About Us

Ann McKay, R.N.C., John McGonigle, M.D. and Mark Brody, M.D. have devoted themselves to homeopathy and related alternative medical treatments. In keeping with the spirit of homeopathy's founder Samuel Hahnemann M.D., we utilize treatments that emphasize safety and the restoration of the sick to health.

Monday, December 28, 2009

A Penny Saved

Amidst all of the furious negotiation going on on Capitol Hill, it is all too easy to forget that realistic health reform can (and must) occur without government intervention. As I mentioned to my colleague Dr. McGonigle, the other day, we could probably trim 25% off the health care budget if we could improve our non-technical, mundane medical diagnostic skills a notch or two. Instead of relying on a thorough history and patient and thoughtful physical examination, doctors and patients are too quick to rush to the MRI, the blood test, or the specialist referral. I doubt most physicians (I include myself) have anything more than the roughest idea how much these expensive evaluations tally in the end, but I suspect it would be thousands of dollars every day for the average primary care physician.

There are few incentives for the average doc to do so, however. It takes more time, more energy, more thinking, and results in fewer patients being seen per day to be more thorough, so as a result there is less revenue. In short, the system is rigged to perpetuate high remuneration for all corners of the medical suite -- the techies and the PCP's. The radiologists and pathologists love this system, since it creates a virtual torrent of business. The PCP's, who are already underpaid, feel they can't afford to do otherwise, and after all, it's the standard of care, isn't it? There is a sense of security that evolves that "everything that could be done" has been done. This sense of security is the same as the pleasant balminess of a warm day at the North Pole. To one who cares to think more about it, it means that a global apocalpyse is upon us, while to others it simply means respite from the cold.

These concerns are just a beginning. On a broader level our society breeds unhealth on epidemic levels by economic and social forces that help to celebrate the moral sicknesses of greed and turpitude. We see this in the food industry and the energy industry, most egregiously. Obesity, heart disease, cancer, and other chronic illnesses are becoming more common all the time, and a large proportion of these illnesses can be said to have an environmental component that is perpetuated by industry and the governmental supports that lie behind them. This would include eating too much refined and sugary food, food that creates pollutants that fouls our rivers, oceans, and the air we breathe, and results in downstream environmental illness. We could easily add to this the pharmaceutical industry, which also has added its products to our drinking water because of an inadequate waste disposal system, and the iatrogenic effects of medications. The pollutants that enter our air and water that come from carbon consumption cause a rise in respiratory illness and disturb the ecosystem. Our energy policies affect our political dealings in the middle east, which leads to wars, and death of our citizens pursuing these political-economic energy goals.

In short, it is hard, when talking about health care, to keep the topic on the health care system itself. Poverty, political maneuverings by the giants of industry, including the food industry, agribusiness, the coal and oil industries, the pharmaceutical industry and many other economic powers are linked in a massive juggernaut of illness production that helps to keep medical costs high.

We doctors spend most of our time cleaning up the mess this vast illness production system creates. And we sometimes do so in ways that contribute to it. Why do we spend our time this way instead of working to prevent illness in the first place? Are we ignorant, dumb, or just greedy? Most doctors, I believe want to do good. They want to be well paid, too, but they are willing to work hard for their money, even if working so hard isn't particularly good for their health, the health of their family relationships, or ultimately, even for their patients. I think that it comes down to there being few incentives to do the right thing, and every incentive to keep the system going as is, even as it careens towards disaster. To make a more frugal system, the system must change the rules of the game. It must incentivize salubrious behaviors on the part of the physician. And corporations must be incentivized to produce salubrious products. The system must be purged of the economic and social inequities that amount to a moral sickness. It's a dangerous self-deception to think that moral illness can flourish with no effect on physical or mental illness.

How can we incentivize doing the right thing? I can't say my vision is that broad. But I do know that it begins with acknowledging that we have incentivized the wrong thing.

Wednesday, December 16, 2009

Succussing Homeopathy

Long have been the laments about homeopathy's churlish treatment by the pseudo-scientists and second-rate journalists. Two hundred years and counting. When I first learned about homeopathy I was shocked that its practitioners hadn't contacted the media to advise them of this boon to mankind. I went from feeling that we as homeopaths were remiss in not publicizing this amazing healing practice to anger that the media were not interested. As I learned more about the powerful resistances that existed within the scientific and popular world to homeopathy, I became more accepting of the low rank homeopathy was relegated to in the great chain of medical being. Still, it has been hard to continue to patiently accept the low status of homeopathy, and not to be angry at the frequent attempts to "expose" it as fraudulent, to denigrate it, or to consign it to a state of desuetude.

Recently, I had a bit of an epiphany. As my partners in alternative practice, the honorable John McGonigle, MD, Julien Ginsberg-Peltz, MD, and Ann McKay, RNc, who do, in addition to homeopathy, acupuncture, functional medicine, Reiki, nutritional counseling and allopathic primary care medicine in various combinations, contemplate with me expanding our size and our numbers, it has dawned on me that size creates opportunity but also problems.

There is something comfortable and friendly about smallness. I'm aware of this because for many years I had at most one office-mate with whom I shared a much smaller space. Since joining forces with another three, I'm aware of a slight decrease in the level of coziness and intimacy. At our present size, we are small, and overall, our office still feels very comfortable to me. As a foursome, I think we still create an atmosphere that is conducive to the healing work we do. But as I envision our numbers growing, and the size of our office expanding, it concerns me that some of the virtues of smallness may get lost in the expansion. A recent New York Times article describing the architectural and design problems that the giant Kaiser-Permanente group have tried to remedy in order to promote a more salubrious environment for healing sensitized me to how much your size can affect your style.

By extrapolation to the practice of homeopathy, I would predict that greater popularity, visibility and more favorable coverage in the press would have its own downside too. Fame comes at a price, as Tiger Woods would have no trouble telling us. For those who have been following his story in the media, it is not hard to see that his interpersonal pratfalls have become awkward, embarrassing and costly to him, thanks to his being so famous. Be famous and you, too can appear on the pages of the National Enquirer. If homeopathy were to become more popular, it might become less effectively practice, it might be cheapened, and ultimately (horribile dictu) McHomeopathized.

If we can look at the allopathic world out of a perspective less colored by envy, we can see that the flaws of the system are laid bare for all to see. The fact that "alternative" medicine is pursued by millions of Americans who spend billions of out-of-pocket dollars on it is testimony to the dissatisfaction that exists with conventional medicine. Recent health care news indicates that there are (shockingly, it is said) many Americans who refuse to take drugs that research has indicated might reduce their risk of developing cancer, or refuse to get vaccinated against H1N1 even though the vaccines are shown by research to be "safe" and "effective." These reporters do not seem to be aware that Americans have also been reading their articles about the numerous other research-backed treatments that have been ultimately scuttled because the research turned out to be flawed. These would include Diethylstilbestrol, Thalidomide and Bendectin in the past, and more recently, HRT and Vioxx. Fame gives the opportunity for you to be seen under a microscope, warts and all.

So, wonderful as homeopathy is, do we homeopaths really want this kind of scrutiny? Are we that sure of ourselves that we do not think our work can not be criticized, if more visible, not for what it is imagined to be, but for what it really is? And do we want to risk developing an Icarus syndrome, where we become so big, and so strong that we must inevitably fall? I think there is much to be said for the quieter subtler approach. The marquee lights that draw attention can certainly stir up a great deal of envy, but all that glitters is not gold.

One of my many wonderful erstwhile mentors, Roger Morrison, MD, once told me that the best way to popularize homeopathy was to "be successful in your practice." At the time, this seemed to me to be too modest. Surely, homeopathy deserved more credit than the small penumbra of popularity that glowed around a private practice could bring, no matter how successful it was. Now, I begin to see more clearly the perils of size, and the wisdom of smallness. In England in the seventeenth century, there was a relatively quiet change of power, the Glorious Revolution, accomplished with only a few skirmishes, not much to write home about when compared to the American Revolution or the French Revolution. This "bloodless" revolution was achieved by some strategic political moves, and was able to accomplish a change of power in a more quiet way than almost any other historical political revolution. It is this type of quiet revolution, achieved by the power of success, that I think offers homeopathy the best chance of achieving more currency and popular acceptance. It is indeed, to paraphrase what Roger Morrison wisely said, our own success that will succuss us into power. There was also a guy named Hahnemann who came before Morrison who had a few things to say about less being more.

Tuesday, December 8, 2009

Identity Crisis

Those medical practitioners who fall outside of the mainstream have an identity problem of sorts. First of all, do we practice "alternative" or "complementary" medicine, and how are these different? Second, are we "holistic" in our approach or "integrative" and does this matter? Maybe some of us do not wish to have any of these labels applied to us. For some, any of these labels may bring with them pejorative connotations, suggesting that these treatments are in some way less valid or more "out there." For others, they may be a banner of humanism or progressive thinking.

Whatever we call ourselves or others call us, it is important to be clear about what we mean by our different monikers. For me, "alternative" implies a different choice, a kind of "either-or" relationship with conventional medicine. It implies a different way of thinking, a different approach, and a different model of healing. Contrast seems to be the key concept.

