me, like everyone else I know, are labile, in the moment kind of creatures & we’re all vulnerable to having BPDs. (more…)