Sunday, August 12, 2012

AHS12 as a Practicing Clinical Physician

This past weekend I had the terrific opportunity to attend the Ancestral Health Symposium 2012, and also speak to a much larger audience than I could have anticipated.  I'd been to the original symposium in LA last year, and got a real sense of how much the interest in ancestral health lifestyle has grown in such a short period of time.  I'll probably gossip a little more in a later post, but for now I wanted to give some of my personal ideas inspired by the excellent post of Paleolithic MD, a Physician Manifesto.

Last year, I was thrilled when two physicians came up to me and we were able to talk a bit of ancestral health shop.  Sometimes being a Western physician interested in ancestral health principles can feel incredibly lonely, exhilarating, and even frightening.  In March I went to PaleoFx and met a core group of family medicine and physical rehabilitation physicians from Utah who wanted to organize a physician's forum.  We bonded immediately, because we have such similar experiences and goals that are not exactly shared by anyone who has not tried to juggle the practice of clinical medicine and evolutionary medicine principles.  Doctors have particular needs, obligations, regulations, and a widely varying patient base, ranging from those who are very ready to make healthy diet and lifestyle changes and those who will continue to smoke while dragging around an oxygen bottle.  

Everyone comes to see a psychiatrist from a different place in life.  I might not talk too much about diet for months or years of working with someone because we are working on keeping someone employed, brainstorming about how to keep from being homeless, or working on how to keep from self-injuring, drinking, or suicide.  Sometimes folks embrace dietary and lifestyle changes as a part of a solution to these enormous problems, but sometimes they cannot or will not… and some may come to me years later and begin to ask about nutrition or sleep, but many, many folks never will.  With very few exceptions, I do not kick people out of treatment just because they don't follow my advice.  Nor can I judge when someone with particular temperament, education, family situation, and stress is not prepared to make major lifestyle changes.  I don't live in anyone's shoes but my own.

After PaleoFx, the Utah docs and I began the embryonic stage of a forum for MDs, DOs, and medical students, and at AHS12, put out a call for other physician attendees to come and talk about joining forces for support, education, and other practical considerations.  Rick Henriksen, MD, on faculty at an academic medical center in Salt Lake City, has done a great job putting together statements of basic principles and ideas.  While AHS11 had a great introductory and research focus that was expanded into AHS12 to include even more anthropology, different angles on the science, and some of the old tired arguments about whether glucose will kill you or not.

We were all surprised when 30-40 people, mostly physicians, showed up, interested to network and learn.  Of course one travels to a conference to network and learn, but I hadn't realized there were quite so many physicians in the "fold," as it were, and if there are this many physically attending the conference, how many are now out there in the community or academia?

Doctors for the most part do not want to burn down the academic medical center.  We want to integrate the best sensible practices of Western medicine and ancestral health principles.  While everyone (including me) can bemoan the number of C-sections and the (lifelong?) alterations in microflora that might involve for the infant, I was seated between two very amazing doctors, both born by C-section, who might very well have perished along with their mothers at birth without the intervention.  I've seen midwifes claim rates as low as 2% C-section, and the near 30% rate in the US is no doubt too high, I don't know that anyone who cares for women and babies who would say the C-section rate should be 0%.

The clinical medicine place where allopathic and ancestral health principles meet is in proper nutrition, preparation, and education to help a mother be as healthy as she can be prior to conception and pregnancy and to avoid some of the complications that may increase risk of C-section (such as obesity, gestational diabetes, or hypertension).  But again, some women won't or can't make the changes that could ameliorate these complications, and sometimes the changes simply aren't enough.  Then the key is to be educated and experienced in childbirth to minimize unnecessary intervention, and to know when to act decisively if a vaginal delivery is not possible.

Often antibiotics are overused, but sometimes, if you don't take antibiotics, you will hasten your death or end up with a disfiguring surgical wound infection.

Physicians must navigate the evidence, plausible biologic mechanisms, unknowns, and various corrupting or biasing influences.  There is the industry money from pharmaceutical companies or supplement companies or shoe companies or traditional entrenched methods that may have no basis, personal pride or narcissism that might make the doctor recommending pig thyroid for everyone seem like a convincing plan, but ultimately the harms may outweigh the good.  There is a mountain of information to negotiate and the motivations of the presenters of the information to consider.

