What is Integrative Medicine

Some of my best friends will ask the question. Without getting too boring, I could tell them the life and times of Andrew Weil. That usually is the long winded approach. I find myself trying to justify my endeavors by speaking of the mans credentials. Harvard College, Harvard Medicine, NIH, Botanist, Author and world cultural traveler, founder of the University of Arizona's Program of Integrative Medicine and Fellowship with graduating classes since 1994. By this time, most time efficient doctors will be answering other questions. Most lay-people will have tuned out after the Harvard names. If I say, he's the founder of a branch of medicine that gets people off perscription drugs, then ears perk up. Most people envision and doctor that will say "ok, the data is out there that medicines dont help so stop everything and go about your normal routine". Little do folks know, the concept he sticks to is to add the physical, mental, spiritual aspects of medicine in addition to special attention to nutrition. Using food as medicine is a old concept but with all the RCT's (randomized controlled trials) that are being quoted, referenced and repeated in medical circles and magazines, basic nutrition really doesn't make the trillion dollar profits for small organizations so it's not spoken of. Doctors don't have the time for nutrition counseling and in many cases, one's medical insurance will not cover a referal to a "dietician" unless the disease is already being manifested. I uses to always refer my patients to the dietician in my building back in the 90's and I distinctly remember when Sandy Gifford had to turn away petients due to poor coverage. (she would still see my patients and educate as best as possible on her own time because of our relationship) ......in fact, doing things on personal time seemed to be what I always had to result in for getting around the limitations of insurance. Up until the time I stepped away from a 10 year practice with retirement just to send a message to the hospital that the patient is the bottom line not the dollar.
I know I was right mostly because of the feedback I still receive from old patients...even until now and I left my practice in 05. Patients are still feeling short changed from the time constraints of conventional insurance based medicine. Patients are also being given bigger and stronger drugs and several of them. I was aware of "laundry lists of medical problems and perscriptions for the elderly in nursing homes in the early 90's but now I am seeing it in 40-50 year olds(hypertension, diabetes, cholesterol). I am also seeing it in 10-20 year olds (adhd, diabetes, asthma). Now within the first year of life (reflux!).
As usual, there has to be a coexistence, modern medicine is great and very powerful. Trauma, rapid reversal of heart disease, cancer, kidney failure, premature birth, having 8 babies. But I think we are forgetting about nutrition, exercise and stress relief. This is how I see what I do is correct. To integrate old fashion health care with modern disease care is a must. Health care has to be individualized. Humans are so dynamic that everyone can't be labeled as a hypertensive or diabetic. I like what Chopra says regarding a new paradigm in medicine. The last few decades, medicine was so boastful to think if we knew the pathophysiologic pathway to a disease, then we could fix the disease by treating the pathway. Obviously this was the wrong thinking and now there are small fixes for every symptom in the world without fixing the mindset of the indiviual coming to us for the ailment/symptom. When I used to hear the term holistic medicine, I would think of someone who had little training in healing that people were going to in desperation of a better answer than what the doctor would tell them. Now I understand more about the best approach to healthcare and through the efforts of Dr Weil and others, the volume of people (healthcare and non medical) are "buying" into treating more than just a symptom or test result. Thus the idea of "integrating" mind, body, spiritual, environmental and nutritional thinking into the treatment plan. Hippocrates, the father of medicine said to use food as medicine, funny that its getting back to this!

What are growing pains?

I remember in residency, when seeing a child for a knee pain or limp and the evaluation was normal, I would usually say "growing pains". The moms and dads would already have heard about the diagnosis but would be at ease when I would agree. I would compare this to seeing a 40 year old male that comes in for left sided chest pain and I clear him of heart disease then say its just "stress". To throw all the potential diagnosis under one obscure title of stress is not acceptable to an intelligent educated american. Same thing with the diagnosis of growing pains. In the case of my nephew who is 6, his doctor said the limping he was suffering from is probably just that. This is probably true but I think an educated parent would like to know a more specific diagnosis. When the knees are painful, we worry about the patella. Sometimes worry about Osgood Schlatter Disease where the thigh muscles (quads) stay tight and the thigh bone (femur) gets longer. This would make the muscle pull at it's insertion points on the knee with more force causing a lump to form.




In some cases, knee pain and a limp at my nephews age could be something worse like Perthes Disease (or at a later age, a SCFE). Both of these are not common but since the results are bad, they have to be considered if limping doesn't go away or gets worse. Little James just started baseball 6 weeks ago which makes me feel better that we have a reason for the pain but I will probably be getting an xrays later. (Don't like the radiation exposure but I'll watch him closely and did ask my cousin to video tape his training next time.)

