Medical education in the days of Big Pharma

I received this detailed email from an unexpected source: a 3rd-year medical student.

In her email, Theresa describes her frustrations in what she is witnessing for the first time, proceeding through her training and getting exposed to the realities of medical life.

Medical training, particularly clinical training from the 3rd and 4th years of medical school, onwards through internship, residency, and fellowship training, consists largely of bullying, "pimping" (meaning rapid-fire grilling of questions at trainees), and sleep deprivation. It is an extended hazing period meant to demoralize and inculcate the trainee into following the lead of superiors. Buck the system and you're . . . out. Imagine you've just sunk $190,000 and 8 years of college into getting to your internship. You are not going to chance being thrown out on principle. So you just swallow your pride, go along with the game, and echo all the answers they want you to repeat.

While Theresa laments the sad state of modern American pharmaceutical- and procedure-obsessed medicine, she provides me with hope that some young people training to practice medicine today will carve out their own paths, not the one laid for them by the pharmaceutical industry, nor fall for the temptation of higher-paying procedural specialties like orthopedics and cardiology. I am impressed with her ability to see this so early in her career.


Dr. Davis,

I am a 3rd year medical student at ________ University. I came across
your blog today, and I'm very glad I did. I appreciate the value of your time,
so I want to be as succinct as possible while still getting across what I'm
really thinking and feeling:

From what I gathered exploring your blog for a while this afternoon, the
wellness strategies you incorporate into your practice are some of the exact
things I want to do with my future patients. Personally, I strongly believe in
staying healthy by eating right, staying active, etc. For instance, I don't eat
grains or much in the way of starches and sugars. So I love the fact that you
are helping your patients make these powerful and foundational changes in their
lives.

As I'm sure was your experience, a full appreciation of nutrition and lifestyle
as a first-line health strategy is not something that was taught to me in
medical school. I came to school with this deep conviction already in my heart
and mind, and now, on my 3rd year rotations, I am still conflicted and at a loss
as to how I'm going to be able to practice medicine the way I want to, which is
to incorporate these all-important principles into the care of my patients.

What I've come to understand about the medical field today is that the
information that exists is primarily subsidized by the pharmaceutical industry,
and dictated to medical professionals as "evidence-based" treatment guidelines
and recommendations by organizations with sincere and official sounding names
like American Heart Association and American Cancer Society. Add to that the
pressure of potential malpractice litigation and the complexities of the
insurance reimbursement game, and it seems to me like what you get is a bunch of
diagnostic and medication management algorithms that any half-trained monkey
could follow. In his sleep. Which I guess would be alright if at least they
weren't algorithms based on misguided, self-serving, profit-seeking Big Pharma,
Food Inc, insurance conglomerates, and agri-politics (I think I just made that
word up.)

A lot of well-intentioned physicians are just parroting the party
line, as their patients dutifully and gratefully chomp down their statins and
diabetes drugs and blood pressure pills. And I'm sorry, but "diabetes
education" programs with curriculum put together by drug companies? How is that
even legal? Massive corporations raking in massive profits that are dependent
on uncontrolled blood sugars telling people how to best control their blood
sugars?!

Anyway, forgive my rant. What I'm getting at is this: How can I practice
medicine, with the freedom to educate/coach/treat my patients with diet and
lifestyle changes to mitigate/reverse their chronic health conditions? Without
feeling like I automatically have to first and foremost prescribe the litany of
drugs dictated by "evidence-based" guidelines? Without excessive fear of
litigation or loss of credibility among my peers? Without having to lie through
my teeth to my patients, and tell them that eating low-fat and heart-healthy
whole grains is the best way (implication also being the only scientifically
proven way) to control their diabetes, lower their cholesterol, etc, etc, etc?

I want my patients to have the full benefit of honest nutrition and lifestyle
information, and medications and surgery as necessary. I'm afraid that there
isn't room for this kind of holistic emphasis in the medical profession today.
Are there residencies that include this kind of training or at least respect
these "unconventional" philosophies? Are there clinics or practice groups that
would allow me to practice with this emphasis, or is there a bias against docs
who do not necessarily conform to the party position? Will I have no other
option but to go it alone under the auspices of my own shingle? How do you
handle these kinds of issues in your professional life?

Sincerely,
Theresa M.


A ray of hope! Perhaps Theresa is just the first among many more medical students who refuse to submit to the brainwashing practices of the pharmaceutical industry, the same mind manipulation that has hopelessly turned most of my colleagues into their unwitting puppets.

I'll be interested in watching how Theresa's experience unfolds. I've asked her to keep us informed every so often.

Comments (43) -

  • Sassy

    10/29/2010 8:16:32 PM |

    I would love to see your answers to her questions.

  • Tara BRIDGES

    10/29/2010 8:24:51 PM |

    Welcome to my world... only as a dietitian it is WAY worse.  Trust me.

    Not only do we have to deal with bogus "evidence-based guidelines," the loss of respect of colleagues, and risk of losing our license... We have to do it all with less than a quarter of the salary that the average physician makes and much, much less respect.

    I'm so frustrated in this field, but I'm at a loss as to what to do...

  • Tommy

    10/29/2010 8:28:25 PM |

    Timely. I was just arguing (discussing) with my cardiologist about coming off my statin (40 mg). I never had a cholesterol problem and still don't, even though I had an MI. I point to niacin and he points to Zocor. I tell him about studies and he claims I'm reading the wrong studies and that it is his job to know these things. He claims the zocor isn't for my cholesterol it is to control inflammation. I again point to studies that dispute statins ability to do that and  again suggest niacin. Again, he says he knows better. She is right...it is a sad state of affairs.

  • Jonathan

    10/29/2010 8:49:12 PM |

    @Tommy
    Maybe your doc needs to watch Tom's latest post.
    http://www.fathead-movie.com/index.php/2010/10/28/video-of-the-big-fat-fiasco-speech/

    And maybe your doc doesn't need to be your doc anymore.

  • Lucy

    10/29/2010 9:54:30 PM |

    Wow-Thank you Theresa. We need more like you!

  • Lori Miller

    10/30/2010 1:28:42 AM |

    Theresa, I'm not a health care provider, just someone who leads an independent life and writes a humble blog on solving one's own health problems, so take this FWIW.

    How do you think for yourself and do things your way? Study the Socratic method. Go by results. Look at how conclusions were arrived at, and weak links in the chain. Don't hang around with people who are dishonest or have stopped thinking for themselves. Always admit your mistakes instead of justifying them.

    If colleagues disapprove of you, check yourself and see if the criticism is valid. Going by what you've said, you'll probably have to choose between professional camaraderie and the best interests of your patients.

    A couple of books that are good tools for thinking for yourself: The Consolations of Philosophy by Alain de Botton and Mistakes were Made (but not by me).

  • kellgy

    10/30/2010 1:35:05 AM |

    I know exactly how Theresa feels. After losing 95 pounds, reversing hypertension, and arrhythmias, I have returned to school for an advanced degree as a FNP. My hope is also to provide an approach of health and wellness through nutrition, education, and exercise.
    I have the feeling that there are going to be more of us than the pharmaceutical companies know what to do with. Maybe I am a hopeful optimist, but the influence of a sustainable evidenced based approach as propagated here is already having it's effects.

  • Valerie LeComte

    10/30/2010 1:43:47 AM |

    I agree with Sassy, I would love to see your answers.  I am a second year medical student and am struggling with similar issues.  
    You aren't the only one Theresa! Good luck!

  • Anonymous

    10/30/2010 1:59:07 AM |

    Theresa,

    The practice model you are seeking already exists.  Check out the Institute for Functional Medicine at www.functionalmedicine.org .  After reading your letter to Dr. Davis, I think you'll find IFM exciting.  Good Luck.

