Internet research and the Doctor-Patient relationship, Part 1

Recently, I was in the check-out line of my local supermarket, when the latest issue of Consumer Reports caught my eye. Though it’s a magazine I rarely read, the headline ‘What Doctors Wish Their Patients Knew’ made me toss it in my basket between the garbanzo beans and rice. As an advocate for closing the gap between doctors and patients in order to improve health outcomes, I eagerly wanted to read this issue. It’s lead me to write two articles this week on the topic of the patients’ Internet research, and how to get the most out of your relationship with your doctor.

The Internet has brought us many wonderful things, including emails from old friends, social movements, and out-of-print 7” inch records from early 80’s British bands. It’s also brought us a plethora of medically-related websites for consumers. According to surveys in this issue of Consumer Reports, 61% of patients did Internet research about their health, whereas only 8% of doctors said that Internet research by patients was very helpful. Exact figures are not important, but what’s indicated here is a conflict that sometimes happens in the doctor’s office.

While some doctors might wish that their patients lived under rocks without any access to medical information, I advocate for patient education and knowledge. That said, the Internet doesn’t always provide either education or knowledge, and sometimes it can be detrimental. What I’d like to outline here is how to use the Internet well to improve your healthcare.

To start, I’d like to address some of the reasons why consumers use the Internet in the first place. One of the primary reasons people turn to the Internet is because they want to understand more about their health  and don’t feel that their doctors explain them well enough. Part of the reason for this is the time constraints placed on physicians, time constraints that are an unfortunate product of the economics surrounding the practice of medicine. I recommend trying to find a physician who will take the time to talk with you, as they will be able to speak to the disease process and any specific issues that you are facing in a way that a website will not. For this reason as well as the next, finding a primary care doctor with whom you connect well is crucial to improving your healthcare outcomes. Most naturopathic doctors are more than happy to speak to you at length to make sure that you understand your health, and there are also a number of family practice MDs and internal medicine MDs who will do the same. If you do find that you need more information, I recommend using reliable websites to get more information about conditions, such as WebMD (www.webmd.com) or Medline (www.nlm.nih.gov/medlineplus/). These websites will provide a lot of detail, though not all of it will necessarily applicable to you.

The other main reason that people utilize the Internet for health-related reasons is because they are not satisfied with the treatment options their doctor is giving them, and so seek alternatives online. Here things get a bit dicier. First and foremost, I would suggest that patients find doctors willing to explore alternatives. This doesn’t mean necessarily using ‘alternative medicine’, but rather doctors who will discuss various options within their own expertise. I find that most medical conditions have around 3 or 4 commonly accepted treatments, and naturopathic doctors may have an even broader range of options. If you do search the Internet for alternative treatments, discuss them with your doctor before starting on any treatment plan. This point is, unfortunately, a main one that separates doctors and patients – some doctors will not want to discuss alternatives, and may be dismissive of them. This fact ties back to my suggestion that you try to find a doctor that is willing to explore alternatives. Most naturopathic doctors will be aware of the range of alternatives, and can speak knowledgeably about them with you.

The other reason I say that this is dicier is because the Internet, like the Wild West, is full of medicine shows, and it’s sometimes difficult even for seasoned practitioners to determine their validity. Making things more complicated is that many of the products available on the internet are marketed as ‘cures’ for condition ‘x’. As I stated previously, there are often multiple potential treatments for any given condition, and in the world of alternative treatments in particular, the success of a particular treatment is very much dependent on your individual situation and your challenges. Thus, while a particular product may have worked for any number of people, it may not do the same for you. A good doctor should help you to navigate these murky waters. Bring the information to a visit, and make sure you have a good conversation about the pros and cons of a given treatment. Also try to find a second source on any information you read – WebMD usually has information about alternative treatments for conditions.

The take-home message is this: Your use of the Internet should improve your relationship with your doctor, not diminish it. The Internet is just a mass of data, and can be hard to navigate. Your doctor can help you sort the wheat from the chaff, and help you sort out which of the good information is applicable to you. It’s important to develop a strong working relationship with your primary care doctor, where you feel listened-to, respected, and understood. Likewise, it’s important to find a doctor whose opinion and judgment you value, as these doctors will best be able to help you navigate the complex field of healthcare options.

Look for part two of this article on Friday, in which I’ll discuss that bogeyman of the Internet, self-diagnosis.

B Vitamins and Endurance Sports

Marathon training season is upon us, and I’ve done some research into the topic of performance enhancement, as well as avoiding negative effects of endurance sports. Marathons are stressful events, both physically and emotionally, and most runners are aware of the important precautions to be taken, including carbohydrate consumption, proper hydration, and avoiding overconsumption of water. There are, however, other concerns to take into account.

Biochemically, it makes sense to supplement with a quality B-Complex vitamin in advance of a race and during training. Most of the B vitamins, including B1, B2, B3, B5, and B6 are utilized either directly or indirectly in the production of cellular energy from sugars, proteins and fats. Increasing intake of these vitamins logically ought to improve energy, a fact borne out in clinical practice. Additionally, there are studies demonstrating that mitochondrial function becomes less efficient during endurance sports, so smart runners should take steps to prevent that beforehand.