"Complementary" implies a dovetailing or consanguinity between differing approaches. The type of healing in "complementary" medicine may come from an unconventional tradition, but it at least compatible if not synergistic with conventional approaches. A happy mutuality seems to be the key concept here.

What one calls oneself, therefore, in my mind, is a statement about one's feeling about conventional medicine. The more hostile one is to it the more likely one is to want to identify oneself as a practitioner of "alternative" medicine. The more one wants to be embraced and accepted by conventional medical specialists or those who favor conventional approaches, the more likely one is to view oneself as a practitioner of "complementary" medicine.

The converse also may apply: conventionally oriented individuals who regard unconventional treatments with suspicion or disdain would probably prefer to label them "alternative" medicines. Those who are more open and welcoming to multiple perspectives on healing would want them referred to as "complementary."

Holistic and integrative have similar meanings, but there are separate connotations for me. One who uses the term "holistic" tends to differentiate oneself from conventional treatments, which are viewed as dualistic, Cartesian, and intrinsically more limited in healing potential. Holism implies an attitude that embraces mind, body, spirit, family, community, culture, and environment together. It holds itself up as a contrast to the conventional model, where a perspective on the larger context of healing is deemed to be absent. The term "integrative" comes close to "complementary" in emphasising the joining together in a kind of melting pot of different healing approaches. Compatibility, rather than difference is emphasised.

These terms are meant to identify discreet phenomena, but life is not always so neat and tidy. At its best holistic healing truly advances an ecumenical view of health and helps to avoid the narrow views that lead to personal, public or familial disasters. It promotes the health of the individual within the realms of the emotional, spiritual, and interpersonal, and takes into account the wider context of the society, culture and environment. At its worst, holism merely is an advertising tool for promoting a certain modality endorsed by the practitioner to the gullible few. Allopathic medicine, similarly, at its best can make use of the "biopsychosocial" model, which though taught in medical school, is all too often ignored. The biopsychosocial model, which might be the conventional version of holism, attempts to broaden the perspective of the practitioner in a way similar to that of holism, but, unlike holism, it does not feel the need to differentiate itself from conventional treatment.

Integrative medicine at its best, brings together disparate approaches to produce better outcomes for patients. At its worst, it leads to disagreements and lack of cohesion in the treatment team, with people sometimes working at cross-purposes. So to advocate holistic or integrated is not enough. What is your underlying agenda in promoting it, cooperation or cooption?

Hahnemann gave birth to homeopathy in a spirit of conflagration. Homeopathy was in many ways a declaration of war against allopathy. Integrative or complementary are terms Hahnemann would have for the most part reviled, I believe, because he felt that the fundamental approach of allopathy was flawed. Yet in spite of these deep differences between the Hahnemannian approach to healing and the "old school" or allopathy, Hahnemann did allow for certain occasions when allopathic healing would be appropriate. Thus even such a firebrand as Hahnemann was forced to permit some "integration" of allopathy into his system. There is a tendency among many homeopaths to be critical of the allopathic approach, to emphasise its weaknesses, and long history of obvious misjudgments -- obvious, at least, when viewed from hindsight. Yet if we are true followers of Hahnemann we must allow for some role for allopathic treatment. How much can be debated, but the monomaniacal pursuit of homeopathic healing to the exclusion of all other types, including allopathy is clearly at odds with what Hahnemann himself said and with the homeopathic tradition. I emphasize here the capacity for integration, whereas others might rightly wish to emphasize the differences between homeopathy and allopathy. I would say that the difference in emphasis springs largely from personal feelings. It is intrinsically subjective. There remains an identity crisis of sorts within the ranks of homeopaths, and it would probably behoove homeopaths in terms of our relationship with other healing modalities to spend more time clarifying our role. Are we complementary or not? Are we against all non-holistic approaches, or are we able to work with them? Are we with allopathy or are we against it? Are we truly holistic, or are we advancing this approach as a form of self-promotion?

Who are you, and what are you, homeopaths?

Sunday, December 6, 2009

Rodney and us

Homeopaths have struggled for two centuries to obtain validation from the conventional medical world. Hahnemann and his early homeopathic colleagues faced vicious opposition within their own lifetimes, and it's been an uphill struggle since then. Today, homeopaths still face the indignity of being described in the popular and medical press as tantamount to charlatans, and our mighty protests to the contrary notwithstanding, there seems to be little hope that this will change in the future.

This struggle is to some extent shared by our brethren in other branches of alternative medicine, but homeopaths have been especially vulnerable, perhaps in response to Hahnemann's early salvos against allopathy, which he savaged in numerous articles and lectures. Keeping up this spirit of strong dissent, modern homeopaths continue to decry the pitfalls of suppression and promote their cures as superior to what is possible in allopathic medicine. Claiming to be superior to another group is surely no way to win friends among members of that group, so perhaps we have ourselves to thank in many ways for our plight. Nonetheless, it is a rare homeopath who does not bemoan the woeful state of disrespect homeopathy finds itself in in the modern world. We are the true Rodney Dangerfields of alternative medicine.

Homeopaths have long emphasised the virtues of their unique therapeutic approach. It is virtually devoid of side effects, divorced from noxious commercial influences, capable of promoting health more generally, and inducing cures in some cases. It can benefit the treatment resistant and the undiagnosable. While these virtues have never been successfully challenged, there have been objections that those who see homeopaths may experience delays in obtaining needed and potentially helpful treatment of a more conventional nature. In Hahnemann's time, this all too often consisted of blood-letting or exposure to powerful cathartics or emetics. However, in our times, the allopathic alternatives, for all of their dangerousness are not so obviously wrong-headed. So we need to be able to counter this objection persuasively.

This type of criticism, which might apply to allopaths as well, as has been seen many a time in the past, with regard to controversial disorders such as Lyme Disease, Chronic Fatigue Syndrome, Bipolar Disorder, and chronic pain syndromes. Allopaths differ widely amongst themselves about the proper treatment for many illnesses and are just as happy to string each other up by the neck as they are any vulnerable homeopath or other alternative medicine practitioner. But homeopaths need to guard more carefully against this allegation than other specialties because we have been contenders for the throne. We hold ourselves forth, however guardedly, as better than the allopaths in so many way.

In this area, I feel that I myself and many of my colleagues are vulnerable. Our vulnerability lies in not having demonstrated our ability to correctly diagnose and manage serious illness. Management includes above all knowing when to refer out, and knowing when to refer out implies an understanding of the allopathic as well as homeopathic diagnosis and the multiplicity of diagnostic and therapeutic options that should be considered if the initial treatment fails to effect a positive outcome. While I have had the good fortune to receive quality homeopathic education at the Hahnemann School of Homeopathy, under the tutelage of such great homeopaths as Roger Morrison, Nancy Herrick, Jonathan Shore and Todd Rowe, and at the Dynamis School, with the inimitable Jeremy Sherr, and during seven years of such training, I came to understand how to manage illnesses of all types that might be seen in a primary care setting using homeopathy, I still lack the fundamental grounding in the diagnosis and management of serious physical illness, because my allopathic training was as a child psychiatrist. And many of my colleagues lack the training in psychiatry and child psychiatry to have this perspective when more severe mental symptoms are part of the case.

This might not be an issue if we homeopaths cured 100% of our cases, but we don't. And the thing we hate most is when the patient/client leaves us to undertake a course of allopathic treatment. We may regard this as a sign of impatience or failure to understand the virtues of our peculiar specialty. But the fact is, we need to know when we are failing and what to do next, even if it means referring out for allopathic treatment. We need to show ourselves and the allopaths that we can handle most problems as an allopath would, treating optimally and then referring out when we've reached the limits of our expertise.

All too often we rely on the allopaths to make the diagnosis for us and then we happily proclaim our success in treatment after the allopathic treatment has fallen apart. But we need to show ourselves to be exemplary diagnosticians as well, if we are to win the trust of allopaths and the community. Speaking for myself, I feel I could use a tune up in my allopathic diagnostic skills. Perhaps we all could, in one way or another. This is the point of CME. But having some kind of certification process within the homeopathic community, demonstrating a minimal level of competence in diagnostic skills, not just of the homeopathic variety, but of the allopathic variety as well would go a ways towards establishing this sort of confidence. I feel I need this kind of certification. I think it would help homeopathy in general if we all had it.

Friday, December 4, 2009

Club Med

There is a famous quip that most medical students have heard at some point prior to graduation, usually in response to their anxieties about surviving the rigors of medical education. It goes something like this: "What do they call the medical student who graduates last in the class? (Answer) Doctor!" I remember hearing this humoresque while a medical student myself and feeling something sinking in my stomach at the time. I suppose the intention had been to quell my worries, but instead I was left feeling that the system was rigged to shepherd through even the worst of us. Was this some kind of hubris on the part of the medical school admissions committee? Were they simply unwilling to admit that at least in some cases they had made a mistake? While we were on the one hand being trained to respect the gravity of the task before us, taking, as we were, others' lives into our own hands, on the other hand, there seemed to be a reluctance to acknowledge that action might be required to protect patients from those who did not meet certain safety standards. Where was the bottom line? Or wasn't there one?