  • Anonymous

    10/30/2010 2:40:22 AM |

    Medicine isn't the only field like that. Clinical & school psychology is just as rigid with its hierarchy of gurus and 'prescriptions for care' that are questionable. I was in the field for 30 yrs. before retiring and I can tell you that if you deviate from the path you'll be drummed unceremoniously. Those smiling faces have knives behind their backs. Where do you turn for straight answers? As always, you have to find them yourself. (My identity is anonymous because my username/password is being rejected. Wonder if 'they' have gotten to blogger dotcom too. JK.)

  • Anonymous

    10/30/2010 3:07:00 AM |

    A typo in my last post; should have read:

    I was in the field for 30 yrs. before retiring and I can tell you that if you deviate from the path you'll be drummed out unceremoniously.

  • Kim

    10/30/2010 4:41:05 AM |

    Theresa, please tell me you will practice in Arizona. I need a doctor just like you. Im sick of being offered bandaids to cover up symptoms instead of figuring out a cause for the symptoms. I wish you the best and hope there are more out there like you and Dr. Davis.

  • moblogs

    10/30/2010 9:09:25 AM |

    Just hearing one account of a student upset with the status quo definitely makes me more hopeful for the future. Eventually these voices accumulate and change happens.

  • Buy Flonase Online

    10/30/2010 11:16:57 AM |

    I was in the field for 10 yrs,Medicine isn't the only field like that, before retiring and I can tell you that if you deviate from the path you'll be drummed out unceremoniously.

  • Anonymous

    10/30/2010 11:25:22 AM |

    I was at the grocery store Meijers yesterday morning.  And when there early, I typically am left having to use the self check out lanes.  I dislike using these machines.  They all to often break while using them, causing a delay as I wait for someone to come fix the problem.  Meijers employees early in the morning are often not motivated to fix much of anything I've come to find in the past.  

    So as is all to often the norm, my self check out machine gave an error.  The machine reported something was on the conveyer belt - while in reality nothing was.  No more items allowed to be checked until the error was fixed though.     I pressed the help button and with little surprise no one came to fix my problem.  So I packed up and was ready to visit another checkout machine.  This simple act apparently is the motivation Meijers employees need!  She came stomping over, full of attitude.  She really let me have it for wanting to leave the machine.  it was kind of funny.  I just smiled as she lit into me, and was working the check out computer to clear the error.  Once done and walking away, I joked, "let me guess you once were a doctor?"  She didn't like that either.  I'll be shopping at Wal-Mart across the street in the future, even though the same setup and type of employees work there.

    Hope you keep up the work doctor Davis!  I've learned a great deal from your sight, as I'm sure many others have too.  I tell everyone about this place.  Having had a life long chronic illness and seen more doctors than i wish, what disappoints me equally about the lack of care in modern medicine, is the belief by most in society that hospitals have all the answers - that taking responsibility for your own health is unreasonable and even dangerous.  I figured out quickly in my quest for an answer to my chronic health problems that I was not going to be cured in a hospital.  All to often rude, even angry doctors would let me know in one way or another all they dealt with is pharmaceuticals or procedures, items that did not work in my case.  Going outside of that was unwelcome territory.  I kept going to see doctors though.  It wasn't for me that I went.  I did it because family and friends believe in modern medical myths.  I even got to the point where I would take  family members to my meetings with physicians so they could hear what was said for themselves.  That seemed to make doctors nervous.  If I brought someone with me, they would bring a colleague with them!  I actually found these "group health gatherings" to be good, not only to further inform disappointed family members, but also for what ever reason I didn't receive the level of lip from doctors.  

    Anyway, not to bash on doctors and hospitals, just my hope is that someday a majority of people come to realize it is alright to take health care into your own hands.  Hospitals don't have all the answers, and all to often the answers that they do provide are inferior to a good proven diet and a few supplements.  I guess there will always be a place for expensive drugs and procedures, they just shouldn't be the first option, when there are other healthier and cheaper possibilities, in my opinion.

  • Anonymous

    10/30/2010 11:26:53 AM |

    I was at the grocery store Meijers yesterday morning.  And when there early, I typically am left having to use the self check out lanes.  I dislike using these machines.  They all to often break while using them, causing a delay as I wait for someone to come fix the problem.  Meijers employees early in the morning are often not motivated to fix much of anything I've come to find in the past.  
      So as is all to often the norm, my self check out machine gave an error.  The machine reported something was on the conveyer belt - while in reality nothing was.  No more items allowed to be checked until the error was fixed though.     I pressed the help button and with little surprise no one came to fix my problem.  So I packed up and was ready to visit another checkout machine.  This simple act apparently is the motivation Meijers employees need!  She came stomping over, full of attitude.  She really let me have it for wanting to leave the machine.  it was kind of funny.  I just smiled as she lit into me, and was working the check out computer to clear the error.  Once done and walking away, I joked, "let me guess you once were a doctor?"  She didn't like that either.  I'll be shopping at Wal-Mart across the street in the future, even though the same setup and type of employees work there.
      Hope you keep up the work doctor Davis!  I've learned a great deal from your sight, as I'm sure many others have too.  I tell everyone about this place.  Having had a life long chronic illness and seen more doctors than i wish, what disappoints me equally about the lack of care in modern medicine, is the belief by most in society that hospitals have all the answers - that taking responsibility for your own health is unreasonable and even dangerous.  I figured out quickly in my quest for an answer to my chronic health problems that I was not going to be cured in a hospital.  All to often rude, even angry doctors would let me know in one way or another all they dealt with is pharmaceuticals or procedures, items that did not work in my case.  Going outside of that was unwelcome territory.  I kept going to see doctors though.  It wasn't for me that I went.  I did it because family and friends believe in modern medical myths.  I even got to the point where I would take  family members to my meetings with physicians so they could hear what was said for themselves.  That seemed to make doctors nervous.  If I brought someone with me, they would bring a colleague with them!  I actually found these "group health gatherings" to be good, not only to further inform disappointed family members, but also for what ever reason I didn't receive the level of lip from doctors.  
      Anyway, not to bash on doctors and hospitals, just my hope is that someday a majority of people come to realize it is alright to take health care into your own hands.  Hospitals don't have all the answers, and all to often the answers that they do provide are inferior to a good proven diet and a few supplements.  I guess there will always be a place for expensive drugs and procedures, they just shouldn't be the first option, when there are other healthier and cheaper possibilities, in my opinion.

  • Anonymous

    10/30/2010 11:32:15 AM |

    Hope you keep up the work doctor Davis!  I've learned a great deal from your sight, as I'm sure many others have too.  I tell everyone about your writings.  Having had a life long chronic illness and seen more doctors than i wish, what disappoints me equally about the lack of care in modern medicine, is the belief by most in society that hospitals have all the answers - that taking responsibility for your own health is unreasonable and even dangerous.  I figured out quickly in my quest for an answer to my chronic health problems that I was not going to be cured in a hospital.  All to often rude, even angry doctors would let me know in one way or another all they dealt with is pharmaceuticals or procedures, items that did not work in my case.  Going outside of that was unwelcome territory.  I kept going to see doctors though.  It wasn't for me that I went.  I did it because family and friends believe in modern medical myths.  I even got to the point where I would take  family members to my meetings with physicians so they could hear what was said for themselves.  That seemed to make doctors nervous.  If I brought someone with me, they would bring a colleague with them!  I actually found these "group health gatherings" to be good, not only to further inform disappointed family members, but also for what ever reason I didn't receive the level of lip from doctors.  
      Anyway, not to bash on doctors and hospitals, just my hope is that someday a majority of people come to realize it is alright to take health care into your own hands.  Hospitals don't have all the answers, and all to often the answers that they do provide are inferior to a good proven diet and a few supplements.  I guess there will always be a place for expensive drugs and procedures - as if I have a choice in the matter - they just shouldn't be the first option, when there are other healthier and cheaper possibilities, in my opinion.

  • Dr. William Davis

    10/30/2010 12:32:36 PM |

    Hi, Sassy--

    This was my simple response. I operate in the real world, too, and do not have perfect solutions. I also invited her to my office to see what it is I do and how I do it.