As my patients know, history is 80% of the diagnosis and I think baseball will be the reason for the pain (overtraining). The Saguil Approach is to start with a working diagnosis, evaluate for abnormality, watch the training pattern, surface and shoe type, consider an xray, rule out groin issues and consider 1-2 weeks off to see the results. I suggested that if it is due to baseball practice, try childrens motrin/advil three times a day the day of and the day after practice. Pain that breaks through that conservative treatment will mean we have a bigger issue to be investigated faster.

To note, if there is no limp and just complaints, may consider "secondary issues" like he doesn't like the sport or the coach, or worse, there's a bully around.

Does a normal Cholesterol level mean I have no problems with my heart?

Usually in the ER, patients will come in with a high blood pressure reading, slightly overweight and a history of smoking. After I comment about please rechecking this with the primary care doctor, the defensive answer is I just had a normal physical and normal cholesterol level. Ooohhh my gosh! I think it is the fault of the medical community in giving false hope that chasing a number keeps people healthy. I admit, with the short time we have to discuss, evaluate and treat symptoms in my exam room, it is easier to give a temporary "bandaid" to an effect of the disease and not the cause of it. Perhaps in the next decade, we can have doctors that fix things fast but medical advisors that guide people to make life changes.

Focusing on heart health, cholesterol is a good parameter to check in blood testing at the office once or twice a year but healthy lifestyles and habits will make permanent changes so that you may not have to ever check another blood test ever! (My doc friends are going to hunt me) This is what I believe and I walk the walk, I am a protector of life; family, friends and patients. If people are giving out poor medical or dental advise, I work to educate the patient on other options, natural healing and healthier living. I believe we doctors are giving a false sense of security to people when just controlling cholesterol levels and not making suggestions for life change. The reasons for bad health are multifactorial; can't change the world with one visit. Sometimes it just takes proper planning over the course of time. Building a practice from scratch seemed harder than moving a mountain. Now that I have utilized those around me who have the same passion for helping others, the task at hand seems so easy. (We could have opened a clinic right down the street from the old place, with less overhead and more life breath coming from the physical location never seen before!) This reflects one of my beliefs that when the world is viewed with reservation and contempt, a "black and white" picture will be seen. When viewed with love, faith and energy the colors will be infinite.

Just don't believe maintaining a normal cholesterol level will keep you free of disease. Strive to improve your health, diet and mind even with normal tests. Push the envelope with what you can perform with your body and mind, find a good doctor, dentist, trainer, therapist and life partner. Together we can change the world! There will always be bad economies, bad debt, bad medicine and bad people around but when we all lock elbows together, our concepts and faith are indestructible.

Check out this blog for other things to do in getting that heart healthy;
http://saguilapproach.blogspot.com/

Bioidentical hormones

At the Whole foods lecture someone brought up the question about what can I do with wt loss and other symptoms of menopause? The question was more of a hormone issue. (If the "menopausal" symptoms where controlled, good possibility that the weight wouldn't be as much an issue).
We are taught in medical school that all women go through a phase when the ovaries will stop working. Their role in life is to make ovum (eggs) once a month from 16 to about 45 years old. Once they have reached 45, usually the organ will slow down and stop making eggs and the hormones. When hormone cycles that have been in balance for 30 years between the brain, the ovary and the uterus stop, other organs that have had the pleasure of being bathed with hormone will cry out and say....wheres my estrogen!...wheres my progesterone! Brain goes through problems with function- memory, emotional lability, sadness anger temperature lability, muscles go through atrophy, fat depots go through accumulation, adrenals go through fatigue, sex organs ....well later on that one. As docs we are taught if the symtoms are there, check a blood test and if the hormone is missing or low, replace it! In theory, having what you where lacking should make the symptoms all go away (until you get tired of the pill or get a side effect -cancer) Many women did well as far as we know but then society as front loaded the majority of women's attitudes to say what you are feeling is normal, you have to go through it and your only choice is to take the hormone.

Here is the reveal: you can't "cookie cutter" humans! Different people have different presentations and although the blood levels will be fixed, the person that was suffering slightly before menopause hit will still be suffering after the hormones are taken, and some of those closet symptoms will not go back in the closet. If the doc doesnt take 10 minutes to listen to what you are truly suffering from, it will be missed so get a new doc!