Stanley Wolfe, a physician who writes for Public Citizen, and edits the newsletter "Best Pills, Worst Pills," which recently published a predictably poorly argued and researched piece critical of homeopathy, has latched onto the weakness in medical self-regulation. He regularly publishes in his newsletter, in truly absurdist over-reactionary style, a list of the disciplinary actions by the departments of health in each of the 50 states, rank ordering them so that the "best" states have the most disciplinary incidents of physicians. By his cockamamie logic, the states with the best medical climate have the most disciplinary actions. The more the better! His assumption appears to be that bad medical practice is more or less uniformly spread amongst the various states, and that those states that have more disciplinary incidents are necessarily more vigilant about keeping the profession clean of the bad eggs than those states that have fewer incidents. Of course, this is just an assumption. It is possible that some states have more errant physicians and that some health departments have overly punitive health commissioners or regulatory boards. But forget about this, Dr. Wolfe presumably would say.

Nonetheless, the difficulty that the medical profession has regulating itself has become an embarrassing showpiece for the media, usually rising to our attention when some egregious action by physicians of great sensational import fly onto the media's radar screen. What I first tasted in medical school, I now see, was the immense clubbiness of the medical profession. The reluctance to take regulatory action against its members was just one example of this clubbiness. It was also visible by the negative attitude that the medical profession had towards competing health care fields. Polite tolerance seemed to be the most that most of my mentors could muster up towards osteopaths, chiropracters, and even in some cases nurses or allied medical professionals. At times polite tolerance gave way to dismissiveness or even supercilious disdain. It was clear that they were not part of the club. Evidence, argumentation, and open discussion were not considered to be germane, since these outsider's approaches were so manifestly misguided, if not outright dangerous or harmful.

In a recent book on Lyme Disease, Cure Unknown, by Pamela Weintraub, this clubbiness is revealed in an even more sinister form. Physicians who have specialized in treating Lyme Disease over the past two decades have often faced vilification and even legal indictment by their colleagues for practicing in ways that were outside the accepted standards. Some of them were forced by medical authorities to stop treating patients diagnosed with Lyme Disease or close down their practices. Weintraub details how some of those physicians who led the attack against the so-called "Lyme doctors" often had conflict of interests, having fiduciary relationships with insurance companies, who had a stake in limiting treatment, or who had monstrous speaking fees because of their reputations as experts in Lyme Disease.

To me, this is a frightening scenario, where the medical profession goes to the darkest aspects of clubbiness: attacking those who would differ from the accepted standards, regardless of the merits of those standards. In the medical profession, the "standard of practice" is considered to be the basis of good practice, and is the legal guidepost by which malpractice is often determined to have occured or not. Like in organized religion, there is a certain orthodoxy in the medical establishment which does not admit to faults or dissent. Those who are seen as heterodox are guilty of a kind of heresy -- the heresy of non-adherence to the standards. Such heretics must be disciplined or expelled.

While this Inquisition-like attack is not a common occurence within the medical profession, it is frightening to one such as myself who has embraced a number of non-traditional treatments into my practice. While I have studied both homeopathy and Bowenwork in an effort to bring more to my patients than I have been able to with conventional treatment alone, this would appear to matter little to those who are on witch hunts. Nor would evidence that would suggest that these treatment modalities are safe and effective. That these treatments are not part of the club appears to be the more decisive factor. Getting into a club, as it turns out, is easier than getting out.

Thursday, November 19, 2009

Primary Neglect

Considerable media attention has been given in recent times to the dearth of primary care physicians in our country, by comparison with a relative oversupply of specialists. The plethora of high-priced specialists is just one factor among many that is given for our financially troubled health care system. In a recent New York Times article, one of the commentators, a medical student, revealed one of the obstacles to primary care from the perspective of the medical student. Trained in academic institutions, medical students' mentors are academicians who tend to place a premium on the highly unusual cases - so called "fascinomas" and have little interest in the quotidian tasks of the primary care physician -- runny noses, sore throats, and garden variety aches and pains. Primary care is accorded a low prestige value, whereas more arcane and specialized subject matter is accorded high prestige. Indeed, one of my colleagues, a pediatrician, reported that about 90% of his pediatric residency group went on to subspecialize and only about 10% went directly into primary care.

The fact that primary care does have a lot of paperwork, phone calls, and commonplace acute treatments alongside indolent, incurable chronic illness, all accomplished at a lower pay rate per hour does not help. Overall, the outlook for primary care does not seem very bright, even though health care reform is going to create the need for even more primary care physicians in the imminent future.

I was discussing this state of affairs with two of my colleagues, co-bloggers Dr. John McGonigle and Ann McKay, RN and we were addressing the fact that with homeopathy in your treatment armamentarium, primary care can actually be remarkably exciting and intellectually as well as morally satisfying. Even a case of athlete's foot, as I was saying to Dr. McGonigle, could be fascinating, if there were some unusual aspects to the case. I found myself wishing that more medical students could be awakened to the exciting possibilities that were available in primary care. Yet, on later reflection, I could see several serious obstacles to homeopathy being introduced into primary care or into the medical world in general.

Homeopaths tend to have trouble restraining their enthusiasm for their field, because we all find it immeasurably and unfailingly fascinating, but in our enthusiasm, we sometimes overestimate the receptivity of our audience. In fact, although it does not seem to daunt many of us, homeopaths are used to being responded to with blank stares as they wax lyrical about their beloved profession. But for all of its charm homeopathy has many weakness as a for-sale item to the medical establishment. Here are some of them:

1. It is hard to learn. It take a lot of time, money, and commitment to become even moderately competent. Many people are unwilling or unable to spend the time or money to pursue any goal, no matter how lofty, or how important to them. It's just too difficult.

2. It lacks face validity. Unfortunately, it takes a lot to overcome the bad reputation that the mudslingers have succeeded in establishing for homeopathy, and the fact that we deal with infinitesimal dosages makes us unpalatable to many and indigestible to most.

3. It requires a great deal of thinking. In these days where we are all trying to make a quick buck, taking a long time with your patients and exercising one's brainpower to the max is not a popular pastime, notwithstanding idealistic medical students' proclaimed desire for interesting work. In medical school, one learns a simple aphorism that epitomizes medicine's relationship to cogitation: "See one, do one, teach one." This self-congratulatory shibboleth might well be translated: "I'm so smart, I don't even need to think to be smarter than you, and I certainly will act as if I'm that smart, even if I'm not." With this kind of hauteur, who wants to struggle to find a simillimum?

4. Many medically oriented professionals are science-oriented in their professional ethos and attitude. Homeopathy, for all of it's empiricism, is better suited to those who are willing to think less geometrically and linearly. Homeopaths need to embrace poetic approaches to understanding reality, and must be able to appreciate and value communicated rather than numerical understandings of human suffering. This weltanschauung simply is a poor match for the average biochem major who wants to pursue the highest heights the techno-medical world has to offer.

I continue to try to promulgate homeopathy, because it is such a wonderful gift to the world, but I can't help wondering about the folly of my efforts from time to time. It simply is too hard to let such a precious gem go unappreciated, I suppose.

Wednesday, October 14, 2009

Nature lover

I am sometimes caught in the awkward position of being asked by my patients something like, "Homeopathy -- that's a kind of natural medicine, isn't it?" Many people seek to place homeopathy in a classification of "natural" treatments, making the implicit leap that "natural" is better. Many so-called "natural" treatments, such as botanical medicine, functional medicine, and in particular homeopathy have been assailed by the promoters of techno-medicine as potentially dangerous. A big flap over "ma-huang" led to its being taken off the market, mainly because it is dangerous when taken in excess. This reality is no different from virtually all other over the counter medicines, but ma-huang had the misfortune of being more prone to abuse because of its powerful stimulant effects.

In spite of my discomfort with what often seem to be politically motivated attacks on alternative treatments by those who appear to be biased against them, I do believe that there is a certain truth to the notion that not all that is natural is better, just by virtue of being "natural." Indeed, for those who aren't aware, the FDA now permits foods to list among their ingredients "natural flavoring" or "natural ingredients" even when those "foods" are largely chemicals. Anything that emulates natural is apparantly acceptable for the label of "natural." The meaning of natural has been greatly diminished by these kinds of marketing tools which the FDA has kindly consented to. Indeed, it has come to be somewhat of a cliche, and a mantra for political causes.

So nowadays I am quick to tell my patients that while homeopathy is indeed made from substance found in nature, its particular virtues lie not in being natural, which in some cases can equate with toxic, but in its extreme level of safety and its unique capacity to catalyze healing. Having robbed my patients of the quietly reassuring but ultimately false belief that "natural" is necessarily a good, I nonetheless sometimes find myself paradoxically arguing in favor of a more naturally determined understanding of health.

Some years ago, when DHEA (Dihydroepiandrosterone) was being touted as an antiaging supplement, I asked my personal physician his opinion of it. It seemed to have earned many glowing testimonials, but something about it made me worry. My physician advised me to respect the balance of hormones that my body had endeavored to create. I ignored this balance at my own peril, he intimated. Whether it was the intent of his comments or not, he left me pondering the virtues of respecting what nature has wrought, and not to be too quick to trample on what had been forged over eons by Darwinian forces into something supremely adaptive.