    Sadly, your criticisms and concerns are right on the money.

    The problem: It will take 30 years and legions of our colleagues before there is a "sea change" of practice patterns and what we do becomes the norm. In the meantime, you have a satisfying and honest career to carve out.

    Training will try to push your round shape into a square hole, forcing you to mimic the thinking of conventional medicine. It may be a compromise you have to draw. I know of few good opportunities to break out of this mold. I believe that University of Arizona offers some sort of holistic medicine training. More of these programs are popping up. While they may not be precisely what you are looking for, perhaps they offer more leeway and less dogmatic training.

    I do sense that more and more of the primary care community are slowly rejecting conventional approaches, but I estimate it's less than 5%. But it used to be practically nobody. So it's a start.

    One good thing to know: I do what I do with little friction from colleagues. Most have no idea what it is you're talking about, but most stop arguing when they see what you can accomplish. Then they kind of turn a blind eye to how you did it, rarely asking why you did worked and their approach didn't.

  • Dr. William Davis

    10/30/2010 12:39:14 PM |

    Anonymous from Meijers--

    I hear you. I agree wholeheartedly that there is a huge and growing role for self-empowerment in health. It certainly will not come from conventional health channels, but from unconventional sources, such as online health information, direct-to-consumer testing, and other growing services.

  • Dr. William Davis

    10/30/2010 12:40:52 PM |

    Hi, Tara--

    I empathize.

    I know several very excellent dietitians, all of whom are affiliated with hospital systems (the only ones who hire), who are deeply frustrated as you are.

    I can only hope that we achieve a "critical mass" sometime soon, numbers of dissenters sufficient to be heard and not shunned, criticized, or fired.

  • Anonymous

    10/30/2010 12:47:31 PM |

    My dad is a family physician (MD) for 30+ years and over the past few years has been implementing many more natural approaches to preventing illness. It is a DIFFICULT path to take and one that is fought every day in the exam rooms with the patients and in the hallways with other doctors.

    What amazes me is other doctors willingness to RX medications that JUST CAME OUT ON THE MARKET without having done their due research, yet they very quickly judge and frown upon my dad's approach to medicine which he arrived at after many, many months of reading and researching these alternative therapies.

    While they claim to not doubt his intentions, its clear they disapprove of his methods, even in the face of proven results (less flu, fewer office visits for his patients, improved lab results).

    The reality is, he studies more in one evening (after seeing patients all day) than others study in a year. When he employs a therapy, its because he's researched the hell out of it and he's convinced it's the right approach to take. He understands the science behind HOW it works.

    Taking a preventative approach is difficult enough, but enduring the constant judgment from others who practice big-pharma medicine is what makes my dad the top-notch physician that he is. He doesn't back down from a good opportunity to educate both patients and other physicians alike about why he's decided to prevent disease instead of simply treating it.

    How refreshing to see others (especially younger physicians) who are also enduring this difficult path. It is the right thing to do.

    (P.S. Dr Davis- Vitamin D, Magnesium, Iodine, and now Lipoprotein A....you and my dad are following similar paths. I tried getting him to check lipoprotein As on his patients about a year ago (after studying them on your blog), but he was coming up to speed on Iodine at that time. Now he's embraced lipoprotein A and I know it's going to save lives. THANK YOU!)

  • Anonymous

    10/30/2010 1:30:38 PM |

    If a physician steps outside guideline-based medicine (statins for MI), he/she would open themselves up for the lawyers if the patient had an event.  

    The system is defective, but in some situations, the fear of getting sued is stronger than any influence from pharma.  

    Also, many training programs do not allow interaction with pharma reps at this time (from what I have heard).  This has been a new development in the last 1-2 years.

  • Carolyn Thomas

    10/30/2010 4:45:44 PM |

    Interesting comments from this med student.  Welcome to the wonderful world of marketing-based medicine!

    But we live in hope! Many medical schools are in fact taking action to address the pervasive influence of Big Pharma on medical education.

    For example, here in Canada pharmaceutical companies have long supplied free lunches – and even fridges to store them in – in the student lounges of all Canadian medical schools.

    But if the association that represents Canada’s medical schools has anything to say about it, there really will be no such thing as a free lunch anymore – at least for medical students.

    This also means no more talks given by physician experts paid by pharmaceutical companies. No more unsupervised meetings with drug reps.

    The Association of Faculties of Medicine of Canada say that their aim is to limit the influence that the pharmaceutical industry has on medical students and residents, as well as to address the public’s concerns about the perceived coziness between medical schools and Big Pharma.

    Dr. Irving Gold of the AFMC described the potential impact of drug company relationships on these students:

    “There’s no question that the environment within which you’re trained will have an impact on the way you perceive these issues. The public has to trust that the doctors they see do not have any debts to pay to individual pharmaceutical companies or to the sector as a whole.”

    More on this at "Pens, Pizza, Parties: How Big Pharma Freebies Impact Your Doctor" on THE ETHICAL NAG: MARKETING ETHICS FOR THE EASILY SWAYED - http://ethicalnag.org/2009/12/08/pens-pizza-parties/

  • Larry

    10/30/2010 7:33:19 PM |

    Hang in there Theresa M.
    You have to do what your heart tells you to.

    Anyway.... about Dieticians and Hospital food.
    Does the average dietician really, truly, believe that the food they serve is really nutrititional ?
    Does Monsanto dictate the cirriculum ?
    We've all seen Cancer patients being fed juice, milk, bread, cereal, canned (dead) food, potatoes, cookies, cold cuts, etc.
    How can a dietician with a conscience, be part of this ?
    Not trying to be offensive, I'm just asking, as they have to know the whole paradigm is wrong.

  • Gutted

    10/30/2010 9:32:22 PM |

    Thank you, Theresa, for speaking out! Hopefully, we'll see more and more medical students like you who really care about patients' health versus playing the Big Pharma, imaging and "slice 'em up"  marketing games. Unfortunately, with all the greed I see in this world, I don't have high hopes. But please don't let that stop you!

    It doesn't help that I was victimized by the medical profession in a big way. My ob/gyn of 20 years rushed me into surgery for possible ovarian cancer. Despite a benign frozen section, he proceeded to remove all my female organs. I suspect part of the reason was to train two gyn residents. This experience has shown me how corrupt the medical profession can be. Many things in the oncologist's records gave the appearance of collusion with my ob/gyn. I now realize that the oncologist was protecting his referral base to the permanent detriment of my health. A complaint to my state's medical board resulted in no disciplinary action. The outcome of a complaint I filed with my insurance company was confidential but the doctor is still in their network.  

    After many problems from the assault on my endocrine system amd anatomy (aging 15 years overnight along with profound depression and anxiety which I'd never experienced), I started frequenting hysterectomy forums. That's when I discovered that my story is quite common. If women were getting informed consent from their gynecologists, 1 in 3 women would not be hysterectomized by age 60 (1 in 2 by age 65). 73% of women are castrated at the time of hysterectomy. These women have a much greater risk of all-cause mortality. Yet, the carnage continues to the tune of a hysterectomy every minute in the U.S.  

    The book "The Treatment Trap" is a real eye-opener into the dark side of medicine. I highly recommend it.

    Here's an article - Lies, Damned Lies, and Medical Science - about the flaws of medical studies:

    http://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/8269

    Per the article, a leading expert in medical research credibility estimates that up to 90% of published medical information is flawed.

  • Tara

    10/30/2010 11:43:40 PM |

    @ Larry

    I work in outpatient, but I can go ahead and tell you that the inpatient dietitians don't actually "serve" the food, nor do the prepare it or even choose it.  The food service company (typically Aramark or Morrison) is responsible for the selection, preparation, and serving of food to patients.  An inpatient dietitian's job is to oversee patient care related to nutrition in various disease states, calculate needs, educate, and in some cases order/manage TPN or tube feedings.