Clinical experience is also important when addressing this topic, as there has not been considerable research measuring the effect of B complexes on athletic performance. Based on my own observations and those of other practicing physicians, B vitamins, and especially vitamin B12, improve patients’ energy levels considerably, and indeed that is a common use for them. Patients frequently report higher energy levels, including for sports. It makes sense, then to use them for patients looking to boost performance in endurance sports.

Much of the research done into B-complex vitamins combined with exercise has focused on homocysteine levels. While most people are familiar with homocysteine for its hypothesized connection to heart disease, it can also be measured as an indirect marker for folic acid and vitamin B12 metabolism. The studies consistently indicate that homocysteine is elevated after endurance sports, especially in patients with low vitamin B12 and folic acid levels, and further studies indicate that vitamin B12 metabolism is significantly altered during endurance sports. Far from suggesting that marathoners are more likely to have heart attacks, these studies indicate that marathons place an increased demand on these two nutrients, and that supplementation is important.

The bottom line is that it’s important to supplement with B vitamins going into a marathon or other endurance sport. They would be a remedy to some of the biochemical stresses that runners endure during such events, and may boost performance as well. An easy way to get B vitamins, beyond standard supplements, is by adding Emergen-C or a similar product to the water you drink during exercise (I’m not advertising this particular one, but it’s widely available). Emergen-C supplies a full B complex, as well as vitamin C, which is useful to counter the oxidative stress of a race, and electrolytes, which help promote proper cellular function, as well as maintaining proper hydration and fluid balance. Hope this is helpful to all of you athletes out there! May you have a safe and happy season!

How Will Social Change in the Middle East Affect Health in America?

For those not moved by politics, fear not! I have an article on B vitamin supplementation and endurance sports, and another on fish oils in the pipeline. But for everyone else, read on…

I was moved to write again on this topic by reports from Bahrain stating that doctors and nurses have been beaten and are being prevented from tending to those peaceful protesters who have been wounded. There are reports of ambulances being prevented from reaching victims. There are reports of protesters being attacked and beaten at the hospital. As a doctor, there are not words strong enough to express my condemnation of these acts. Government interference with protest is reprehensible, but at least there’s precedent. Government interference with doctors tending to the wounded is inexcusable.

In a previous post, I stated that self-determination is a necessary requirement for optimal health, and that we Americans should encourage social change in the Middle East to promote health. Having appealed to your altruistic side, let me now appeal to your selfish side – even if you don’t care one bit about the people of the Middle East or their rights, your health will benefit if the Arab world wins its democracy, and the US changes its foreign policy in the region.

Let me first define terms. I’m suggesting that the US government decrease military funding of the region, decrease troop deployment in the region, and reinvest in human and social capital in the region (education, health, etc.). I believe that this is achievable, and that the US will still maintain if not increase national security by actively working to win the good will of the Arab world. The election of Barack Obama garnered the US favorable publicity in the Middle East, and that was accidental – it has decreased recently, but I believe we can regain this goodwill through deliberate action. Most importantly regarding health, I believe that winning good will is less expensive than military control, and that this policy will come with significant monetary savings, which can be reinvested in social services here in the US.

The first way that social change in the Middle East will improve American healthcare is therefore a matter of funding. As a clinician, I have seen patients struggle with the cost of healthcare, and find it deplorable that no programs exist to help these people. For example, I remember a patient of mine with Type II Diabetes who struggled to pay for her blood glucose test strips. This was a woman in her early 50’s, a parent and grandparent who had several people depending on her to make a living. When I first saw her, she was a stroke waiting to happen; she had the highest blood sugar and hemoglobin A1c I’ve ever seen, the highest total cholesterol I’ve ever seen, and the highest blood pressure I’ve ever seen. I’m still a young clinician, but believe me, when I say they were high, they were high. We were able to bring her back to a healthier state within a few months, but this state was tenuous, and compounded by the fact that she was struggling to make ends meet even without the added healthcare costs. Make no mistake, these were life-saving measures we were taking, and we were barely holding on. Were this woman to have a stroke and either die or be unable to work, the social cost would be enormous, as she and her dependents would have to rely on government assistance, not to mention have to pay for emergency medical services. Mind you, this could be prevented for less than $5 a day, accounting for test strips and her medication. Meanwhile, the US currently spends $3.5 million every day on military aid to Egypt. Using those potential savings to sponsor better healthcare programs here in the US could improve the health of American citizens, improve quality of life, and potentially save the US money in other areas.

The second way that these changes could benefit American health is environmental. Plain and simple, oil belongs underground, not in the air. While air quality has slowly been improving in the developed world, air pollution is implicated in respiratory diseases and other chronic conditions. Additionally, use of these hydrocarbon fuels contributes to global warming. How global warming will directly affect the health of individual humans in the long term is not yet known, though there is increasing concern about nations’ ability to feed their people due to climate change. A great portion of these fuels come from the Middle East, from countries ruled with iron-fisted strongmen, rulers against whom people across the Middle East are now revolting. We are now finally at a point where renewable energy sources are becoming real possibilities, not just castles in the air. A deliberate plan of political and military withdrawal from the region, coupled with investment in renewable energies, with the intended goal of reducing consumption of fossil fuels, would have a marked effect on human health.