Questions often come up in my practice about how to understand the merits of drug interventions, surgery, dietary supplements, hormone replacement treatment, vaccination, and so on. People are understandably confused in this modern world where you can find someone touting the virtues of just about anything, however outlandish, if you look deeply enough into cyberspace. Amidst the din of conflicting opinions, each competing with the others to be recognized, I encourage myself and my patients to submit their question to the test of whether it reasonably conforms to nature's way. I encourage patients to consider whether the action they are contemplating taking is forcing the body to become something it isn't designed to be, or whether it seems to be promoting the body's (and the world's) journey towards health.

In keeping with this, I have recommended that with regard to the influenza vaccination, that people get it (if they choose to get it at all) in the intranasal spray rather than by intramuscular injection, since influenza is generally communicated by inhalation of respiratory secretions, rather than by puncture wounds. I've advised people not to use hormonal therapies or strongly suppresant treatments on a chronic basis. I've come to believe that trying to eliminate illnesses through mass vaccination should not be accepted unequivocally as a virtue because it creates holes in the ecosystem whose consequences we can not measure or predict. The same applies to genetically modified foods, and to many drugs or treatments that are highly promoted, but have not yet passed the test of time.

Recently, a study showed that robotic surgery for prostate cancer was no better than the older, vastly less expensive type of surgery. The reputation of the highly touted Gardasil vaccine was tarnished by reports of serioius adverse reactions, including a number of deaths of young girls. Many psychotropic drugs such as serotonin reuptake inhibitors and neuroleptics, originally marketed as better or safer than the older drugs, are now known to have serious risks that warrant black box warnings.

On the other hand, one can argue that any and all medical interventions are not naturally inspired, since they invoke some use of technology and the manipulation of the natural order by human intelligence. I think we must all take care neither to blindly accept as safe nor to recklessly dismiss as dangerous the ways we try to manipulate nature towards human aspirations. To judge the virtues of our actions, I think it is wise to assess how well they reflect a respect for the natural order. Without undue respect for Mother Nature, we risk her taking umbrage, and penalties for this transgession I believe are likely to result. By being too timid, we risk not exploring the vast terrain of progress that the natural world offers.

Tuesday, October 6, 2009

Homeopathy's place in health care reform

Watching our legislators wrangle over the different plans being considered, I sometimes wonder whether any of them has a truly profound understanding of the systemic problems that have led to this reform initiative. It is clear that all involved understand that change is necessary: that there is a need to cover the uninsured and under-insured; that there is a need to assure that people have real insurance, not nominal insurance, and to hold down the ever-expanding growth of health care, which now consumes somewhere around 16% of our gross domestic product (GDP). Everyone seems to have a different idea of how to do it, yet to me none of them seem to relate their solutions to causes of the problems. As a homeopath, this band-aid approach seems to be in lock-step with conventional medicine, which aims for a solution without truly understanding the causes of the disease.

The causes of our health care mess are certainly manifold, but probably include the familiar suspects, such as over-bureaucratization of the system (so called "overhead" costs), the high cost of pharmaceuticals and medical devices, and insurance companies' providing too expensive or inadequate coverage. They probably also include excessive doctors fees, over-medicalization and over-treatment, overuse of diagnostic technologies, a lack of incentive for using less expensive treatments over more expensive treatments, fear of lawsuits and excessive medical malpractice fees, lack of patient incentives to follow-through with their treatments, both preventive and therapeutic, and excessive medical school debts, which force doctors to require higher incomes than they would otherwise need. As a homeopath it is hard to omit that there is an emphasis on suppression of disease, which leads to vast co-morbidities from iatrogenic illnesses. According to the American Institute of Medicine report in 1999, 10's of thousands of people die yearly from preventable medication effects. This does not include the non-lethal illnesses that result from iatrogenesis. Moreover, suppression of disease leads to the outcropping of even more disease, which leads to the need for more and more medical care.

A health care reform bill that makes any sense needs to address these multiple etiologies for the illness that afflicts our health care system. The goal of universal coverage makes sense, but so do things like balancing the budget and peace, yet there always seem to be good reasons not to do these things, because we realize that simple sounding problems do not necessarily lend themselves to simple solutions. Here is my bare-minimum list for what good health care reform should include:

1. Reform of medical education costs. This means reducing physican post medical school debt. It would eliminate the need for doctors to charge excessive fees so they can pay off the gargantuan debts they have accumulated over four years, which of course, are only added to any college debts they have not yet paid off. As I have alluded to in early blogs, physicans could trade in free years of medical school education for an equal number of years of community service, either in underserved areas or at medical clinics for the indigent, where fees typically are very low. Salaries would be lower, but the needs of the indigent would be taken care of and physicians would not feel the need to charge high rates or go into expensive specialties so they can pay off their debts. They would be more comfortable going into lower paying primary care specialties.

2. Pay for such primary care specialties must be increased along with other incentives or mandates for medical students entering primary care. Medical school may need to be legally mandated to graduate a certain percentage of students into primary care residencies, or lose funding or accreditation. Increasing the number of primary care physicians would tend to balance out our over-specialized high-cost system.

3. Legislation must help to hold down the costs of malpractice insurance and the fears of lawsuits that tend to cause over-testing and over-treating. Physician errors must increasingly be dealt with intramurally, with tighter professional self-regulation and non-monetary forms of compensations or penalties in cases of malpractice.

4. Government must regulate the insurance industry more to prevent "cherry-picking," denials of coverage for various pre-existing conditions and other hidden clauses that keep insurance companies from having to pick up the tab for their subscribers illnesses and threaten all Americans with medical bankruptcy. Insurance industries may need to have a mandate to be non-profit, to prevent the whims of the marketplace from corrupting the real purpose of insurance, which is to prevent financial disaster for all citizens as a result of health problems.

5. Physicians need to have an incentive to reduce the health care expenditures of their patients without compromising their health. This would tend to promote doctors' interest in doing a better job and securing compliance from their patients. It would also be a shot in the arm for homeopathy, which has been shown to be one of the most cost-effective means of treating a wide variety of health problems. Although some would object that this will lead doctors choosing healthier patients, doctors would be rewarded not for the total expenditures, but for the amount they were able to reduce total health care expenditures for their patients or at least to hold down the growth of expenditures as compared to their colleagues with comparable patients. One can argue about the feasibility of such an idea, but if doctors are accountable for their results, they will be more likely to work hard to improve their results than when they get paid regardless of thier patients' outcomes. Government can get involved by rewarding those physicians who can demonstrate cost-savings compared to their colleagues with cash rewards. A system similar to this already exists in the United Kingdom.

6. Patients must also have incentives for improving their own health, as measured by health care utilization. It is well known that at least 40% of health care problems are linked to self-induced illnesses, such as obesity, diabetes and hypertension, with their sequelae due to lack of exercise, poor eating habits, smoking, drug abuse, gambling, or other self-destructive behaviors. If patients actually could have their health care premiums reduced by reducing their consumption of health care resources, such financial incentives would likely motivate them to take steps to improve their health. Using health modalities such as homeopathy, they would be able to reduce their dependence on pharmaceuticals and reduce their need for medical treatment in general. Some might argue that people would tend to avoid treatment that was truly necessary, only to pay for it later with higher costs, but this tends to assume a ridiculous level of short-sightedness. Sure, it may occur occasionally, but people will learn quickly enough and adjust their behaviors. In addition, no one is penalized for getting treatment. One is simply rewarded for reducing consumption of health care resources.

7. Doctors, technicians, hospitals, insurance companies, pharmaceutical companies, and the entire health care industry will need to accept a down-sizing. We are already staggering under the weight of a morbid obesity in financial terms, and much as noone wants to have lower salaries or fewer jobs, there's no way to reduce obesity than to lose weight. Many will be looking at unemployment, some will be looking at lower income. This is what has happened in other countries already that have universal coverage. It must be imposed from the government, and it will not happen unless government over-rides the lobbying from the special interests that insist that their slice of fat should not be trimmed.

8. Coverage will need to be made universal by extending government insurance to all those who can not presently afford it or by mandating that everyone get health insurance and that insurance companies offer a broad pallete of policies along with government subsidies, so that all will be able to afford to choose a private plan (or be faced with fines). The latter is the Massachusetts model, and it is causing significant cost overruns for that state. So it may not be the best solution, or will need to be paired with other legislation that will tend to hold down costs from the many new members of the insurance pool.

There you have it. A sensible, if impossible reform plan, grounded in the causes, not in idealogy or partisanship. Now if only I could get anyone to take a look at this...

Sunday, September 20, 2009

Perceptions of homeopathy

A recent New York Times article, printed on a health blogsite, about the use of Arnica gel (Sept 17, 2009) invited all kinds of comments, both supportive and critical of homeopathy, including one from our own Dana Ullman. Homeopathy tends to evoke strong opinions. However, the strength of the opinion often has no correlation with the strength of the arguments used to support that opinion.

There are many types of reactions people have to the idea of homeopathy, far more than the types of reactions that are observed to its clinical applications, which are generally just good, bad or some mixture of these two. As a physician who has been practicing homeopathy for over 8 years, I have found it fascinating to observe the multitude of reactions that it tends to elicit, most of which are apparant in this New York Times blog/article.