    Many of us HATE the awful food that is served in hospitals, but we have no say in the matter.  Hospitals are run like businesses, so the quality of food is not as important as the cost.  When my dad had his bypass surgery, I cooked and brought him food from home.

  • Dr. William Davis

    10/31/2010 2:34:52 PM |

    Hi, Tara--

    You know, the plight of enlightened dietitians today reminds me of the way the German people must have felt when the National Socialism movement coerced them to follow their dictates on pain of imprisonment.

    The whisperings of neighbors was all it took to have the Gestapo knocking on your door at night.

    Your experience, by the way, would be a great conversation for this blog. Please tell us more.

  • blogblog

    11/1/2010 6:42:05 AM |

    I was friends with two Indonesian medical graduates. In Indonesia medicine is a six year undergraduate degree. Students spend the entire first year studying anatomy and physiology in considerable depth. They then spend the next five years working full-time in a hospital or small clinic. They begin to perform circumcisions after their first year of studies. Before graduation they must deliver a minimum of 100 babies!

  • blogblog

    11/1/2010 7:14:29 AM |

    Hi Tara,
    with respect being a dietitian or other health practitioner is simply not comparable with practising medicine. I should know because I studied exercise physiology as a postgraduate. My academic workload was probably less than 1/4 that of a medical student.

    The fact is that allied health degrees like nursing, dietitics and exercise physiology are actually quite easy.

    The amount of underlying theoretical knowledge, the workload and responsibility is vastly greater in medicine than in any other health related profession.

    The reality is you get 1/4 the pay of a doctor because your job is 1/4 as hard. You don't have to work nights, weekends and public holidays. You also don't have to be on call, work 36 hour shifts, make instantaneous life and death decisions or deal with grieving relatives like doctors do.

  • Anonymous

    11/2/2010 1:03:07 AM |

    "In Indonesia medicine is a six year undergraduate degree. Students spend the entire first year studying anatomy and physiology in considerable depth. They then spend the next five years working full-time in a hospital or small clinic. They begin to perform circumcisions after their first year of studies."

    But only on adults who ask to be circumcised, right?

    I certainly hope the mutilation of nonconsenting infants is not the standard of care in Indonesia.

  • blogblog

    11/2/2010 5:55:28 AM |

    Hi Anonymous. Indonesia is a Muslim, country so circumcision is routine for babies.

  • buy differrin online

    11/2/2010 3:52:18 PM |

    I was just arguing (discussing) with my cardiologist about coming off my statin (40 mg). I never had a cholesterol problem and still don't, even though I had an MI. I point to niacin and he points to Zocor. I tell him about studies and he claims I'm reading the wrong studies and that it is his job to know these things. He claims the zocor isn't for my cholesterol it is to control inflammation. I again point to studies that dispute statins ability to do that and again suggest niacin.

  • Tara

    11/3/2010 2:12:06 AM |

    @blogblog

    I think you missed my point... My post wasn't to complain about the difference in our salaries.  My point was that because we are in a lower position, we have an even tougher fight ahead.  It's hard to make a change when your grassroots efforts are poorly funded and your profession is not respected.

  • blogblog

    11/3/2010 7:28:16 AM |

    Tara,

    I'm sure that you are well intentioned and wish to help people but you aren't in a position to do that within the conventional dietetics framework.

    The only really influential and widely respected professionals in health care are senior medical specialists working in teaching hospitals. The opinions and knowledge of others is often deemed irrelevant.

    I am speaking from the Australian perspective so my comments may not be relevant to you.

    The dietetics profession has an extremely unethical relationship with the food processing industry. Many food manufacturers employ dietitians primarily as effective PR personnel to give their extremely unhealthy products some credibility.

    The Dietitians Association of Australia actively endorses the type of unhealthy products manufactured by their commercial partners. In the recent past the DAA has even actively promoted confectionery as part of a 'balanced' diet for children.

  • Rogue Dietitian

    11/6/2010 5:26:05 PM |

    @Tara -- you're not alone! I too am a "rogue" dietitian and am so frustrated with my colleagues. I am lucky in that I work at a naturopathic practice where my nutritional point of view is in sync with the doctors I work for. So, I am not expected or criticized for straying from the ADA/USDA grain-dairy model. I hear your frustrations with the field. Luckily, there is so much you can do with it though. I had to find my own way.

    During my internship, I had reservations about having to give diet advice I didn't believe to be prudent -- eat a low fat diet, drink lots of milk, etc. Instead, I changed the script and focused on other pieces of advice. For example, for heart patients I focused on getting them to eat more vegetables, and ditching the margarine, and "forgot" to mention the parts I don't agree with. Or for diabetics, eating fewer carbs and focusing on gluten-free sources like potatoes, brown rice, etc. My preceptors were thrilled I was getting people to eat more vegetables, and I didn't feel like I sold out. Good luck to you.

    Dr. Davis, I have only recently discovered your blog but am enjoying it. I have some non-traditional ideas on heart health I would love to dialog with you about sometime.

  • Dr. William Davis

    11/7/2010 3:59:52 PM |

    Hi, Rogue--

    That's great! A clever, "stealth," way to say what you believe.

    You are welcome to post recipes here or to go to www.trackyourplaque.com and use the "contact" link. I look forward to seeing what you've come up with.

  • rangojigi

    11/11/2010 9:21:37 AM |

    I would love to see your answers to her questions.
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  • Anonymous

    11/13/2010 3:27:27 AM |

    I learned a long time ago that 99.9% of doctors are worse than useless. I don't plan to ever see a doctor again. Sadly, I'll soon be forced into the medical system, like most Americans.

  • 2medicure

    12/10/2010 4:57:30 AM |

    Well after reading your blog and the comment from all the expert i will love to visit this blog to get update about good healthy habits

  • Dana Seilhan

    12/11/2010 9:35:44 AM |

    Anonymous, no one's being forced into the medical system. They're being made to pay for insurance.  No one says you have to go to the doctor.

    I was startled to learn there are actually sound economic reasons for making everyone buy into health insurance in a given country.  Too long to explain here but the book I learned this from, well predated the "health care reform" debate.  In a nutshell, if you didn't want to have to buy a health insurance plan, you should have supported the idea of single-payer coverage.  But you didn't want that, because it was "socialist," if you are like most Americans.  So this is the alternative everybody gets to live with, since they decided it was more important to have health insurance companies than to fund health care like we do police and fire departments.  Dem's de breaks.

  • dr cate

    9/19/2011 12:48:11 PM |

    HI Tara
    I work with a dietician who, like you, has a real passion for her job. She told me that she feels like she has participate in "tragedies unfolding every day" when the doctors send patients to her expecting the usual advice. She is fighting back, though. She has a health radio show you can listen to: http://www.wkxl1450.com/site/index.php?option=com_content&task=view&id=4182

    I encourage you to seek out doctors who think outside the box in your area. I have been so grateful to have Chris available for my patients, and I know other doctors would be grateful for someone like you, too!
    (PS I am relocating soon to Napa, CA, you don't happen to be there...?)

  • Barb

    10/5/2011 12:20:23 AM |

    Not meaning to be a s*&t disturber, but then why do an alarming number of doctors seem to only know 1/4 of what other allied health practitioners do?? Are they being taught too much 'feather' and not enough chicken??

  • jpatti

    5/31/2012 3:29:00 PM |

    I have a sister who doesn't understand much about biochemistry.  She asks me for advice all the time with various issues/problems.  Vast majority of my advice is dietary/supplements.  Sometimes, my advice is for prescription meds, which I can usually locate without a doctor (not talking narcotics or anything).

    But my advice to her in a ACUTE situation is... don't wait to ask me, do what the doctor says.  IMO, if you have a broken bone, or are actively having a heart attack, or have a big infected boil, mainstream medicine is OK, pretty much the best we've got.  

    When you have a CHRONIC disorder, or are trying to preempt having one, that is when taking your health into your own hands is good.  That is when you look up all the prescribing info for the drug they want to put you on before taking it.  That is when you become more of an expert on your disease than they are.  

