Thursday, November 24, 2011

Giving Thanks For Another Year

The modern American holiday season is a mix of stresses, joys, rituals, and extensive advertising. With so much going on, it’s hard for many of us to remember why we’re celebrating in the first place. With that in mind, I’m writing this week’s blog entry as a paean to autumn, because for me, the holidays are a great time to reconnect with the Earth. The leaves change, the winds blow colder, and all around us, things are changing. While throughout the summer we grow lazy and comfortable, the autumn reminds us of how we are inextricably linked to the planet’s changes.

I gained my strong appreciation for this natural shift in the seasons while I was living in Cambridge, Massachusetts and was a member of the Lindentree Farm CSA. Summer was always a time of excess, a time when I’d wonder every week about what exactly I was going to do with yet another 10 pounds of summer squash and zucchini. Eventually, we’d make our way towards the peak of the season, getting tomatoes, corn, peppers, potatoes, and the rest of the foods we associate with harvest. But at the end of the season, things changed – we’d see kale, cabbage, root veggies and pumpkins, foods that remind us less of irresponsible gluttony and more of careful storage.

I remember clearly spending one November day out in the fields at Lindentree, scrabbling amongst the dirt for a few leaves of spinach. While July and August had featured tomato vines, pea vines, corn stalks, and large heads of lettuce, all forming an undulating sea of green that rippled in the warm breeze, November found the fields empty. Everything had been chopped down and hauled off for composting, or had been tilled under. The warm, gentle breeze was gone, replaced by a chilly wind that skimmed across the bare earth, finding little resistance. The time for lazing in the sun was gone – it was time to head indoors and rest for the winter. It was a beautiful thing, this change that had occurred, and in celebrating the holidays, this is always foremost in my mind of things for which to be thankful.

This soup was concocted from a mix of everything that Lindentree Farm provided in late September and early October, so some of the food isn’t perfectly seasonal, but hopefully you froze some of it when it was coming in such mass quantities a few weeks ago.

1 winter squash (such as butternut, acorn, pumpkin or kabocha), providing about 2-3 cups pulp
2 tbsp butter
1 medium onion, chopped
1 bell pepper, chopped
1 medium carrot, sliced
¼ tsp cinnamon
½ tsp thyme
¼ tsp nutmeg
2 bay leaves
2 large tomatoes, chopped, providing about 2-3 cups
2 apples, cored and chopped
¼ cup half & half or cream
Salt and pepper

Peel and chop the squash, then boil it in just enough water to cover for about 15-20 minutes, until soft. Don’t get rid of the boiling water – you’ll need it later.
Sautee the onion, pepper and carrots in the butter over medium heat until the onions are soft, stirring to prevent carmelizing.
When the onions are soft, add the spices and sautee for another 2 minutes.
Add the tomatoes, apples, squash, and about 1 ½ cups of the reserved water, and bring to a boil. Cover and let simmer for about 30-40 minutes, until everything is tender and soft.
Puree in batches in a blender or food processor. When everything has been pureed, reheat lightly, adding ¼ cup half & half or enough to achieve your desired creaminess. Season with salt and pepper to taste.

Thursday, November 17, 2011

A Naturopathic Physician By Any Other Name

In the course of writing this blog (and especially last week), I find that I sometimes use the terms naturopathnaturopathic doctor, and naturopathic physician somewhat interchangeably. Though this isn’t exactly wrong, there are differences between these terms, in some cases subtle ones, in other cases legal ones. Additionally, it may be confusing for consumers to tell the difference between these terms. Therefore, I’m devoting this week’s blog entry to a brief discussion of these terms, to help all of the consumers out there who are trying to get the healthcare solutions they want.