I’m making grand plans here, I know, but this is not a time for timidity and business as usual. Far from being distant events affecting people ‘over there’, the changes happening in the Middle East have potentially great implications here. It has often been said that out of all crises arise opportunities. Some say that for every door that closes, another opens. That has never been truer than it is right now. By protesting peacefully for their rights, the people of the Arab world are trying to close the door on militarism, unsustainable economic policies, and environmental degradation. Rather than trying to keep our foot in the door, let us instead turn around and open the next.

Race and Homeopathy

In addition to the changes taking place in the Middle East, you may also know that it’s Black History Month here in the US! I’ve decided then to tackle a small but important topic in this article, which is primarily addressed towards practitioners, though consumers may get some value out of it as well.

At this point, it’s well-documented that a disparity exists between the quality of health care delivered to African Americans and their white American counterparts, even after one accounts for economic differences – meaning that the ability to afford ‘better’ health care doesn’t always mean that better health care is received. However, exactly why this happens is not fully understood, although at least part of it comes down to physician decision-making. Efforts are underway to correct this, although they are largely directed towards the traditional medical establishment. These efforts are mostly directed towards insisting on evidence-based approaches for all patients, and insisting on standards of care, thus reducing the role of physician decisions in these cases.

Within alternative medicine, however, we face different challenges. In homeopathy in particular, I’ve noted a unique problem I’ve not previously seen addressed.

It’s very important in the practice of homeopathy to get a strong sense for a patient’s personality in the interview; thus, it’s important to tell if the patient generally presents as flat, as bubbly, as nervous, etc. I have found that sometimes, this important aspect of the interview can become clouded unless the practitioner is aware of it. What do I mean by this? I mean that patients may modify their behavior because of racial dynamics present between the practitioner and the patient, and unless the practitioner is aware of it, they may miss a prescription. This is by no means a comment on the skill or sensitivity of practitioners, but rather an observation I’ve made and would like to share.

Two specific instances I’m thinking of where this came into play involved African-American patients who ultimately responded to the remedy Phosphorus, one of which was a patient for whom I was the prescribing homeopath. For those unfamiliar with homeopathy, the remedy Phosphorus is commonly associated with patients who are very friendly, ebullient, and cheerful; these are the people whose smiles light up rooms without fail. In both cases, their physical symptoms strongly pointed towards this remedy, but their personalities anywhere but towards Phosphorus – they appeared quiet, flat, almost indifferent during the interview. In my particular case, I began to suspect that my patient was ‘muting’ her personality during the interview, as she began to reveal her true nature, though not until very late in the interview. In both cases, the patients were being interviewed in ‘white’ environments, and so modified their presenting personalities; the correct prescription was made in both cases, but it was only because the physician was sensitive to the fact that their patient wasn’t being their ‘true selves’.

As we work towards reducing racial disparities in health care, this is an area where natural health practitioners are going to have to be conscious. Being aware of how racial dynamics might be playing into your interviews is an important step in delivering better health care.

Social Justice and Health

This is the first of two posts this week on the topic of health and social justice, done in part to make up for failing to post last week. The reason I was too preoccupied to get a post in was that, like many people around the world, I was watching with rapt attention the events unfolding in Egypt. This is clearly a topic with broad political implications, and while I would like to discuss this event in the context of social justice and health, I am going to avoid discussion of those complexities – this is, after all, a blog on health, not politics.

I remember a class I attended once in which we were asked to come up with a definition of health. Mind you, this was being addressed to a room full of naturopathic students and doctors, so the responses were more philosophical than you might get from a room full of radiologists, but nonetheless, our answer were broad, ranging from ‘being free of pain’, to ‘having mutually beneficial relationships’, ‘eating a healthy diet’, and on to ‘having a fulfilled spiritual life’. Ironically or not, no one mentioned ‘living as long as possible’, as all of the answers focused on quality of life, not quantity of life.

One thing that came up was ‘the ability to express oneself’. Another was ‘taking charge of one’s life’. These two concepts are usually thought of political rights, rather than factors in health, but their place in health is valid and important. Part of health is the ability to become one’s true self, and to achieve one’s greatest potential, and to thus experience maximal quality of life. This aspect of health is only possible when people have the political right to free expression and self-determination. In some ways, the current struggle in Egypt is a struggle for health, then. I could try to link these by drawing a long line from a repressive dictatorship to chronic stress to increased cortisol levels to decreased immune function to increased illness, but I don’t think it’s necessary to be long-winded. Self-determination is necessary for a healthy life. Period. It’s my duty, then, as a doctor, and our duty as a society to promote health by insisting on human rights.

Change comes with challenges, to be certain, but through these challenges we grow and develop. This is true not only for those striving for freedom, but also for those who observe and help. Remember that it is only because of environmental stresses that plants create those life-sustaining substances known as antioxidants! As we help others become healthier, we do so ourselves. Let’s grow healthier together, and achieve our greatest potential as individuals and as a planet.