    I had a CABG several years back, I've been a T2 diabetic for years, I had a bad rT3 problem, and adrenal insufficiency (reversed both the rT3 and adrenal issues and am weaned off meds), I have low sex hormones (E, P and T), I have systemic yeast.  I know more about my COMBINATION of diseases than any doctor cause I'm more INTERESTED and have GOBS of time to research each issue and the endocrinology (which includes nutrition. since cholesterol and vitamins A, D3 and K2 all profoundly effect hormones) and of how they all interact.  I can spend hours looking at a diagram of steroidogenesis and trying to figure out myself.

    So... if a doctor wants me to use more insulin for tighter control, I know I need more K-Dur to counteract the K loss from insulin else my BP will go skyhigh.  They don't.  They just see my BP go high and want to put me back on Lisinopril (which never lowered it, after 2 years of increasing doses).  I know niacin fixes my lipid panel better than statins - and that I can climb stairs on niacin.  I know that high omega 3 intake, and high vitamins A, D3 and K2, and lots of CoQ10 are absolutely required for my health.

    I DO know more than they do about my chronic stuff, and my sister's chronic stuff, and my daughter's and husband's issues.  If it's anything chronic, I WILL know more in a few weeks time than any doctor treating me.  Cause... no one can be an expert on EVERYTHING and I CARE more when it effects me or mine than they do.  I'm one of 30 patients they are seeing today; I'm the only me I've got.  I just flat out CARE more.

    But in an acute situation, I trust them.  My sister needs an MRI on her back, I agreed she needs it, and just said, "Do whatever they tell you if it's based on the MRI."  Cause... I can't become an expert in 10 minutes, and the acute stuff, they are mostly pretty good at.  Someone has to decide in those situations, and you don't have time to become an expert.

    There's other stuff mainstream medicine has gotten right.  Antibiotics as an example... though the overuse of them is what they got wrong.  Similarly, while I think we overdo vaccinations, the fact is that when polio came through a town and killed or crippled most of the children, that was some bad stuff.  Mainstream medicine gets some things right.

    The problem with medicine is that it is not evidence-based, though they say it is.  At BEST, it takes 10-15 years for good research info to change the practice of medicine.  At worst, if there is no profit motive, good research info may NEVER change the face of medicine.  

    IMO, with mainstream medicine, you take what is good and leave the rest.  But throwing out the baby with the bathwater makes no sense.  Doctors do have their uses.  No matter how we rant against their stupidity, there is some worthwhile stuff there.

    One of MY reasons for hanging out here is that Dr. Davis changes.  When I started hanging on this blog and his website and bought his first book, he wasn't discussing thyroid, or K2, and his dietary ideas were quite a bit different than today (though the anti-wheat stuff was there even then).  

    Not that I agree with him 100% about everything, but... he DOES change the way medicine does not; he actually DOES do evidence-based medicine, based on actual evidence, not just evidence provided by pharmaceutical studies.  And since evidence changes over time, and he keeps learning, his recommendations change.  That gives me confidence in his latest ideas, to go research them for myself.  

    And for those who can't really research for themselves, without a solid science background and an understanding of how to read studies, if they have cardio issues, I just tell them to go do what he says.  I've told people to read his books, sent them to the blog and website, I've even sent a few people to see him, cause they were local to him and able to get there.  Cause even if I don't agree 100% about everything, he's the only cardiologist I know who is actually reversing CHD.  

    Granted, Dr. D is a maverick and himself rants against mainstream medicine.  But... he rants agaisnt specific stupidity.  I'm sure if you were having an actual MI right now, he'd recommend a procedure to save you.  Just... he'd rather you not have the MI in the first place, which is why he rants.

    But... baby and bath water...

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Quieting the insulin storm

The cycle of eating, satiety, and hunger is largely driven by insulin and blood sugar responses.

For instance, if I eat a bowl of Cheerios, my blood sugar will surge to 140 mg/dl or higher (how high depending on insulin sensitivity). The flood of sugar from this Frankenfood triggers the release of insulin; blood sugar then settles back down.

The decline in blood sugar back down to normal or below normal powerfully triggers hunger. Variable degrees of shakiness, mental fogginess, and irritability also commonly occur. Most people experience this to some extent; some experience an exagerrated version called "reactive hypoglycemmia" and can suffer peculiar personality changes, irrational and even violent behavior.

Foods made with wheat or cornstarch raise blood sugar higher and faster than table sugar. Accordingly, blood sugar and insulin swing more widely with these food: highs are higher, lows are lower. People who therefore follow the standard mantra of "eat plenty of healthy whole grains" therefore experience a 2-3 hour long cycle of eating, brief satiety, and recurrent hunger. Cravings for snacks, impulsive eating, and overeating all occur during the period when blood sugar has dropped and hunger is powerfully triggered.

Eliminating this up and down fluctuation is therefore key to regaining control over appetite, losing weight, reducing small LDL and triglycerides, reducing blood sugar, and putting out the fires of inflammatory responses.

You can accomplish this by:

1) Eliminating foods that trigger the exagerrated rises in blood sugar--Wheat, cornstarch, polished rices, white and red potatoes, and candy.

2) Adding a healthy oil to every meal--a strategy that prolongs satiety and helps suppress sugar-insulin fluctuations.


The ful nuts and bolts details of this diet will be released with the New Track Your Plaque Diet. Part I has already been released; part II is coming any day on the Track Your Plaque website.

Scare tactics

"You're a walking time bomb."

"I can't be responsible for what happens to you."

"Your blockage is in the artery called the 'widow-maker.'"




Familiar lines? These are the well-rehearsed warnings commonly used by cardiologists to persuade a patient to undergo a procedure (heart catheterization and all that follow).

Something happens when you hear these words about your health. Most people's resolve to explore alternatives, get another opinion, think it over, promptly crumbles when they hear these words. These particular warnings have been time-tested and are surprisingly effective.

Unlike many other conditions, heart disease does indeed result in catastrophic events without warning. Unlike, say, cancer, heart disease can wreak damage suddenly. That's all true.

What bothers me is the vigor with which the opportunity for hospital procedures is pursued.

The thinking is that hospitals procedures = saving a life. In the vast majority of people, this is nonsense. Procedures like heart catheterization, stents, bypass, do save lives if someone is in the throes of a catastrophe. The problem is that most people who undergo procedures are not in the midst of catastrophe and have every hope of avoiding it altogether with some simple efforts towards prevention.

Imagine this conversation: "Yes, Mr. Smith, you do have heart disease, Even though you have no symptoms and your stress test is normal, I believe that we should 1) identify the causes of your heart disease, then 2) correct them. Of course, if you don't want to engage in this prevention process, then there may be a point at which heart procedures may be necessary. But I believe that you have great hopes of avoiding them and avoiding heart attack."

Self-Directed Testing

In the last Heart Scan Blog post, I listed the poll results on success vs. failure in trying to obtain requested blood work through doctors. The results of that informal poll revealed that a substantial number of people encounter resistance to one degree or another in trying to obtain blood tests.

But the world of self-directed testing is growing. In addition to your ability to circumvent your doctor by getting your own blood work done, you can now:

--Obtain many imaging tests on your own--Heart scans can be obtained without your doctor's involvement, for instance. The ultrasound screening services, like that offered by Lifeline, mobile services that provide carotid, abdominal aorta, and osteoporosis screening services; full body scans, and others.
--Identify and treat some conditions--Internet information has gotten quite powerful to assist individuals in recognizing when a condition might be present. (However, this is also a landmine for trouble if not properly used.)
--Genetic testing--While just in its infancy, direct-to-consumer genetic testing is now offered by two outfits that I'm aware of.
--Unusual laboratory tests--e.g., heavy metals, omega-3 fatty acid content, cancer markers.