Naturopath – Without a doubt the oldest term of the three, naturopath is also the broadest in its meaning. The term arose in the late 19th century to describe a growing movement of health practitioners who utilized natural methods, including diet, lifestyle, exercise, and herbs. Most graduates from a four-year, accredited program in naturopathic medicine would identify themselves as naturopaths when asked. However, in states without naturopathic medicine licensure laws, a broad range of other practitioners can also call themselves naturopaths, many of whom have received their ‘degrees’ through mail-order correspondence courses. Naturopath and naturopathy do not imply physician-level training, and so they are the broadest terms for practitioners of natural health, including but not exclusive to licensed naturopathic doctors. These terms have fallen out of favor in recent years because they are non-specific. I sometimes think of these terms as being comparable to the label ‘natural’ on food products – there’s not a lot of regulation over the term, and you really need to read the label before buying, so likewise, you need to assess the credentials of anyone calling themselves a ‘naturopath’. Here’s a list of accredited programs that you can use when checking up on a practitioner’s credentials.

Naturopathic doctor – Starting in the late 1970s, the practice of naturopathy became significantly more medicalized. Four-year post-graduate programs combining didactic and clinical education had existed for a long time (notably at the National College of Naturopathic Medicine), but with the founding of the John Bastyr College of Naturopathic Medicine (now Bastyr University) in 1978, they became standard. These programs were now attracting college-educated young people who had strong scientific backgrounds, many of whom had considered pursuing MDs, but who were seeking to promote health through less invasive, non-toxic, more natural methods. The colleges began conducting research, with Bastyr being the first naturopathic college to receive funding from the NIH in 1984. Similarly, licensure laws began to expand, and licensed naturopathic doctors began to have access to pharmaceuticals in addition to the natural therapies that were and are the mainstay of naturopathic medicine. This major shift in education and practice called for updated terminology. Naturopathic doctor and naturopathic medicine were favored over the older terms. As I said earlier, though graduates of accredited programs would accept the term naturopath, most are more accustomed to referring to themselves as naturopathic doctors. The older term came into usage over a century ago, whereas the more modern term gained prominence in the closing decades of the 20th century and was reflective of seismic changes in the education and practice of naturopathic medicine.

Naturopathic physician – Reflective of the most recent wave of change in the naturopathic profession, naturopathic physician is becoming an increasingly preferred term. The term dates back to at least 1985, when the American Association of Naturopathic Physicians was founded, though the term was in usage before that. Taking the term naturopathic doctor a step further, naturopathic physician represents the trend within the naturopathic profession to move into the role of primary care providers. In states like Washington, that have a long history of licensing naturopathic physicians, with a broad scope of practice (including a range of pharmaceuticals and even minor surgery), and with insurance coverage, naturopathic physicians are increasingly playing the role not of ‘alternative’ providers, but of primary care providers. In this role, naturopathic physicians are family doctors who do yearly physicals, order screening labs to check up on things like cholesterol, and make sure you’re up to date on mammograms, for example. Not every person with an ND practices this way, but an increasing number are, and they are filling an important role in American healthcare. Though it is always important to check up on potential providers in states that do not license naturopathic doctors or physicians, the term naturopathic physician is rarely used by practitioners who have not graduated from one of the seven accredited programs.

As I hope you can see, these terms have their own unique meanings. Sometimes, the English major in me uses them interchangeably, just to prevent the writing from being monotonous, but the naturopathic physician in me grates against it every time.

One of the great advantages of licensure laws is that it takes the guesswork out of finding healthcare – if you live in one of the 16 US states or 5 Canadian provinces that license naturopathic doctors, you can rest assured that a person calling themselves a naturopath, naturopathic doctor or naturopathic physician went to an accredited program, and that you are in capable hands. If you aren’t so fortunate, always check the credentials of someone using these terms – someone who went to an accredited program will be more than happy to tell you about it, and most in fact hold licenses in another state, which they would be proud to show you. Licensure efforts are ongoing in many unlicensed states, so if you are truly motivated, find out how you can get involved with your local naturopathic organization!

Thursday, November 10, 2011

Are Naturopathic Physicians Opposed To Conventional Treatment?