First comes the superficial thinker. He knows homeopathy is wrong from the start, because it’s obvious. There’s “nothing” in it, so anyone who believes it can have any effect must be delusional. Research, scientific evidence, and clinical evidence are of no concern to this individual. Familiarity with the history, philosophy and clinical record are also considered irrelevant when nonsense of this type is being proferred as science. By these same arguments, superficial thinkers have argued in the past that the world is flat, that evolution is a hoax, that airplanes can’t fly, and that the earth is at the center of the universe.

Second comes the anti-naturalist. Pointing out that many “natural” substances can be toxic, the anti-naturalist thinker seeks to raise doubts and mistrust about natural treatments, whether they advertise themselves as such or not, because natural treatments are not universally safe.This individual ignores the fact that other (non-natural) treatments are virtually all rife with serious risks, and overall, natural treatments tend to be safer, albeit not necessarily completely risk-free. Intent on rescuing gullible souls who flock like moths to the flame to unproven treatments because of their superficially “natural” label, this individual misses a key point: that many people seek non-traditional alternatives because more conventional approaches simply don’t work for them, or because they have been alienated from conventional treatments by how technology has in general wreaked havoc with nature.

Then there are the stiff-neck thinkers who object to homeopathy based on an imagined lack or absence of scientific evidence. They are unfamiliar with homeopathy, and therefore are unaware that hundreds of studies have been published using the“gold standard” of randomized controlled trials, often in highly reputed allopathic journals (!) where homeopathy has mostly been vindicated as a scientifically valid treatment. It is ironic that sometimes these individuals state that homeopathy should be subjected to the “same” scientific standards as conventional medicine, at a time when the scientific validity of conventional medicine has been greatly weakened by reports of bias among researchers, who are paid by drug companies, by research that is suppressed that is unfavorable to drug companies, when scientific papers are frequently “ghost-written,” and when the authors are on the payrolls of drug companies, even if the drug companies didn’t do the research themselves. Homeopathic research is light-years ahead of modern medical research in terms of being free from economic bias.

There are the “what me worry” thinkers who embrace it uncritically, because it worked for them, or because they are “into” natural treatments, or because their families have used homeopathic medicines. Anecdotal evidence is not without validity, but these individuals minimize the need for more rigorous evidence. The value of anecdotal evidence is generally minimized, and I think unjustifiably so, because anecdotal evidence, when it occurs frequently, acquires a certain gravity than single case reports do not. Still, the greater worry is not so much that these thinkers will blunder into useless treatments as that they may blunder into dangerous treatments (which homeopathy has never been shown to be).

There are the “suspicious” thinkers who seem to distrust it just based on it being different from what is familiar. Any number of excuses might be brought up to question homeopathy’s validity, and they are never at a loss for another one, even if one can argue successfully against any one of them. These folks simply have irrational fears about something that is too different for them.

The wise soul, who I rarely encounter, knows that evidence is ultimately a chimera. Without leaping into the extremes of relativism, the wise soul knows that acceptability and provability are almost always to some degree in the eye of the beholder. Attitudes of blind acceptance or sweeping dismissal are generally over-reactions, whether it comes to homeopathy or anything else in life. The wise soul knows that nothing is completely certain in life, outside of the realm of mathematics. One is always left making judgments, with the imperfect instrument of our emotionally clouded perceptions.

Thursday, September 10, 2009

Who are we, the homeopathic aficionados?

Today, a friend asked me about how my transition from psychiatrist to homeopath came to be, and whether this created conflicts for me. I said that I had always had greater conflicts with my role as a conventional physician, since I wanted to accomplish deeper healing and growth in my patients than I felt was possible by the use of medications, upon which modern medicine appeared to be so dependent. Homeopathy aspires to accomplish deep healing, on physical, mental, emotional and spiritual levels. As this was revealed to me during my tutelage in homeopathy at the Hahnemann School in California, it could not have been an easier transition. The hard part, as Dr. Roger Morrison, one of my mentors there once quipped, was that once you go down that road, you can never go back. He certainly was right for me. Once you've tasted the profound changes that can result from a successful homeopathic case, it is all but impossible to settle for the palliative effects of conventional therapies.

Many homeopaths arrived on the shores of homeopathy as flotsam and jetsam from other medical fields, both conventional and alternative. The stories are similar in many cases: they are about people looking for a deeper more profound and effective way of helping their patients. But what about the patients. Who are they and how do they come to homeopaths? I've identified a number of types of patients who come to see me. If you see yourself in any of these types, you might want to call a homeopath for an appointment.

One way of identifying who homeopathic patients are is to first define who they are not. They are not persons who are satisfied with their current treatment and medical care. They are not people who are uncomfortable with novelty and the unconventional. They are not people who tend to be independent thinkers. They may be very bright. They may be very sick or very healthy. They usually are dissatisfied with their own treatment or the medical system they have encountered in their lives. They may be hippie-granola-lefty-radical types, or they may be more conservative in their political and social leanings. But they are quite sure that they want something different.

1. Homeopathic patients generally are dissatisfied with the medical care they are receiving. It didn't work, it didn't work well enough, it caused intolerable side effects, or it caused annoying side effects. These individuals often have long histories of trying numerous drugs and even alternative therapies without satisfactory results. To paraphrase a modern homeopath, Dana Ullman, who has written beautifully about homeopathy in many books, when modern medicine is failing people, that is when homeopathy comes into its own.

2. Some individuals go beyond side effects in their reactions to medication treatments. They are unable to tolerate nearly all pharmaceutical agents. These hypersensitive folks simply can't tolerate most conventional therapies, and are relegated to finding gentler alternatives such as homeopathy.

3. Some individuals don't fit into the boxes that physicians were taught to put people into. They don't have easily diagnosed problems or they have problems for which there are no well established treatments: these include fibromyalgia, chronic fatigue syndrome, chronic pain syndromes, fevers of unknown origin, irritable bowel syndrome or other treatment resistant symptoms which don't add up to any clear diagnosis. Often these individuals are made to feel like pariahs in the medical system. Patients readily perceive that their doctors don't consider their complaints to be legitimate. Many doctors regard these individuals as having psychiatric problems, to be seeking "secondary gain," or attention of some sort, to be hypochondriacs, or to be just plain nuisances, since they never seem to get better and no sense can be made of their problems. Homeopaths do well with these patients, since they have a totally different diagnostic system, which is able in most cases to make sense of what is a confusing mish-mash to the conventionally trained physician.

4. Some homeopathic patients are simply cautious and fearful about undertaking trials of medications or surgery, whether for themselves or for their children. They tend to be people who read broadly and are aware of the side-effects and risks that are down-played by the pharmaceutical industry and conventional medicine, but which keep popping up in the news. They may have had a bad experience with a medication or surgery in the past, or know of someone who did, and are leery of exposing themselves or their loved ones to the risks of conventional treatments. While the fears of such individuals tend to be pooh-poohed by some conventional doctors, or even labelled as hysteria, these people from the perspective of homeopaths are not over-reacting. They are simply respecting the basic Hippocratic admonition that doctors appear to be less mindful of these days: that first and foremost, doctors should do no harm in their healing efforts (Primum non nocere).

5. There are a certain number of people who come to me who are probably overly prejudiced against conventional or allopathic treatment. They view conventional medicine as anathema and clearly have an axe to grind. I treat these individuals anyway, because I don't take sides when it comes to helping the sick. I just do the best I can.

But I don't share these patients' complete hostility to modern medicine (some of them are taking medication anyway!), because I believe that conventional treatment does have a time and place. These individuals are always looking for another angle because of what appears to be a deep anger at conventional medicine. I too have some anger about the way a lot of conventional medicine is practiced, but I know that many modern treatments are beneficial and necessary. Conventional doctors are not evil. Lives are saved, and people do experience benefits from modern medicine. However, many are harmed unnecessarily, and it is probably only in about 10 percent of cases (my own personal estimate) that modern medicine is clearly superior to safer alternatives. In most cases, where there is not an immediate threat to life and limb, safer approaches will work as well or better, and with far less morbidity and mortality. For those who do not respond to safer approaches, more risky ones can be used, with a full disclosure of these risks. To me, it is only sane to begin with the safer options, when there is not a pressing issue of a life and death nature, even if the scientific literature may not be as strong as we would like it to be. The reason most doctors do not do this is that they have been trained to believe that safer alternative treatments such as homeopathy are not valid.

Regrettably, it is only a minority of patients, usually those who are among the most broad-minded and sensible (in my view) with regard to exposing themselves to risk, or those who have had both the worst outcomes from conventional treatment and the boldness and energy to consider other alternatives who cross the threshold of a homeopath's office. For the rest, the conventional wisdom prevails, or people continue to suffer unaware that safer more effective alternatives exist a mere phone call away.

Tuesday, September 8, 2009

Who are doctors?

The mythology around the medical profession is as powerful as it is pervasive. For many of us, images of our favorite TV doctors, who are variously lionized and humanized probably have more impact on our image of who doctors are than any reality based encounters. Doctors are as impressed with the mythology as non-physicians, in part because they helped to create it. Doctor as hero, doctor as genius, doctor as savior, doctor as god with feet of clay. The old joke goes, "What's the difference between a doctor and god?" The doctor knows he's a divine being.