And sometimes there are health problems that can't be changed, but only borne.  Supporting someone in coping can be the physician's most valuable skill.  It is perhaps the oldest one.

As far as the practical implications for ancestral health in the western medicine paradigm today and in the future, I'm most excited about the potential for widespread support of a whole foods, anti-inflammatory, processed-foods restricted diet, and the end of academic dietitian and nutritional support of micro nutrient-poor and then enriched processed foods as "health food."  I'm also interested in the possibilities of immune modulators such as helminths and pseudocommensials for autoimmune disease, and learning more about how technology use affects sleep and mental health.  Other things, such as being on the lookout for iron overload and encouraging regular blood donation, particularly for men, and learning how to avoid toxic imbalances of nutritional supplements while using them judiciously to replete deficiencies will continue to be practical yet tricky.

With all the tinkering, in Western medicine and in ancestral health, we don't want to lose sight of the basics.  Now matter how healthy I make today, I can't undo the sleep-deprivation of the past weekend.  No matter how many times I quantify hormone levels with lab tests, I can't get your hypothalamus and testicles or ovaries or adrenals to work together if you don't help them out by eating and sleeping and laughing enough.    

I'm excited about the future collaboration of evolutionary-minded doctors.  Now, getting doctors to agree on much of anything can be like herding cats, and establishing some maverick (but very sound!) principles in the age of increasing pressure for evidenced-based medicine to be cookie cutter medicine delivered from a manual can seem daunting.  As doctors, however, the first thing we must remember is to meet the patient where he is.  If we start there, it is much harder to fail.  Our job is to exemplify, as best we can, good principles of healthy living and to deliver support and healing.  We will do a much better job integrating the best science of modern medicine and the sensible, proven traditions and experiences of our human past.

19 comments:

  1. I'll be honest, I was a bit nervous to post my "manifesto" last night because I did not know how others would respond. As always, the Paleo community has has shown a great deal of support in emails and tweets. Thank you Dr. Deans for mentioning my post, as well as adding your excellent perspective! We are a TEAM in this struggle and we can overcome one patient at a time.

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    1. We can't throw the baby out with the chlorinated bath water. But it's good to have a nice rant every now and again. They tend to be my most-read posts.

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  2. Well said!

    It always comes back to the one on one interaction we have with the patient in front of us.

    The herding of cats comment is so true,LMAO

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  3. I attended, too, but as a volunteer. To that end, I was out of sessions more than in and observed self-identified paleo folks in their element. I'm thrilled that there is a growing physician constituency, and that it's organizing. I really identify with you and your concerns when you're "out there" and trying to gain legitimacy, recognition and acceptance for cutting edge practice.

    But as a doctorally prepared nurse in Boston, it worries me that Harvard, in particular, is becoming a chief driver of this on the medical front only because it carries with it a huge blind spot - it has never hosted nor has it expressed any interest - a graduate program in nursing.

    The demographics at AHS by casual observation: white, child bearing age, wealthy, highly educated, predominantly male, healthy. I experienced both sexism and ageism over the weekend. To the few people with whom I identified myself as a former nurse, I was instantly dismissed, my input carrying with it no perceive value. It didn't help that I am older, female and have observable health deficits. I saw others largely ignored when they weren't of "the demographic". It's concerning.

    Harvard (at the School of Public Health) is a global leader in advancing multidisciplinary clinical education for the health professions. Thank goodness the steering group included an academic/research leader in nursing so that it had a voice. The Lancet published the group's white paper and is supporting the initiative. (Health Education for a New Century on the HSPH website)

    Ancestral health in the US will only advance, IMHO, if all of the helping professions learn about the principles, and if those principles are incorporated into undergraduate and graduate clinical, academic and research curricula. That's the platform by which the principles can be modeled and transformed into standards of care and practice across the professions.

    I'd dearly love to join up with an ancestral health constituency, but I found myself left out at the symposium. As luck would have it, the Globe had publicized a public RFP by the Menino Administration for a demo grant ($5 million pot to be awarded to one state with $1 million pots to be awarded to 4 more)for improved living. No one I approached at AHS12 was interested, so I cobbled together something that is ancestral health-based within an intentional community framework. I'm sure it will go nowhere as a solo submission. I so wish that there had been at least some group discussion about how best to approach a first QOL/health effort using these principles.