There’s a very common misconception about naturopathic physicians, that they are ‘opposed’ to conventional treatments. This belief leads some to believe that naturopaths are ‘against’ vaccination, ‘against’ surgery, ‘against’ pharmaceuticals, etc. Unfortunately, this way of thinking can get in the way of optimal health care.

The reason this belief is so prevalent is hard to determine. It may be due to a small but vocal minority of naturopaths who claim to ‘oppose’ conventional treatments. On the other hand, it may be due to a similar vocal minority of MDs who make exactly the same claim, in an effort to discredit naturopathic doctors. It may be because naturopathic physicians, as a small profession, are lumped in with other movements or groups that indeed are opposed to conventional treatments. It may be simply due to the fact that some people find it easier to define naturopathic medicine by what it isn’t, than by what it is; thus it’s easier to call it anti-vaccination, anti-pharmaceutical, anti-surgery, rather than holistic, natural, and life-affirming. One way or another, this misconception is present and needs some mention.

I always like to quote a mentor of mine who passed along the following tidbit, ‘There’s no room for dogma in medicine.’ A born healer in the tradition of village wise women who treated the sick using herbs, she once said this to me while prescribing Paxil to a patient for whom that had been the most effective treatment. When practicing in a patient-centered ethic, your opinions and beliefs always come second to the needs of your patient. Sometimes this means working with a patient for an hour on improving their diet and exercise regimen (or introducing one where there hadn’t been one before), other times this means prescribing life-saving antibiotics.

I think any naturopathic doctor worth his or her salt would say that they support intelligent medicine, rather than strictly supporting one or another discipline of medicine. This means discerning use of lab testing, imaging, diet, supplements, medicines, and other therapies. It’s rare that you meet a naturopath who is ‘against’ conventional treatment, but it’s fairly common that you meet a naturopath who feels patients are frequently given treatments that are too forceful or invasive before milder, gentler options are fully explored (and sometimes even mentioned). On the other hand, most NDs have had experiences where a stronger treatment was the best option for a given patient, even given the ND’s preference for a gentler medicine.

I myself worked once with a patient who came in having had an acute flare of chest pain for which she had gone to the ER. This patient had a long history of anxiety, and specifically mild chest pain during anxiety attacks. She walked into my office with a number of complaints, including a feeling that despite a long list of tests and prescriptions, she didn’t know what was wrong with her. When she had gone to the ER, she was first evaluated to make sure she wasn’t having a heart attack. She wasn’t, which was good news. If anything, she was in excellent health. The hospital kept her overnight to do further evaluation. At each step along the way, everything was normal. Not merely normal, but actually excellent. In fact, all of her symptoms could have been explained by her history of anxiety, a fact she kept mentioning while at the hospital. In the end, she walked out with two prescriptions (neither of them for anxiety), a large stack of lab and imaging reports, and a feeling that she was dreadfully ill when in fact she wasn’t. In my time with her, we worked on her anxiety, as I was satisfied that she wasn’t suffering from cardiovascular disease. We worked on her diet, I had her doing regular exercise, a few other lifestyle changes, and I prescribed her a homeopathic remedy which helped relieve her anxiety symptoms. She was a patient best helped by mild treatments, but who had had too much testing, too much treatment, but not enough attention.

Now let me relate the tale of another patient. This patient came in with a vague feeling of being unwell, some vague symptoms of joint aches and fatigue, and a general sense of malaise. ‘Angst’, though far from a medical diagnosis, is a fairly common complaint in Seattle, where I received my education (it may or may not be due to the vitamin D deficiency which is fairly rampant in Seattle). I saw this patient while I was still in school, so I had the benefit of being able to read old chart reports, during which I noted a few references to a longstanding, non-healing skin ulceration. As any doc will tell you, this was a pretty big red flag, and so I made sure to check it out during the appointment. Fortunately for the patient, I was being supervised by a doc who specialized in dermatology, who identified the lesion as a dead ringer for squamous cell carcinoma, and immediately started writing a referral to a dermatologist. “But wait,” said the patient, “I came to you because I thought you didn’t believe in that stuff. I don’t want to go see a dermatologist, and even if I do go, I don’t want their treatment. I want to discuss the spiritual factors that caused this to develop. I want to work with you.” This was a patient who wanted less treatment but needed more. Far from being opposed to conventional treatment, I now had to make the case for a biopsy and whatever further treatment might be necessary. We eventually prevailed on her to take our referral to a dermatologist. The spiritual aspects of cancer are important, and an area in which naturopaths have an important role to play, but equally as important are proper diagnostics and potentially life-saving treatment. I told my patient that I too wanted to discuss her spiritual life, but that she needed conventional help as well, so that we could continue to have that discussion.