The sober reality is that physicians are people like everyone else and vulnerable to the same flaws and weaknesses. One of the most pervasive and legendary characteristics of physician training is its competitiveness. Competitiveness cuts both ways: it may show how tough you are but it also shows how much you care about yourself at the expense of others. Competition begins with the pre-med courses, where getting an A or a B+ may mean the difference between getting into med school and not. Many people are unable to matriculate, and apply and re-apply. Once you are in, the competition begins in earnest. Volumes of memorization enough to blind you and bludgeon your brain into insensibility. Yet emerging from that even stronger! Then the competition continues with equal intensity for the best residency programs, at the best universities, the most prestigious faculty. Years of sleep-deprivation ensue, while managing multitudes of patients simultaneously in your sleep deprived state. Still, they are able to conjure up arcana from the vast stores of knowledge accumulated over years of immersion in medical learning. Then comes the next competition: the most lucrative jobs, the most prestigious university affiliations or medical centers, or multi-specialty groups. Who has the best cases? Who can stump his colleagues? Who can make the most subtle diagnosis? Who's on top?

The downside of this competition, for all of its impressiveness is that it tends to yield (what else) competitive doctors. Competitive doctors are interested in their own advancement above and beyond their other more humanitarian concerns. This problem affected me deeply during my medical training. Because while there certainly were caring people even among the fiercely competitive, and while some good could emerge even out of self-interested doctoring, there was a certain falseness to the myth that was being fostered in the process. The benevolent aspects of doctoring were always being discussed, but the jousting, the self-interestedness, and the competitiveness never were.

When I tell my medical colleagues that I have become a homeopath, it does not surprise me that many of them are uncomfortable. It took me some time to understand this, but I believe that the discomfort arises out of the competitive culture of medicine. The notion that you might have an edge, even by knowing something that other doctors know nothing about, because it wasn't part of their training strikes a blow into the soul of every doctor with an ounce of competition. This may explain the stunned and awkward silence of my fellow doctors on finding out that I have something I know that I feel confers an advantage to me over what they do. It probably explains the hostile reception homeopathy has had over two centuries from mainstream medicine. In the world of medicine, I regret to say, defeating the competition sometimes seems more important than being a good doctor.

Monday, September 7, 2009

National Health Insurance

Yesterday, I received in the mail yet another solicitation to join Physicians for a National Health Plan (PNHP). I used to belong, in the days when simple solutions seemd to me to be simply right. Since starting down the unconventional road of homeopathy, I have been more wary, and their applications have for the most part ended up in the recycle bin. But occasionally, I write them a letter, explaining my reservations about joining. In the letters, I express a number of worries that keep me from joining their well-subscribed to but as yet politically unsuccessful organization. First of all, PNHP never really says exactly what it is proposing. In its newsletter it posts massive volumes of clippings the editors have gleaned from newspapers and journals around the country, depicting the economic wastefulness of the current system. It then cites examples of systems, such as Canada's or other European nations', where their national health insurances have far less administrative costs. But PNHP never describes what kind of national health care system they endorse. These details are presumably too trivial to warrant our consideration.

Being against national health insurance simply means you are pro big-business, right? But what would a national system actually actually look like? Would it mean that only doctors and approved medical clinicians could do treatment? What about chiropracters, acupuncturists, osteopaths, or homeopaths? What would become of them? Would they be considered part of the waste too, since the evidence for their treatments is held in lower repute by mainstream medicine than that for more conventional treatments? Although trained as a psychiatrist, I have studied homeopathy in its application to primary care type problems for over 7 years, even though I have not done a family medicine residency. Would I be permitted to charge for my services? Or perhaps I would be banned from these practices altogether, relegated only to treating conditions that have been narrowly defined as "psychiatric."

In short, I worry about what would become of alternative medicine in general, and I also worry about what would become of my own practice. The PNHP literature does not address these issues, nor does it address the issue of how to handle the high costs of prescription drugs and medical devices, the high fees charged by physicians, particularly specialists, the low fees awarded to primary care physicians, the rising costs of treating self-induced medical problems (those based in behaviors or life-style choices), the effects of high malpractice insurance rates, and the impact of outlandish medical student debts on the practice of medicine. It does not address the issue that neither doctors nor patients have or wish to have any restrictions on the tests, procedures and treatments open to them, regardless of costs. Yet the costs are killing us.

National health care appears to be a Gordian knot kind of solution. It actually has a limited though valuable contribution to make, because waste does increase costs. but it can only be part of a broader solution. It addresses only one part of the problem, because national health insurance has no relationship to the underlying causes of our expanding health care system. The bureaucracy that adds costs to the system is not expanding, but costs are. And the reason is that doctors are prescribing more and more expensive tests, drugs, and other treatments, and patients are agreeing to more and more expensive drugs, tests and treatments. If we were to enact a national health insurance plan, we would soon find ourselves confronting these problems head on, and the system would be forced into rationing. And rationing might be done along any kind of guidelines, since PNHP and other advocates of national health insurance haven't evidently thought much about this. It might well be the death knell for many types of alternative medicine, including homeopathy. It might lead to a narrowing of all of our choices for health care. This would not necessarily be entirely a bad thing. But lets talk about what kinds of rationing we might favor, when we talk about national health insurance before it is enacted, not afterwards. Otherwise, we don't know what it is we are endorsing.

Friday, August 28, 2009

Sleeping Beauty

It has been nearly 10 years since I began studying homeopathy. What began as a search for something that would help me to obtain better results with my patients has become an avocation and a passion. Entering into my exploration of homeopathy, I had no concept of how profound this medical art is, and no inkling of how much it would affect my practice and my way of thinking about medicine.

The shocking reality of homeopathy that struck home not long after I began my studies in earnest at the Hahnemann School in the fall of 2000 was that homeopaths were treating nearly everything I was treating with as good or better outcomes, less morbidity and at less expense. Whereas the best I could hope to acheive was palliation of my patient's symptoms, they were acheiving true cures. While I was treating people for years, if not decades, they were treating people for months and obtaining more dramatic results. All this was being accomplished at far less cost and with little or no adverse effects. This appeared to be true not only for psychiatric patients, whose concerns were initially of greatest interest to me, but also to patients with more general medical problems, many of which were of a serious nature. This was not just "complementary" medicine. This was a whole parallel medical universe, existing in silent neglect alongside the behemoth of the medical industrial complex.

In a flash, I perceived that if the allopathic world found any treatment even for any single disease, that was as effective, as inexpensive, and as safe, it would be a media bombshell, and would in fact revolutionize medical practice. Here then was my second great shock: the allopathic wold was aware of homeopathic treatment, but was utterly indifferent. Homeopathy had a bad "rep" in the allopathic world, so all the hooting and hollering about cures and safety and inexpensiveness were falling on deaf ears. In fact they had been falling on deaf ears for over 150 years, and so the amount of hooting and hollering had been reduced to almost nil. Homeopaths had many stories to tell about homeopathic research that was dismissed, criticized, neglected, ignored, or devalued because of the fact that it was obvious, prima facie, that the treatment was nonsensical.

Accepting the unreceptivity of the world to homeopathy has been something that has always been hard for me. Sometimes I can laugh at it, like the joke about the man looking for his keys under the lamp (even though he dropped them elsewhere) "because that is where the light is." At other times, the tragic consequences of homeopathy's relative disrepute pain me. I see people experiencing the consequences of unsuccessfully treated illnesses or dealing with the side effects of the treatments and I am pained by what seems to be unnecessary suffering. This pain is transduced into outrage when I see the medical industry bringing in massive fiduciary gains in spite of these (unnecessary) negative outcomes.

This brings me to my point -- that in these times of medical cost overruns, and with health reform in the limelight, homeopathy is uniquely poised to make a contribution. Noone, not the health insurance industry, nor the hospital industry, nor the medical profession, nor the pharmaceutical industry, nor the medical device industry wants to see its profits significantly cut into. And keeping the medical system substantially the same is the best way to ensure that none of the major industry financial concerns are negatively impacted. Unfortunately, it is also the best way to make sure that we do not change the exploding costs of health care. Here's the naked truth: the current system is just too expensive. Until this elephant-in-the-room is named, we will continue to pursue chimerical or band-aid solutions. The silent and neglected universe of homeopathy -- safe, effective, and miles less expensive -- lurks in the background. If it weren't called homeopathy, it would be called a miracle solution, a deus ex machina, a godsend. But because it is, it will likely remain in silent desuetude, a sleeping beauty waiting to be awoken, while the vines grow taller and the kingdom is engulfed.

Friday, August 14, 2009

The Boundaries of Homeopathy

In an effort to expand my repertoire of treatment options, I recently began training in a type of bodywork known as "Bowenwork." Developed in the 1950's through the 1970's by the late Tom Bowen, an Australian sports trainer, Bowenwork attained such success in Australia that by the 1980's it was spreading world-wide. It's applications have expanded far beyond it's author's original intents, largely by virtue of empirically demonstrated results, to include, in addition to general musculo-skeletal injuries or illnesses, respiratory problems, kidney problems, some mental and emotional disturbances, and a variety of other general systemic illnesses. It's adherents report success rates of 80-90%, with virtually no adverse effects and relatively few sessions (3-5 on average) to complete the majority of treatments.