    Several physician presenters bemoaned the difficulty in finding grant/research $$ to advance the science in ancestral health and to help underserved patients engage in it. Granted that a demo grant going through local political channels isn't ideal, but it would raise awareness and bring the principles and practices to vulnerable/underserved populations while raising awareness by clinicians, politicians and public health agencies.

    Egads - I'm hijacking this thread. Sorry! I'd be thrilled to have a discussion around this on an appropriate forum with other interested folks.

    Thanks for all you do! It's really appreciated!

    aek

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    1. I am a Registered Nurse, but attended the symposium essentially as a "civilian" as I was not sponsored or paid by my institution.

      I did not have the poor experience you had AEK.... I found most of the participants and presenters to be accessible and eager to hear my perspective as a Nurse. But the thing I most appreciated was not the professional colleagues but the other folks, especially every day folks (not invested in an agenda, just seeking out information and community) that really caught my attention.

      Seems those of us in healthcare have a wonderful opportunity to call on these regular folks to carry the water on this one.

      One thing did concern m, and I think you alluded to it....the dogmatic folks can make it hard to fin the valuable middle as we chart this new course together. I loved to see ome of the presenters challenge one another, but at times there was strong undercurrent of "this is the only real path" that will get in the way of taking the message forward.

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    2. Most likely grant money cannot be allocated until and unless terminology is defined. People are using terms such as 'Ancestral health', 'Paleo', 'Primal', 'Hunter-gatherer', 'Low carb-high fat', etc. usually lacking firm reference to any defined prehistorical evidence. There is information out there from archeological sites now being studied for more than bones and stone tools. Speculation, hypothesizing and fantasizng appear to be getting mixed up holus bolus when it comes to the discussions.

      Even as it is, individuals who promote something change their minds and promote something entirely different.

      Maybe people in the 'developed' world just have too much choice, no real food culture and a need to create community based on the only thing they've got in common anymore. Then they have something to defend and get tribal about.

      It all gets confusing at times. Is this all a philosophy, a religion, a practice, science, entertainment, business or a pissing contest?

      Oftentimes it's hard to tell.

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    3. My sister in law was there as a volunteer. She is a nurse and had a terrific time. The ancestral health doctor club is a starting point. Ultimately I would like to see a collaboration with groups from chiropractors to nurses to naturopaths… doctors have our own set of issues and in the beginning the group will work better being a bit exclusive.

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    4. I worked with her at the Reg table. She's delightful!

      Thanks for your and the other responses. I'm glad that others are finding community and support,and I hope the physicians develop the same.

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  4. Dr Deans, I've been reading for a while but have never commented (at least I don't think so). Were it not for conventional medicine I'd likely be dead now, as would be my two wonderful children. I'm one of those people who had to have two c-sections (the first emergent; the second after a failed VBAC attempt).

    While I have had my problems with allopathic doctors, namely for the ten years it took for me to get autoimmune diagnoses and any sort of useful advice regarding how to deal with those diagnoses, I am forever grateful for the skilled OB-GYNs who delivered my children after the midwife couldn't do anything else.

    I am grateful to the doctors who treated my father's ALS and my mother's cancer (without judgment, even though she had likely spent years with the disease before going to the doc). I'm grateful for the surgeon who guided me through my OWN cancer scare this last year. And for the doctors who treated my three-year-old's Lyme disease.

    Thank you (and PaleolithicMD, whose post I just read) for doing what you do within medicine. I think the tweets by Dr. Wahls were pretty inflammatory, if for no other reason than the fact that they were very short-sighted. Disease will continue to exist even if we all eat a paleo diet and get plenty of sleep. The diseases may not be diabetes or heart-related, but I'm fairly certain paleo won't cure ebola (etc.).

    I'm excited that there are doctors out there who want to prevent disease and just suboptimal health through paleo. Ultimately I think the integration of a good lifestyle AND good medicine is going to be what moves us all forward.