One drawback to the emerging world of self-directed testing: There is no insurance coverage. However, this will become less and less of an issue as time passes, since it is clear that most Americans will need to bear a greater portion of healthcare costs in future, since some conventional services may even be rationed for cost containment; higher copays and the emergence of medical savings accounts, providing the individual with more control over how healthcare dollars are spent; competition in self-directed healthcare services, which will reduce costs. Imagine, for instance, several more direct-to-consumer services to obtain blood tests appear. They will need to compete on price and service.

While my colleagues are terrified of the potential for abuse of such tests, my reaction is the opposite: I am enormously excited by the potential for individuals to seize more and more control over their health.

Of course, with greater freedom comes greater responsibility. But the long-term net result will be, in my view, a healthier, more satisfied healthcare consumer with reduced healthcare costs.

Self-testing

Here are the results of the latest Heart Scan Blog poll (84 respondents):


When you ask your doctor to perform a specific blood test, does he/she:


Do it without question?
38 (44%)


Do it but express reservations?
25 (29%)


Do it very grudgingly?
13 (15%)


Refuse outright?
9 (10%)



I was encouraged that 44% of respondents are/were able to obtain the blood work they requested without resistance. Sadly, however, the majority do either encounter reluctance or outright resistance.

Why would your doctor impose barriers to your ability to obtain laboratory tests? Well, several potential reasons:

1) He/she feels that they are charged with your health safety, and you might be led down a misleading, potentially dangerous path.

2) He/she feels that the tests are truly unnecessary and that you will be wasting the money of the "system."

3) He/she doesn't understand the tests, or is unfamiliar with them.

4) He/she feels that the doctor should be in complete control, not you. How dare you try to usurp the doctor-as-dictator of your health!


In reality, number 1 is understandable but rarely occurs. I have indeed have had requests, though rare, for outrageously inappropriate tests for the issue at hand, usually due to a misinterpretation of some information by the patient.

I'm not sure how often number 2 truly is. For instance, it is not uncommon for the doctor to have an ownership stake in the laboratory. There are several large primary care groups in Milwaukee who are notorious over-users of laboratory tests, with extraordinary batteries of dozens of tests every few months on the flimsiest reasons , clearly motivated by . . . money. On the other hand, there are physicians who do consciously try and order tests rationally and cost-effectively. I suspect that this is a minority.

I feel quite confident that number 3--your doctor's ignorance--is probably the most common reason he/she is reluctant or refuses to allow you access to a test. Most respondents I suspect are referring to many of the tests that I have been advocating, such as lipoprotein testing, lipoprotein(a), and vitamin D blood levels. I am uncertain how any of these could be construed to be dangerous. But ignorance of the value of these tests is rampant and resistance is nearly always based on not having explored these issues and having no appreciation for their importance. Of course, the beleaguered primary care physician is, no surprise, inundated by so much information across such a wide range that he/she has become expert at nothing, barely able to even deliver the full scope of genuine up-to-date primary services any longer. My colleagues, the cardiologists. . . well, you know my feelings about their attitudes: If it doesn't make money, then why should I bother? Devote months or years studying something that doesn't ring the cash register?

I see this dilemma as yet more evidence of the growing disenchantment with the doctor-as-gatekeeper model, the centuries old paternalistic "I will tell you what to do and you will do it." It worked when the doctor was educated and had access to knowledge you could never realistically obtain because you couldn't read, or you were too poor to afford books and education, or because medical information was made privy only to select people.

It's not that way anymore: The information you have access to is the same information my colleagues and I have access to: a level playing field. Along with the changing rules of the game, the game itself must eventually change.

I believe that people should have access to self-testing. Indeed, there is a growing industry of direct-to-consumer laboratory testing, such as that offered by Life Extension and LabSafe . For the most part, these offer tests without potential insurance reimbursement.

But the landscape is changing: We are just beginning a new age of self-empowerment, self-directed healthcare.

Whenever I say this, some people are angered that the majority of people will be too lazy, stupid, or poor to join the movement. What I am not saying is that we should agitate to make the system a patient-only directed process and completely remove the doctor. What I am saying is that the patient should and will play an increasingly important role in determining the content and direction of his/her care, especially as the patient becomes far more knowledgeable about issues relevant to his/her health.


The new tools of health measurement

If there were a new mantra of the new science of insight into health and long life, it would be “measure, measure, and measure.”

Never before in history have we had access to the analytical, laboratory, imaging, quantifying health tools that we have today. We can locate, scan, measure, all down as far as the level of basic codons of the genetic sequence.

The health-inquiring public has so far been permitted just a tip-of-the-tongue taste of these quantitative phenomena in such things as cholesterol values (“know your numbers!”) and blood pressure. Women now discuss their bone density scores over coffee, men their PSAs (prostate specific antigen).

But a curious irony has emerged: Like early 20th century males uncomfortable with women battling for suffrage, healthcare professionals, themselves comfortable with measurements and numbers, are distinctly uncomfortable when some of the same information falls into the hands of the healthcare consumer.

These phenomena play out in especially dramatic fashion in the world of heart health. The public now has broad access (many without a doctor’s order) to an extraordinary array of health measurement tools that can potentially yield enormous benefits for prevention of the most common conditions, information that can be applied by tracking over time.

Measures like heart scan scores, vitamin D blood levels, lipoprotein(a)--measures that most doctors have little or no interest in obtaining, yet they serve crucial roles in maintaining and tracking your health.

The new paradigm is emerging: the tools are getting better and better, they are becoming more accessible.

Increasing sales, growing the business

I continue my portrayal of the fictional hospital, St. Matthews. Though fictional, it is based on real facts, figures, and situations.

Despite their success, administrators at St. Matthews’s Hospital continually fret over how to further expand their enterprise.

Market share can be increased, of course, by competing effectively with other hospitals, but that can be a tough arena. After all, St. Matthews’ competitors deliver pretty much the same services, and draw areas for patients overlap. The last thing the hospital wants is the appearance that heart care is a “cookie cutter” process, the same everywhere. In fact, this trend has hospital administrators wringing their hands. Two competing hospital systems in town recently launched multi-million dollar ad campaigns employing some of the same aggressive tactics St. Matthews’ marketers used successfully in past.

If St. Matthews is going to grow, new markets will need to be explored. What other strategies can a hospital system use to continue climbing the growth curve?

St. Matthews’ hospital administrators have drawn a number of lessons from other businesses. How about squeezing more procedures out of the population you already take care of? That’s an age-old rule of business: your easiest sales come from repeat customers. A former stent patient is going to “need” annual nuclear stress testing ($4000), more stents (about $25,000–39,000 per hospitalization), CT angiogram ($1800–2400), bypass surgery ($84,000), and so on. “Check-up” catheterizations, though clearly of little or not benefit to patients, are silently encouraged, yet another example of the bonanza of repeat procedures possible.

The lesson that “once a heart patient, always a heart patient” has been honed to an art form in business practices at St. Matthews and other hospitals like it. If you enter the system through your primary care physician or cardiologist, there’s an excellent chance you’ll end up with several procedures, diagnostic and therapeutic, over the ensuing years. Accordingly, St. Matthews provides a very attentive after-discharge follow-up program, complete with access to friendly people, phone centers, “support groups,” and even an occasional festive get-together, all in an effort to ensure future return to the system.

All in all, the St. Matthews Hospital System is a hugely successful operation. It provides jobs for thousands of area residents and provides high-tech, high-quality healthcare. Like any business—and no doubt about it, St. Matthews is a business with all the trappings of a profit-seeking enterprise—it grows to serve its own interests. The tobacco industry didn’t grow to its gargantuan proportions by doing good, but by selling a product to an unsuspecting public. So, too, hospitals.