Sometimes known as the "homeopathy of bodywork," Bowenwork also uses minimal dose methods (less is generally more effective), it embraces the notion of healing through energetic processes, and also, it seems to have the same absurdist mode of action -- i.e., it is completely inexplicable. Bowen workers twang and pluck muscles, tendons, ligaments, and other physical structures in the body much like guitar strings. This plucking process, which are referred to as "moves" are for the most part extremely gentle and pain-free, although why they should have any salubrious effects is in no way apparant. Certain moves may elicit some discomfort, but the presence of pain is generally considered to be an indication that the practitioner has not used proper technique. Like homeopathy, treatments must be given time to have an effect, and too rapid repetition of a treatment can be counterproductive. My interest in Bowenwork was actually stimulated by other homeopaths, who have written or spoken favorably about Bowenwork (including Jeremy Sherr).

One of the things that has struck me about Bowenwork as I have been learning it is how tightly regulated it is in comparison with homeopathy. Certified instructors are the only ones permitted to teach, and they must undergo additional training to be certified. To be certified as a Bowen Practitioner, one must pass a practicum, and demonstrate proficiency in business matters as well. In short, the Bowen establishment want the purity of the technique to be preserved and they also want people to be successful in their practices, so that Bowenwork achieves the success its founders felt it deserved.

By contrast, homeopaths have no mandatory certification process, and pretty much anyone can study or teach it. There is a certain amount of infighting within the homeopathic community about which approaches are legitimate (this infighting actually began in the late 19th century, with the so called "highs" and "lows", who fought over the legitimacy of the high potency remedies vs. low potencies), who is most qualified to practice homeopathy, and which homeopathic organizations should represent homeopathy to the public and the scientific community. There is the National Center for Homeopathy (open to anyone), The American Institute of Homeopathy (open to M.D.s, D.O.s, dentists and certain other qualified practitioners with medical backgrounds) and the North American Society of Homeopaths (organized and run by naturopaths). There are several types of certification, and practitioners may have anywhere from zero to three certificates, depending on their ambitiousness. The value of these certifications seems largely nominal, as the non-homeopathic world does not tend to regard homeopathy as legitimate, and being certified in an illegitimate practice confers little or no more respect. These certifications are valued by homeopaths as personal acheivements and to some extent by the rest of the homeopathic community, although they are not regarded as necessities.

While there there appears to me to be a tendency in the allopathic community to label all treatments as on the one hand "medical" or "evidence based" or "legitimate" and on the other hand as "alternative" or "complementary" or "of questionable legitimacy", the truth about the varieties of treatment is far more complex. Some conventional treatments are of little value, even though evidence may support their validity. Some evidence is simply not very high quality. Other treatments, though lacking in large randomized controlled trials, are buttressed by testimonials, dramatic case findings and other empirical evidence. It is important that we as homeopaths define our boundaries a little better. Some lay treatment practitioners are far better at what they do than many board certified physicians, or other licensed health professionals. I myself have had several sports injuries which were helped by non-medical professionals, one a sports trainer, and the other a naturopath. I had been evaluated by several experienced and well trained orthopedists, had x-rays, bone scans and MRI's done all to no avail. These non-medical professionals fixed up the problems, which had become quite chronic, in short order.

Yet, I know that if I had advanced osteoarthritis, a complex fracture, or other severe pathology, I would have been in better hands with the orthopedists. It's not a question of who is better, but who is better for what problem. Homeopaths with medical backgrounds have an advantage in treating complex medical illness where there are medication issues to deal with in conjunction with the homeopathic treatment. This is not to say that those without medical backgrounds are unable to treat people with such illnesses. Rather, I wish to make the point only that overall, in such cases, those with a medical background are more likely to be well equipped to handle severe pathology, managing the allopathic and homeopathic treatments together. Those without a medical background may do fine treating these cases in some circumstances, but overall, they will more often be in their comfort zones in cases where such severe pathology and pre-existing medical treatment is not a significant issue. You don't need 12 letters after your name to prescribe Arnica for a bump or bruise. Conversely, having the 12 letters does not necessarily mean that your results will be better in the treatment of chronic illness, where constitutional remedies are likely to be most effective.

Homeopaths need to define the scope of their work better, and within the homeopathic community those of us with different backgrounds should define the scope of our work vis-a-vis other homeopaths better. Certification would be more useful if it gave some indication of where our strengths and weaknesses as healers lie, rather than simply some more letters of unknown significance to tack on after our names in the vain hope of impressing ourselves or others. The same would be true for physicians and other practitioners of alternative medicine. Being board certified in a medical specialty, from my experience, means being a good test-taker. There has been no evidence that I know of that being board certified is correlated with better care or more satisfied patients. Yet people often act as if this is the case. What foolishness!

Wednesday, August 5, 2009

Make 'Em Pay

The newspapers are publishing articles about Obama's sagging popularity, due in large measure to decreasing support for his health reform plan. Skipping over the fact that Obama doesn't actually have a health plan (he has just issued guidelines to Congress for the types of changes he would like to see), it seems to me that few have credited Obama for actually having the courage to take on a problem that he surely must understand is a hornet's nest of conflicting interest groups. His efforts to make insurance plans more fair and to cover more people is laudatory, but the problem he and the Congress have not shown signs of being able to successfully address (other than to raise taxes on the wealthy) is how to hold down the growth of the health system. All the players are for reform, as long as nothing is taken off their own plate.

Surely, if doctors were asked to line up to have their salaries reduced in order to save the government from going bankrupt, this would be the shortest line imaginable. Noone would show up. The insurance companies, who are already feeling great pressure to keep up their returns to please their shareholders are not going to be lining up to cut back their rates either. The pharmaceutical companies are not producing any new low priced drugs to help people get off their more expensive treatments. "New" and "low-priced" are oxymoronic in the pharmaceutical business. And hospitals and health care corporations are not fighting for the opportunity to give back their excess riches for the good of the community. They are too busy trying to stave off bankruptcy because of their own ever-increasing payouts.

Nor are people volunteering for less care. They are often being pushed into getting less because of the inability to afford the care that is presently available to them. And they are not happy about it. Noone is bragging about how much they are helping our society to manage its budgetary problems. No, if it is talked about, it is in the form of a complaint about not taking their medications so they can eat or pay their rent.

Here lies the problem: everyone wants less, but no one is willing to accept less for him or herself. I think it was Emerson who once said something like, "Every man will change the world, but no man will change himself." If I were Obama, I'd realize this and make 'em all pay. No one wants to suffer, but if we all partake in the suffering more or less equally, at least it's fair.

Sunday, August 2, 2009

Uninformed consent

In a recent New York Times piece (July 30, 2009: Treating Patients as Partners, by Way of Informed Consent) Pauline Chen discusses the trends towards involving patients in their own care. Comments on her blog range from those who think patients are too stupid to sign off on any medical treatment to those who supported the idea that patients should be given even better explanations of their health care treatments than they presently do. The unstated issue in informed consent is that patients are being asked to take responsibility for taking risks to their health without a full understanding of what these risks mean. In fact, it is not clear to me that doctors themselves fully understand the meaning of the risks they are asking their patients to take.

Some of my colleagues tell me that in discussing the risks of a treatment with people it's important not to frighten them, or it's important to put the risk in perspective for them. What this means to me is that we as doctors must present the risk from our own perspectives as physicians rather than objectively. It starts from the premise that the patient should consent to the treatment, because we as physicians have decided (beforehand) that the benefits that might accrue from the treatment outweigh the risks. But this is a biased position. Risk assessment is very much in the eye of the beholder. Some people are petrified to drink tapwater out of fear they might be poisoned and others smoke, use drugs and all manner of foods and substances, or lie out in the sun all day because they believe that their own personal risk is low for these behaviors. In some cases they will be right and in other cases, wrong. But doctors know who is right and who is wrong no better than patients do. They only know statistics, and statistics do not usually account for individual risk, only for group risk.

Moreover, doctors are for the most part familiar only with medically oriented treatments, and not with alternative medical treatments. When your doctor tells you to take a proton pump inhibitor for GERD, does the doctor know what the botanical treatments, acupuncture or homeopathic treatments have to offer? Is the doctor familiar with the risks and benefits of these and how they compare with proton pump inhibitors? Of course not! These are not made a part of physician training for the most part in the United States (but not necessarily in foreign medical schools). So when the "alternatives" to proton pump inhibitors are discussed, they are usually dismissed summarily, without a full appreciation of what is being dismissed. It is usually assumed by physicians that only treatments that are endorsed by the conventional medical establish have any merit, because if there were others that deserved attention, they would have learned about them in their training. There is not a shred of truth to this assumption, but it is firmly embedded in most doctors' thinking.