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  5. According to references cited in 'The Escape from Hunger and Premature Death, 1700-2100' by Robert William Fogel (Nobel Laureate in Economics, 1994), it takes 3 generations to overcome the adverse effects of famine. This has a huge impact on the ability of women to give birth vaginally to babies of an acceptable healthy weight.

    In regards to your comments on midwives and C section rates: there are many factors besides maternal nutrition prior to conception and prenatally which impact the ability of the mother to give birth 'naturally' without complications.

    My mother was a child in Eastern Europe during World War 2. Her mother was a young teen during World War 1 and endured famine conditions after that war.

    My mother became pregnant immediately after arriving in Canada as a refugee from a communist country.

    Prenatally, I was turned 3 times in an effort to prevent a breech birth. Despite the attempts of the doctor, I turned myself back around. I was a breech birth. Back in those days and probably also due to the ecomonic status of my parents, C-section was not readily offered as an option.

    Subsequently, my brother (20 months later) was delivered head first but he's got CN4 palsy, undiagnosed as a child (once again because of economics and a lack of consultation with a smart ophthalmologist). This has resulted in his having skeletal developmental malformation, facial asymmetry, and serious backpain. Despite the fact that he was delivered head first, there was some damage resulting from the process.

    So why? Because my mother has a twisted pelvis and mild scoliosis. I have no doubt that as a fetus I turned from being head down because it was not comfortable. There was something wrong. My brother managed to squeak out the 'right way' because my mother's pelvic outlet had stretched due to delivering me, but not without injury .

    Damage to CN4 is not all that unusual since it is a very long delicate nerve.

    Difficult deliveries can and do cause dislocation of the upper cervical vertebrae. Undiagnosed, these result in asymmetrical skeletal development and lifelong chronic pain.

    Unfortunately the pediatric examination of newborns is minimal. Sometimes even cleft palate is missed! These days babies and mothers are sent home 24 hours after birth.

    Probably a 30% C section rate is high, but 2% is low. In the developed world, midwives screen the patients so that women who are at higher risk of complications are delivering in hospitals where C-sections are readily available.

    There are limits to everything and eating a nutritious diet in adulthood prior to pregnancy etc. won't always result in a perfect delivery or a perfect baby.

    g

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  6. Having an undergraduate degree in Zoology, the idea of evolutionary or ancestral medicine makes much sense to me. Only time and randomized controlled trials will tell if it pans out.

    Interested healthcare professionals may want to check out evemedreview.com. From the website: "The Evolution & Medicine Review (EMR) is a new scientific publication created by and for the community of scientists, scholars, clinicians and teachers working at the interface of evolution and medicine/public health."

    This is not an endorsement, and I confess I haven't spent much time there yet.

    -Steve

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    1. Yes, that site looks good (though, like you, I haven't spent a whole lot of time there).

      For me, the vast majority of my practice is very conventional, and the EvMed part mostly involves being more aggressive in following up and treating vitamin D and B12 deficiencies. I treat vitamin D with a goal of 30-50, though, not 60-80 as some do, and B12 I aim to keep above 400 which is actualy a standard APA recommendation for anyone with mood or anxiety disorder, so, again, not really radical. I do check a lot of ferritins, but mostly for insomnia indication, and I very rarely have anyone who is high (most of my patients are women, and their levels are typically in the basement). I typically punt these to the PCP as my good colleagues don't really mind me repleting D at a reasonable rate (though I have uncovered 4 hyperparathyroid folks in two years so I do make sure to check calciums when I replete the low low Ds, but, again, basic medicine) The rest--really tone down on the processed foods and crap, sleep well, learn some breathing and meditation and yoga (depending on the individual) is all very safe and common sense. It's really a matter of the degree to which I emphasize it.

      After two years of this blog, I now have many intakes coming who have already implemented "paleo" in their lives. Most of them are interested in ways to minimize meds, but safely, or wondering whether their supplement regime is rational. I think they come to me knowing I'm not the biggest supplement fan (except for judicious amounts of magnesium, for which I recommend RDA amounts or a little above, again, not radical!), but I do try to keep up with the latest, and my work with SAMe and NAC is still consistent with evidenced-based protocols. The number one research psychiatrist at MGH for depression in adults uses SAMe frequently.