I hope this helps to capture the relationship of the naturopathic physician to conventional medicine. It’s far from simple, and certainly can’t be summed up as being ‘opposed’ to conventional treatment. Naturopathic physicians straddle the line in a lot of ways, between the old and the new, the gentle and the strong. In all cases, it’s the uniquely individual needs of the patient, seen in a totality, that determine what treatment is appropriate. As I now say too, ‘There’s no room for dogma in medicine.’

Friday, November 4, 2011

Questions About Sports Medicine

The New York Times has been running a series of articles on the topic of sports medicine, written by Pulitzer Prize-winning journalist Gina Kolata. One catalogued the author’s own attempt to recover from an injury, another discussed issues of evidence-based medicine arising around sports medicine, and the most recent discussed the specialty’s alleged overuse of MRI technology. The articles, while fairly open-minded in their investigation, are also sharply critical of sports medicine.

Here’s a brief (very brief) summary for those who are too busy to read the articles: Sports medicine is rife with treatments that are expensive, high force (meaning they involve more forceful interventions such as surgery, as opposed to more moderate interventions like therapeutic exercise), and which may or may not be effective. Patients often experience a long line of treatments but may not gain any relief. Additionally, doctors rely too heavily on expensive imaging procedures without taking adequate case histories, resulting in overtreatment. As I said, these are the criticisms levied by the author.

So what does a naturopathic physician think about all of this?

I’d like to address two main points that these articles have brought to light. The first is one of ethics. A confluence of various economic factors act on all doctors, ranging from med school debt to mortgages to the need to give one’s own children the advantages we’d want them to have. In all professions, there are practitioners who act less scrupulously for economic reasons. This is not owned by any one profession, though it manifests differently in different professions. Some docs order expensive testing, others perform elaborate procedures, still others recommend costly supplement regimens. All professions suffer from economic issues, and sports medicine is no exception. By no means should sports medicine be demonized, and indeed the articles above are full of quotes from sports medicine specialists seeking better work from their colleagues.

I can’t speak to the experiences of my MD colleagues, but at ND school, the ethical practice of medicine was a topic of serious debate. As a naturopathic physician, I place an emphasis on low-cost treatments, such as diet and lifestyle, treatments that require work, but cost little. Not only do these treatments have weighty scientific backing, but they also provide lasting results at minimal cost to the patient. Additionally, I focus on taking a good history, which only costs as much as the visit, and provides the most important clues to diagnosis.

The second point I’d like to address is one of sloppy medicine. Again, this is not owned by any one profession, but is a shared problem, though it may have different permutations in different professions. In my time at med school, the docs I worked with all drilled home the important point that all patients deserve your best effort. Rushing through an intake, jumping to testing before you hear what the patient has to say, employing a gimmicky or faddish treatment, or worse, giving every patient the same treatment, is just bad work. There’s any number of reasons why this can arise, and sports med docs are hardly the only offenders, but patients deserve better.

Here’s the take-home message: Sports medicine has its own unique problems, but isn’t at any more fault than other professions out there. When looking for a doctor to work with, be they a sports medicine doc, a chiropractor, gastroenterologist, or whatever, do some investigating first – look around online and see what their colleagues and patients say. Your work doesn’t stop there – when in the visit, make sure you feel the doctor listens to your story, and ask for a few potential treatment options. The doctor-patient relationship is a two-way street and it requires work on both ends to achieve the best outcome.