Diets can be changed, exercise can be changed or introduced, lifestyles can be dropped or started, supplements can be taken. Even the hormones can still be used but perhaps a bioidentical can be tried before the standard pills are tried. Everyone has probalby heard about how "prem____" the progesterone substitute comes from purified horse urine. I say leave it to the horses! By contacting a local pharmacy that compounds, you can get a chemically derived hormone look alike. Investigating these guys would be what I suggest.....

-while in Florida I used Pharmacy Specialists 393 Maitland Avenue. Altamonte Springs, FL 32701 (407) 260-7002.
-here in Illinois, Martin Ave Pharmacy, 1247 Rickert Drive, Naperville Il 60540 (630) 355-6400

...and both places will ship, just need a script from the doc.


Anyway...the lady at the lecture mentioned she tried bioidenticals but have a hearing issue. (That would easily be fixed with acupuncture) but this should be brought up to the doc and the pharmacist. I think she was in the right direction but just needed a little guidance on what else to be looking for. I forgot to ask her that even through the hearing issue, how were the symptoms of menopause with the bioidentical? Bottom line, checkwith the insurance and if covered try them out....like having a custom made suit versus an off the rack.

Wake up little Suzie

A nurse at the ER stated she was getting more than enough sleep but still feeling exhausted in the am. She is also is attending school, enrolled with army and raising 4 kids. She smokes and has had an issue with constipation ok with otc softners in addition to her kids needing the same otc's. (over the counter's) My first suggestion was to get a sleep study in order to determine if an abnormal sleep waves could be causing a dangerous problem. She apparently doesnt snore, is not falling asleep at the wheel, not suffering from memory issues and not being awaken by anything in the bedroom environment. The Saguil Approach would be to first teach about sleep hygiene so she can better understand the issues that cause problems. Sometimes when patients understand the pathophysiology of and injury, they may be able to better find the reason that I can't see on the outside. After making sure no dangerous sleep issues are going on, valerian would probably help reduce her reaction to the stress of all that is going on. I would always suggest omega 3 for fighting any unseen seasonal affective disorder (later told me she is on an ssri for chronic depression that is "stable"). The cigarettes have to stop after dinner, caffeine should be tapered to nothing after lunch. I always suggest an early morning wake up alarm the same time 7 days a week. An evening ritual one hour before desired sleep time is also important to start. My experience is that grad students in the same scenario always suffer from and exacerbation of old symptoms in the last year of grad school. Best I can do is make sure nothing dangerous is occuring and provide some supportive suggestions until 3 months after graduation. This would be a complicated patient since there seems to be underlying issues, (chronic constipation, tobacco addiction and multiple endeavors with over extension of normal daily duties). Good thing is she is plugged into other specialists for each issue, bad thing is all these guys are doing there own thing without concern for the other body systems. This is typical for western medicine, treat the disease process not the patient. The brain, the body and the spirit arent considered one. This is where the spirit, would be the biggest component that if worn down would effect the normal functioning of the other body system (speaking on western terms). Truth is I could make anyone go to sleep with the right potent drug but if the true reason isnt found, more and more meds will be needed in addition to other medicines to reverse the side effects from the sleep drugs. We should just hibernate through the winter and wake up in spring, thin with grown kids.

Do I have to take a vitamin?

The american dietetic association is conservative in its suggestions to the public about nutrition in the US. With gas prices forcing people to work longer hours or second jobs, most americans who ate poorly before are now diving into fast food, stress eating or binging after a 12 hour shifts. Kids will follow when at home by themselves or in the care of a non-kitchen friendly guardian. (My brother in law used to joke by saying he would watch the kids by pouring a large bowl of cereal and placing a few boxes of juice box drinks in front of the tv/xbox for the time I was at work....I still wonder if he was kidding or not). Poor nutrition with higher stress living asks the body to go into fight or flight for extended periods of the day. An average human will have enough endorphin and adrenalin to sustain bursts for about a day but then after that, body store depleation. That would be depleation of glucose, glycogen (sounds good for weight loss!) but also neurotransmitters, body steriods controlling bodily function (like pooping, eating, concentration and sleep) and then those nasty hormones responsible for laughing, love and good sex.

Bottom line is that we learn poor eating in high school, keep it up in college, take it to work and teach it to our kids. Vitamins are necessary to sustain a basic level of function when an adult is eating 4 meals of low cholesterol, low fat, high fiber with 3-10 pieces of fruits and/or veggies daily. The average person reading this doesn't eat that way. Personally, I have to go to whole foods, dominics, jewel and target to find the best choices for fruits and veggies and not go broke every month. I like to say I do it for my kids but my fibromyalgia is under control, back pain is gone and I can still do 60 minutes of cardio with 30 min of yoga without needing medicine for blood pressure, inflammation or joint pain.