      I would say it is quite typical for some of my "paleo" patients to either be fearful of conventional medicine or to have had a very horrific experience with it. I respect that and in general I have the discussion about options, risks here, benefits here, standard protocols here… but most psychiatrists would agree that if it ain't broke, don't fix it.

      So, in summary, I focus on some areas that the evidence tells us we should focus on… it's not alternative medicine, it's just careful on one end and a bit radical in my emphasis on lifesyle on the other. That's easier to do in psychiatry, where lifestyle has been a huge focus forever, and we have time to talk (more or less) and see patients frequently, and don't have that many labs or tests to check for the most part.

      I haven't put anyone on helminths, some folks have gone low-carb or wheat-free but typically with help from the PCP and close regulation of the diabetes meds. I haven't put leeches on anyone in my office :-) But I'm very interested for the RCTs to come out for some of the interventions (larger ketosis studies in dementia and autism, anything in bipolar disorder, helminth and low dose naltrexone studies in autism, chronic fatigue, and OCD). I think those sorts of evmed immune modulation are the next step forward, and it has exciting possibilities. Nothing is without risk, of course.

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  7. In the countries with the lowest maternal and infant mortality, the C-section rate hovers around 4%. The United States has an abysmally high maternal and infant mortality rate. Most folks around here don't know that.

    Almost everyone in the United States who has a C-section believes their own was the medically crucially lifesaving necessary C-section. You never hear a woman say, "Well, I had a C-section but it was just because I think (or have been taught) birth is scary and painful and I just wasn't in the mood to put myself through that." You never hear a doctor say, "I ordered that C-section for you because birth is scary and you seem like you are in a lot of pain and I don't see a good reason to put any of us through all that hassle. Plus, I'm used to fixing things and I'm uncomfortable when I'm not in control."

    I suspect those are the most common reasons for our high C-section rate in the United States, coupled with our willingness to sue doctors and our dependency on a corrupt third party insurance system. Ask a doctor or a mother who has experience with C-section why the rate is so high and they will answer "I don't know but mine were Medically Necessary" every time. Which shows a 26% discrepancy between our understanding of medical science in the United States and reality.

    Take all that into account and your example is apt. Our C-section rate is a wonderful example of society's multifaceted fear driven choices based on delusion in the name of science. The medical community is slow to change, even when change is in everyone's best interest. And the biggest reasons are probably psychological in nature: our collective fear of pain, death, and loss of control, and our need to blame. Fix these things and you can fix what's wrong with birth and our health care system.

    Until we look squarely at the underlying causes of dysfunction in the medical community, change will be very slow. We have obstetricians who don't even know what normal birth is, much less how to support it. Asking doctors across all disciplines to grasp something as nebulous, vague and poorly researched as healing through nutrition seems.....daunting.

    I'm very grateful for the work you are doing, Dr. Emily. Its hugely important and wrought in the face of overwhelming institutional dysfunction. Yay team! Keep up the good work!

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    1. Possibly statistical analysis of the age and physical condition of women who are given C sections needs to be taken into consideration.

      I realize that in the United States there are an awful lot of very young women giving birth, but up here in the great white north, the primigravidas are significantly older than they used to be. They are physically not terribly fit. They work fulltime until just before the birth because they want to max out their year of maternity leaves as 'post partum'. It does take some considerable effort to push out a baby. A lot of these women are not 'too posh to push', they just don't have what it takes anymore.

      The other consideration is obstetricians get a very low remuneration for uncomplicated vaginal births. Most of the women in the labour rooms are not being attended by their personal obstetrician but by whoever is on duty at the time. That doctor does not have a longterm relationship with the woman. It is to the doctor's financial advantage to perform a C-section than to wait around for hours.

      However, there also appear to be many instances where labour does not begin at the estimated 'end of term' and induction does not work when the head of the fetus is malpositioned. These days obstetricians do not have much practice with forceps and due to the potential damage caused, they opt instead for C sections.

      In Toronto due to the large immigrant community, there are thousands of women who have had severe genital mutilation performed in their countries of origin. Specific techniques have had to be developed by the obstetricians who attend these women to ensure the safest possible delivery.