Curiously, hospitals like St. Matthews continue to operate under the sheltered guise of not-for-profit institution with the associated tax benefits, ostensibly serving the public good. This means that all end-of-year excess revenues are re-invested and not distributed to investors. But non-profit does not mean that individuals within the system can’t benefit, and benefit handsomely. Under St. Matthews’ non-profit umbrella, many businesses thrive: 35 pharmacies, extended care facilities to provide care after hospital discharge, drug and medical device distributors, even a venture capital arm to fund new operations. The financial advantage conferred by “non-profit” status has permitted the hospital to compete with other, for-profit businesses, at a considerable advantage. For this reason, attempts have been made over the years to strip them of what some believe is an unfair advantage; all have failed.

While profits may not fall to the bottom line, money does indeed get paid out to many people along the way. Executives, for instance, pay themselves generous salaries and consulting fees, often from several of the entities in this complex business empire. Physicians are brought in as “consultants” or are awarded “directorships” for hundreds of thousands of dollars per year—Director of Research, Director of Cardiovascular Services, etc. Don’t forget the $3.7 million dollar annual salary paid to the CEO.

Hospitals and doctors have a vested interest in preserving this financial house of cards. They will fiercely battle anyone or anything that threatens the stream of cash. During a recent meeting of important doctors at St. Matthews Hospital, one cardiologist bravely voiced his concern that bypass surgery was performed too freely on too many patients in the hospital. The doctor was promptly and quietly asked to remove himself from the meeting. Several days later, he received a letter announcing his dismissal from the committee.

The silent conspiracy conducted by hospitals and cardiologists serves their own purposes better than the good of the public. Under the guise of good works, hospitals continue to promote strategies which are, for the most part, outdated, inefficient, inaccurate, and expensive. But that’s the rub. Expensive to you and your insurance company means more money for the recipient: your hospital and cardiologist, and the powers that support them. All this occurs while the real solutions that are of benefit to the public continue to be overlooked, hidden in the shadows.

Top Doctor

Dr. Robert Connors is the hospital’s most prized cardiologist.

Practically a fixture in the cath lab, he generates more revenues for the hospital than any of his colleagues. Last year alone, he performed over 1500 procedures, bringing in $18 million dollars to the cath lab, $27 million to the hospital. Dr. Connors is very good at what he does: 55-years old, he has been involved in high-tech heart care since the “early days,” 25 years ago, when hospital procedures really took off.

During his career, he has personally performed over 25,000 heart procedures and has built a reputation as a skilled operator of complex coronary procedures. Because of his skills, he enjoys a vigorous flow of referrals for procedures from dozens of primary care physicians. His skill has also earned him referrals from cardiologist colleagues who seek his abilities for difficult cases.

On any day, Dr. Connors typically schedules up to 12 procedures. His entire day is spent in the cath lab, usually from 7 am until 6 pm. He meets many patients for the first time on the catheterization laboratory table as staff shave their groin, preparing for the procedure. Much of the procedure itself is not even performed by Dr. Connors, but by one or another cardiologists-in-training, a “fellow,” or member of the fellowship the hospital proudly maintains as a clinical teaching institution. Nor will Dr. Connors talk to most patients at the close of the procedure. He leaves that to either the fellow or a nurse. Dr. Connors views himself as a procedural specialist, not someone who has to take care of patients. He gave up seeing patients in his office over 10 years ago.

Dr. Connors’ procedural enthusiasm gained him the attention of drug and medical device manufacturers. Because Dr. Connors lectures widely and advises colleagues, his comments can dramatically alter perceptions of the value of a technology. He has, on many occasions, catapulted an unpopular device to most-asked-for among colleagues, bringing millions in revenues to the manufacturer. One particularly lucrative arrangement he made around 10 years ago involved a “closure” device, a $400 single-use plug used to close the access site made during heart catheterizations. By swaying his colleagues at St. Matthews Hospital, 50 orders per day (one per procedure) tallied $20,000 every day, $7.1 million dollars per year for the manufacturer. Although he’d used other devices on the market, the 5,000 shares of stock he was offered encouraged him to issue glowing comments to colleagues on the superiority of this specific brand of closure device. Now over 90% of all catheterizations at St. Matthews conclude with the device manufactured by the company in which Dr. Connors maintains partial ownership.

Negative comments, on the other hand, topple other products when Dr. Connors sees fit to pan them. For this reason, device and drug manufacturers run straight to Dr. Connors to gain his good graces as soon as possible after a product is released into the market. Because the competition is just as likely to do the same, it has often come down to a bidding war, the company providing the most lucrative arrangement most likely to win.

Thus, Dr. Connors proudly boasts of how many times he has flown to Hawaii, Europe, and other exotic locations at industry expense. He also boasts of how, for $100,000 paid to him for a “consulting fee,” he can overturn the choice of products lining hospital shelves. As the hospital’s annual budget for coronary devices will top $84,000,000 this year, device manufacturers regard the sum paid Connors as a profitable investment.

Despite his lofty status in the hospital, Dr. Connors has long expressed a love-hate relationship with St. Matthews. While he enjoys his work and has made a more than comfortable income, he has long felt that the hospital administration didn’t truly appreciate his contributions. Five years ago, he therefore demanded that he be made “Director of Research.” After all, he had hired a nurse to help him coordinate enrollment of patients into several device trials brought to him by medical device manufacturers. When he encountered an initial lukewarm response from hospital administrators, he threatened to take his “business” elsewhere to a competing hospital. St. Matthews’ administrators gave in. They provided him with the title he wanted, along with $100,000 annual “stipend.”

True story, though names have been changed to protect the guilty.

Is Dr. Connors just an “outlier” among colleagues who toe a more conservative line? Or does his brand of commercial enterprise in hospital heart care represent the ideal that they seek, brazenly and ambitiously seeking to expand the procedural solution to heart disease to the exclusion of patient care and real human interaction?

Disease Engineering

Imagine you contract pneumonia.

You have a fever of 103, you’re coughing up thick, yellow sputum, breathing is getting difficult. You hobble to the doctor, who then fails to prescribe you antibiotics. You get some kind of explanation about unnecessary exposure to antibiotics to avoid creating resistant organisms, yadda yadda. So you make do with some Tylenol®, cough syrup, and resign yourself to a few lousy days of suffering.

Five days into your illness, you’ve not shown up for work, you’re having trouble breathing, and you’re getting delirious. An emergency trip to the hospital follows, where a bronchoscopy is performed (an imaging scope threaded down your airway) and organisms recovered for diagnosis. You’re put on a ventilator through a tube in your throat to support your breathing and treated with intravenous antibiotics. Delayed treatment permits infection to escape into the fluid around your lungs, creating an “empyema,” an extension of the infection that requires insertion of a tube into your chest through an incision to drain the infection. You require feeding through a tube in your nose, since the ventilator prevents you from eating through your mouth. After 10 days, several healing incisions, and a hospital bill totaling $75,000, you’re discharged only to be face eights weeks of rehabilitation because of the extreme toll your illness extracted. Your doctor also advises you that, given the damage incurred to your lungs and airways, you will be prone to more lung infections in the future, and similar situations could recur whenever a cold or virus comes long.

A disease treatable by taking a two week, $20 course of oral antibiotics at home has been converted into a lengthy hospital stay that generated extravagant professional fees, testing, and costly supportive care. You’ve lost several weeks of income. You’re weak and demoralized, frightened that the next flu or virus could mean another trip to the hospital.

Such a scenario would be unimaginable with a common infection like pneumonia, or it would be grounds for filing a malpractice lawsuit. But, as horrific as it sounds in another sphere of healthcare, it is, in effect, analogous to how heart disease is managed in current medical practice.

First, you’re permitted to develop the condition. It may require years of ignoring the telltale signs, it may require your unwitting participation in unhealthy lifestyle choices. Palliative treatments that slow, but don't stop, the progression of disease are prescribed like cholesterol drugs. The process then eventuates in some catastrophe like heart attack or similar unstable heart situation, at which point you no longer have a choice but to submit to major heart procedures. That’s when you receive your heart catheterization, coronary stents, bypass, defibrillators, etc. and you're proudly declared a "success" of medical technology.