All these diet and supplement suggestions you hear are for an average american with an average diet. Those that carry medical problems and take medicines to control them need more supplements. (My average patient seen in the ER has 2-3 medical problems, 1-2 medicine they are taking and is under 45 years of age.) It funny that the average patient on cholesterol lowering medicine doesn't follow a low cholesterol diet! Average patient with early diabetes doesn't know how many calories or carbs they are taking daily. Average arthitis sufferer doesn't loose weight or participate in yoga or taichi.

Watch my next post to figure how to pick a supplement.

Are there any sideffects to taking advil?

Healthy young man who exercises 5 days a week for about 1-2 hours came to the ER with acute onset of abdominal pain monday. No other history of medical illness or problems like this before. No history of gallstones, pain not worsened with eating, no change in stools or urine and it hurt to take a deep breath or twist. no fever and no other new activity in the last week. No history of heart disease, cholesterol,high blood pressure and I bluntly asked about drug use and he said no.

I was worried about lung problems with an old history of asthma as a teen but physical exam was normal. Then he remembered he was in a motor vehicle accident about amonth ago and air bag did get deployed. he doesnt remember any pain like this but when asked further, he does admit to taking advils daily since the accident. No history of ulcers in the family and no tobacco or alcohol use. (he works as a banker in a high stress position but he didnt know his blood type- type O has higher chance for ulceration). I was confident he had an ulcer but he wanted an xray anyway. The radiation exposure resulted in a normal xray as I told him it would. The GI cocktail, which usually brings down ulcer pain immediatedly only helped a little, brought 10/10 pain down to 8/10. I told him he should be ok with Prevacid and avoidance of advil, coffee, alcohol for 1-2weeks but his mother wanted to get a surgeon involved. Surgeon said she wanted to scope him to look for the bleedin ulcer and asked a slew of questions on blood tests, imaging studies......All very valid for ruling out life threatening disease and I had no problem ordering everything except the surgical procedure. I pointed out that his physical exam did not point to a bleeding ulcer but a mom that works in trauma surgery is sincerely worried about her son. Ultrasound showed no problems with liver or gallbladder, blood tests reinfored the fact he wasnt actively bleeding from an ulcer, kidneys electrolytes and liver functioning was all normal. He did note that as he waited for the blood tests results and ultrasound, pain continued to get better. The only thing I gave him was a cocktail of maalox, benedryl and lidocaine (numbing medicine for the lining of the stomach).

Advil, ibuprofen, motrin are all the same. They are nonsteroidal antiinflammatories that work to reduce pain sensation by reducing inflammation. One problem with this medicine is that it also decreases stomach mucous production and leaves the lining of the stomach unprotected from its own acid causing the eating away of spots in the stomach (ulcerations). Stomach should be able to protect itself and heal up fast. The lining of the stomach is very quick to regenerate/grow, but with daily exposure to advil, stress daily -(stress tends to cause over production of acid), and indulgence in caffeine and coffee, and most likely stimulants in energy drinks for exercise, ulcerations continue to grow and get deeper. I believe the delay in response to the cocktail meant he had a large ulcer or one in the duodenum more so than the stomach. (the duodenum is the part of the intestines that the stomach dumps food into once it is finished with digestion, sometimes contents are held in the stomach for a few hours before they move onto the duodenum/intestine. Likewise, an ulcer in the duodenum is more important than the ones in the stomach since vital blood vessels are right behind the intestine and a hole in the lining can eat right through to the blood vessel. (big mess) The other bad thing the advil can cause is pain relief......yes good for pain from the airbag hitting the man but bad for the ulcer which usually results in pain saying to the patient...hey, dont take that advil anymore!but with less pain from the ulcer, he doesnt realize what hes doing!

Celebrex was made to be so specific for inflammation and not to hurt the stomach it was thought to be a miracle drug for inflammation especially in ulcer sufferers. Great news till we found it caused heart attacks! Funny thing was when the studies came out, a warning from the celebrex companies came out saying all antiinflammatories medicines could cause heart attacks so avoid all of them. Seems to get the attention off celebrex and place it an the whole antiinflammatory drug class. (see how studies can be misinterpreted or specific portions of studies can be stressed and others ignored depending on who is reporting!)

I'm not just coming down on prescriptions, evenherbal medicines have side effects (like liver failure-see my earlier post on the adventrues of Dr Saguil). Just know what is going in your mouth and dont trust everything you read. When possible, rely on food and healthy living, use supplements wisely and always question the doc, pharmacist, nurse about what you are taking.