      Don't know about you, but I really wouldn't have been too happy with a brain damaged child.

      The abysmal rate of death and disability surrounding maternal and newborns in the United States has a lot to do with lack of affordable care. Providing this would only be logical if there were any concern about the situation. But in the United States many women do not even get maternity leave of any significance.

      Seems that in the United States, women giving birth should either be extremely wealthy with platinum rated insurance coverage or be extremely poor welfare recipients.

      Dysfunction in the medical community is consistent with the dysfunction of society.

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    2. What I've demonstrated here is that my ability to perform statistical analysis is as poor as maternity care in the United States.

      C-sections are given for many reasons. Far and away, most of those reasons are not medically necessary. However, medically necessary reasons will always be cited--both to the mother and repeated by the mother. Indicating some profound misunderstandings are happening.

      Another way of saying profound misunderstanding is to say mothers are dying too often--most often from complications of C-sections. Ina May Gaskin is working in the senate and through "The Safe Motherhood Project" to draw attention to this problem, for anyone interested in further research.

      Ina May's c-section rate is 2% over 40 years of midwifery practice and a couple thousand babies. A self trained lay midwife, she may know something important the medical community does not. Which might be why she is invited to lead grand rounds at UNC and Duke even though lay midwifery is not legal in N.C.

      Comparing results and section rates in the safest countries is illuminating. Our inability to comprehend and properly manage maternal health suggests we are getting health care wrong, even our super smart MDs---the ones we pay an enormous amount of money to get it right.

      Sorry for the high jack, Dr. Deans. To bring the conversation full circle, one of the things lay midwifery emphasizes is the importance of proper nutrition. "Proper" being subject to debate, of course. But no one can argue with their results. Well, no one but the AMA, who has fought lay midwifery tooth and nail simply to kill their competition. *IRONY!*

      It was a lay midwife who taught me, 30 years ago, that pre-eclampsia and gestational diabetes are both metabolic disorders and can be completely controlled through diet. There are OBs who would deny this, to this very day.

      www.rememberthemothers.org

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  8. I'm sorry, this is a bit off the topic but I made a numerical mistake I'd like to correct. Of all the people who have or give C-sections in the United States, 4% are truly medically necessary, which leaves a 96% discrepancy between our understanding of medical necessity and reality. Right?

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  9. I'd love to get involved with the forum.

    Are you expecting that it would be exclusive for clinicians only? If so, I hope you would consider allowing non-clinical medical professionals (I'm a biomedical engineer).

    Non-clinical medical scientists and engineers play a big role in developing new medical treatments and devices, and a dialogue with clinicians could help people like me develop practical new treatments based on evolutionary medicine.

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  10. Ultimately it is the clinicians in this field that I learn most from; be they veterinarian (Hyperlipid) or radiologist (Archevore); because clinicians are well grounded in The Limits of the Possible. So, even though they keep a very open mind, their brain does not usually fall out.
    The clinicians are the anchors that keep the rest of us from drifting off into space...
    Whereas others just spin theories, such as whether marginal thiamine status is keeping rice eaters thin, and kept more sugar eaters thin in the past than now:
    http://hopefulgeranium.blogspot.co.nz/2012/08/the-role-of-vitamin-fortification-in.html

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  11. Dear Emily,


    Just wanted to say thank you for sharing your experience! I agree that we can find a happy medium between traditional wisdom and modern science.

    How can we, laypeople, support you and the growing body of ancestral health professionals? In this new field, it can be hard and confusing for us-- people who may have a hard time reading scientific studies-- to search for real, science-based, yet still holistic medical information. Is there an international directory of people like you / institutions that are supportive of this idea?

    I read a lot of articles on Weston A Price Foundation and generally agree with their principles, but I see they are often criticized or dismissed as "quacks". While I don't agree 100% with their views, I do think they have a lot of valuable insights we can benefit from. Same with Gut And Psychology Syndrome by Dr. Campbell-McBride. Understandably, non-mainstream ideas must be subjected to rigorous skepticism and scientific testing, but sometimes this crosses the line into downright oppression and hostility, doesn't it?

    How can we stay balanced and focused?


    Best,
    Feanne
    Art, Design, Music - feanne.com

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