Of course, none of these procedural treatments cures the disease, no more than a Band Aid® heals the gash in your leg. The conditions that were present that created your heart disease continue, allowing a progressive disease to worsen. At some point, you will need to return to the hospital for yet more procedures when trouble recurs, which it inevitably does.

A coronary bypass operation costs, on average $85, 653 (AHA 2008 Update; based on 2004 data). That doesn't include the $25,433 cost for the heart catheterization performed by a cardiologist to provide the surgical roadmap of your coronary arteries. If there are any complications of your procedure, then your hospital bill may total a substantially higher figure.

$85, 653 is just the upfront financial pay-off. Over the long run, your life is actually worth far more to the cardiovascular healthcare system because no heart procedure yields a permanent fix. In fact, repeated reliance on the system is the rule.

In fact, over 90% of people who enter the American cardiovascular healthcare system do so through a revolving door of multiple procedures over several years. It is truly a rare person, for instance, who undergoes a coronary bypass operation, never to be seen again the wards of the hospital because he remains healthy and free of catastrophe. A much more familiar scenario is the man or woman who undergoes two or three heart catheterizations, receives 3,4, or 6 stents, followed a few years later by a heart bypass, pacemaker, defibrillator, as well as the tests performed for catastrophe management, such as nuclear stress test, echocardiogram, laboratory blood analysis, and consultation with several specialists. Re-do bypass surgeries--a 2nd, 3rd, or 4th bypass--now comprise 25% of all bypass procedures.

The total revenue opportunity is many-fold higher than the initial 80-some thousand dollars, but instead totals hundreds of thousands of dollars per person.

What motivation can there possibly be to 1) identify coronary disease early, when in its asymptomatic stage, then 2) identify its causes, then 3) correct the causes, and finally 4) shut off the disease? You and I can accomplish this with a few hundred dollars of cost, perhaps a few thousand over many years (to cover costs of fish oil, vitamin D, niacin, and whatever else it takes to stop the expression of the disease). Nobody therefore profits substantially from your prevention effort--except you.

Then what if nobody told you that heart disease could be managed this way? That's what I mean by "disease engineering."

Dr. Steven Gundry on The Livin' La Vida Low-Carb Show

I stumbled on a great interview with cardiothoracic surgeon, Dr. Steven Gundry, on Jimmy Moore's Livin' La Vida Low-Carb Show. (Or, cut and paste: http://www.thelivinlowcarbshow.com/dr-steven-gundry-part-1-episode-179/)

Dr. Gundry has some fun ways of looking at eating and health. I found his comments on the activation of genes (discussed at a very light, non-scientific level) useful. He argues that when humans consume sugar-containing foods, the signal received by the body is that winter is approaching and it's time to build up fat stores in anticipation of the food shortages of cold weather. He finds parallels for this phenomenon in other species. Of course, for humans, winter (in the form of extended calorie deprivation) never comes. In fact, you might argue that, given our excessive reliance on grains, corn, and sugars, that we are, in effect, always in anticipation of a winter that never comes.

I've not read Dr. Gundry's books, but I found this light interview a lot of fun.

Does fish oil ADD to statin therapy?

Yet another patient came to my office today saying, "My primary doctor said that I should stop taking fish oil. He say's that I don't need it because I take Crestor."

The woman was in tears, confused and frightened over a potential disagreement between her doctors.

Is this true? If someone takes a statin drug, like Crestor, Lipitor, Zocor (simvastatin), pravachol, or lovastatin, they don't need to take anything else because the statin drug is so powerful that it eliminates risk?

No. Not even close to the truth.

First of all, let's accept that virtually the entire body of statin drug literature--hundreds of studies, billions of dollars spent--was paid for by the drug industry. It's no news that studies paid for by the sponsor are likely to favor the sponsor. Imagine Ford sponsored a study of Ford vs. GM cars vs. Toyota, paying $10 million to fund the effort. Guess who is likely to come out on top? "Studies show that Ford makes the best car in America." (Sorry, I don't mean to pick specifically on Ford. It's just a widely-recognized brand.)

So that means that the statin literature likely overestimates the benefit of statin drugs. Even so, it's clear from the hundreds of studies performed that the best we can hope for by taking statin drugs is a reduction of heart attack and death from heart attack of 30-35%--best case. That doesn't sound like elimination of risk to me.

What are the incremental benefits of adding omega-3 fatty acids from fish oil added to statins? The best data originate with the JELIS Trial (Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis), in which 19,000 Japanese participants (who already have a high omega-3 intake from diet, usually ranging from 1800-3000 mg per day) experienced a 19% reduction (relative reduction) in cardiovascular events.

GISSI Prevenzione demonstrated a 28% reduction in heart attack, 45% reduction in death from heart attack with fish oil.

Omega-3 fatty acids from fish oil also:

--Reduce triglycerides dramatically
--Accelerate after-eating clearance of digestive by-products, i.e., they correct post-prandial abnormalities
--Modify the character (fragmentation potential, structural strength) of plaque
--Raise HDL modestly

If you buy your fish oil from Sam's Club, Costco, or other discounter, a healthy dose of fish oil might cost you $3 per month. Compare that to the $120 per month average cost of a statin agent. Why is there even a discussion over this?

Sadly, the doctor on Main Street, U.S.A, is the unwitting puppet of the pharmaceutical industry. The pretty drug company representative with nice legs and a cute smile promises lunch, dinner and . . who knows what else? Wink. The fifty-something, hairline-receding doctor can't resist. "Of course I'll prescribe your drug!"

Don't kid yourself: The drug industry knows precisely how to manipulate the behaviors of the deliverers of their products.

So, do statin drugs make omega-3 fatty acids from fish oil irrelevant? Absolutely not.

It's all about trying to inch closer and closer--not to reduction--but to elimination of risk for heart disease.

HDL: “H” is for “happy”

What role do emotions play in HDL cholesterol?

I’ve often observed a peculiar phenomenon: People who come to the office or hospital in the midst of a difficult emotional situation-e.g., stress at home, financial struggles, hospitalization (usually an unhappy occasion)- can show dramatic drops in HDL cholesterol. Not uncommonly, HDL drops 20 or more mg/dl.

Take Agnes’s case. Agnes had to go to the hospital for an elective procedure, one she’d been dreading for months. Previously, Agnes had been proud of the fact that she’d incrased HDL from 42 mg/dl range all the way up to 71 mg/dl. She accomplished this dramatic increase by eliminating wheat and cornstarch from her diet (which helped her lose 24 lbs), taking vitamin D and omega-3 fatty acids from fish oil, exercise, 2 oz of dark chocolate per day, and a glass of red wine with dinner.

Although I wouldn’t have bothered checking a cholesterol panel for such a procedure, the hospital had a checklist that included a cholesterol panel regardless of necessity. (Such checklists are common in hospitals, meant to ensure that certain basic issues are not overlooked.)

Agnes’ HDL: 29 mg/dl-a 42 mg drop.

Agnes will recover and her HDL will rebound, but the same effect can occur with other stressful situations, such as death in the family, financial worries, marital stress, etc., as well as physical illness.

Interestingly, the opposite may also hold true: Low HDL may increase risk for depression and stress. A study from Finland of 124 depressed persons, for instance, showed a 240% increased likelihood of depression in those with lower HDL cholesterols.

In other words, there seems to be a curious interdependence between HDL and emotions.

Why? Does it represent the indirect effect of adrenaline, cortisol, or other “stress hormones”? Do factors that relate to low HDL, such as unhealthy diet full of carbohydrates and physical inactivity, also tend to cultivate depression?

It certainly seems to be a chicken-egg situation, with one often leading to the other.

Moral of the story: Maintaining a sense of optimism and engaging in activities that bring you satisfaction and enjoyment can help raise HDL, as can strategies such as those followed by Agnes. Avoiding unnecessarily stressful situations can help. HDL is important, since higher levels are associated with much reduced risk for heart disease . . . and perhaps depression.