The literature on drugs that is distributed for patients and the advertising that is seen on television continues to tilt peoples' perspectives in the direction of choosing drugs for yourself or your family. The on-line information resource known as "Adult-Pals: Adult Patient Advisory Leaflet System (see online.lexi-com) describes the side effects of Lithium Carbonate as "feeling lightheaded, sleepy, having blurred vision, or a change in thinking clearly...shakiness, headache, nausea or vomiting...frequent urination." No mention is made of the more serious medical consequences of chronic Lithium use: thyroid failure, and kidney disease. Many of the more disturbing side effects such as weight gain, dry mouth, and diarrhea are omitted. For Risperidone, the side effects are given as "feeling lightheaded, sleepy, having blurred vision, or a change in thinking clearly..feeling dizzy, high blood sugar (usually reverses when stopped), weight gain, change in sexual ability or desire (this is usally reversible), drooling, inability to sleep." There is no mention of the more serious consequences of taking the drug such as tardive dsykinesia (an irreversible neurologic condition characterized by disfiguring involuntary motions), dystonias, neuroleptic malignant syndrome, or metabolic syndrome. In fact, the "information" discourages people from looking at the diabetes and sexual dysfunction as permanent (They describe these side effects as "reversible.") even though Risperdal is almost always prescribed for long term use. The only reason it is not taken indefinitely by patients is that it doesn't work that well or it can not be tolerated for long periods of time by some patients because of the serious negative effects on their health.

While not everyone may want to partake in the decision-making process that most medical treatment requires, leaving all the decisions up to the physicians is a cop-out which permits the more paternalistic side of physicians to flourish more than it ought to. Sorry, to those of you who want to leave all the thinking up to the good doctor, but the good doctor needs you to be a part of your own treatment (excepting in cases of emergency of course, when time does not permit this to happen). Unfortunately, even for those who wish to be part of the decision-making process, all the information needed to make an informed choice is rarely on the table.

Wednesday, July 29, 2009

Safe and Effective

An FDA advisory panel recently approved atypical antipsychotics for use for children, clearing the way for these drugs to be approved formally by the FDA in the near future. These drugs were determined to be "safe" and "effective" for the treatment of pediatric schizophrenia, bipolar disorder and related other mental conditions. It is pronouncements such as this, I'm sad to say, which broaden the chip on my shoulder for modern medicine. The FDA voted on whether to approve antipsychotics based on reviews of the scientific data, which means the published clinical research. Using words such as "safe" and "effective" are extremely misleading, as much to clinicians as to patients, families and the general public, who may have an interest in the health and well being of our children. As one trained in child psychiatry, I can unequivocally state that these drugs are not entirely safe and not entirely effective, not for children, and not for adults.

Years of experience with these drugs, and a massive NIH funded trial, known as the CATIE trial, which was completed about 2 years ago, have shown that these drugs have high drop out rates due to intolerable side effects or lack of efficacy, and that all of the atypical apsychotics appear to be not significantly safer or more effective than the "typical" or "first generation" antipsychotics.
Indeed, when reading the article further (published in the July issue of Psychiatric News), the author qualifies his original report by stating that the committee found that "the results of the clinical trials met the established criteria for short-term use...despite the known risks."
Meeting criteria for safety and efficacy, as it turns out, is very different from being safe and effective. Safe implies to me that there are no serious risks, or even quasi-serious risks. It implies trustworthiness. Effective implies a predictable effect -- reliability and consistency. It means if you take it, it will work. Any other definition dilutes the meaning of the word.

Yet the CATIE study demonstrated that at least for adults there were many problems with serious adverse effects, including metabolic syndrome, which includes obesity, diabetes, hypercholesterolemia and hyperlipidemia, neurologic effects, including Parkinsonian effects, dystonic reactions, akathisia and permanent neurologic damage in the form of tardive dsykinesia, and various other problems, including cardiac arrhythmia and neuroleptic malignant syndrome, the latter a rare but potentially life threatening reaction to neuroleptic medicines. The drop out rate was so high in the CATIE study that the effectiveness had to be measured in days on the medicine until relapse occurred. In other words, during the study, almost all the patients relapsed-- it was just a matter of how long it took.

The medicines are described as safe and effective for "short-term" treatment of bipolar disorder and schizophrenia, both of which are considered to be chronic illnesses. How useful is it to have Insulin available for the "short-term" treatment of diabetes? Does the committee really think that these drugs are going to be used only for the short term? How can we not avoid concluding from what has been written that children are going to be exposed to the dangerous long term effects of these medications?

I am not happy about anyone -- children or adults -- being exposed to the risks of hazardous treatments, especially when safer treatments may be available, such as homeopathy. What gets my goat however, is less the use of these risk-prone and at best partially effective treatments, than the misrepresentation of these drugs by the FDA, by physicians, by drug companies and their representatives, and by the advertising industry. They are called safe when they are not safe (they merely have met safety criteria, which seem to be consistent with something less than mass extermination of all the research subjects, but is certainly far worse than is likely to be believed). They are considered effective when their effectiveness is often partial, temporary, or absent. True, these drugs can work wonders for some individuals, who inexplicably appear to be insensitive to the side effects, and sensitive to the positive effects, but these numbers are in actuality a small minority.

Are the people promoting these drugs evil or deluded or what? I believe that those responsible for misrepresenting unsafe and only partially effective drugs to the public mean well. They are guilty of over-valuing drugs because of their sincere wish to make available to the public tools of potential use for improving health. To some extent they may be guilty of allowing themselves to be influenced by the pharmaceutical industry, which clearly has a pecuniary as well as eleemosynary interest in seeing these drugs succeed. And these drugs do have some potential value. Unfortunately, by focussing excessively on the potential value and minimizing the potential harm, the FDA, the pharmacuetical industry and the medical establish continue to place those of us who are willing to take their pronouncements at face value at risk for serious health problems. These drugs cost a lot of money and the harm they cause is very expensive too, so this is not a mistake to be taken lightly. Ultimately, it is a betrayal of the trust we have placed in government and in physicians to carefully protect the welfare of the public, and to first do no harm.

We will continue to see more and more drugs and medical devices removed by the FDA or given black box warnings as the overly optimistic and ultimately disingenuous ballyhoo around these medical interventions gives way to a more frightening and sober realism. What a shame for those who have to endure such harm. What a shame to allow it to happen in the first place.

Thursday, July 23, 2009

Health Care Reform Revisited

I have a confession to make about my last blog entry: I was not being totally honest. You see, although I made a big point about doctors and patients needing to be made more responsible for the health care costs they generate, I do not believe that anyone is ready to accept any system that is based on responsibility. It is not that people are irresponsible: it is just that they are so accustomed to being shielded from the financial consequences of their health care that the sort of change that confronts people face to face with the consequences of their health care choices is likely to prove intolerable to them. Under such banners as the need for quality care, of professional freedom, and of the evils of over-regulation, physicians will object to a system which restricts their freedom to practice as they wish. It is no matter that this type of practice, where no test, and no treatment is weighed for its financial consequence by the prescriber has led us to financial Armageddon. The medical profession is unlikely to brook any interference in its internal workings and quite frankly, non-physicians are afraid that the wailing baby of physician autonomy will bite them if not picked up and pampered, as demanded. After all, the doctor knows best.

Patients will object to having financial consequences to their health care utilization: they will object that it will be a disincentive to seeking care, and that people will go from over-consumption to under-consumption of care, which will result in worse outcomes overall. It will be objected that when people are sick, they are in no position to bring financial matters into consideration. Overall, it will come down to the same thing: patients wish to have unlimited access to health care resources and pay very little for it. Who wouldn't want that, even though it has led to the brink of financial bankruptcy?

All the objections to making the system responsible for the costs it generates have some merit, but all have potential solutions that do not require throwing the baby out with the bathwater. Injecting an element of physician and patient responsibility in the system is a necessity, if we are to avoid the race to the bottom that the current system of divorced responsibility inevitably creates. It is the delusion that this can be avoided that will die a slow and painful death. In the meantime, every other solution to reigning in costs will be tried, and health care consumption, unchecked by the need to take responsibility, will continue to grow like a cancer.

But I had another hidden agenda, which you might guess at from the theme of this blog. This is that a system that is based solely in allopathic healing is going to have a harder time paying for itself than one which utilizes other healing methods that produce better health. I am tempted to say that any such system is doomed, but such a pronouncement would be too chauvinistic. Nonetheless, it is certain that a system that tries to suppress illness will require new and ever increasing expenses in its fight against the body's vital energy, which will resist those suppressive forces. New illnesses will appear, resistant bacteria, mutant viruses, and new treatment resistant chronic illnesses will appear which will require new research, new drugs, and more expenses. This sycotic type of expansion is built into the allopathic model. We will only be able to truly decrease our health care expenditures when the health care system does more to promote health. Promoting health decreases health care expenditures because healthy people need less treatment. Homeopathy is uniquely poised to help in this regard because it is one of the few systems of treatment whose foundation rests on the improvement of health. Indeed homeopathy and health are almost synonymous, given homeopathy's focus on mobilizing the vital energy, which can be viewed as the quintessence of health. Homeopathy is not the only treatment modality that focuses on improving health: Acupuncture, Bowenwork, Yoga, and Meditation also fit this model. They are generally dismissedor considered to be of limited or tangential value because of a lack of research supporting them. It does not matter how much research supports it, it is never deemed to be sufficient. And of course, the allopathic system has little interest in re-allocating the billions that are spent on allopathic research to research in these alternative systems, so that their true value might be revealed further . The emphasis on allopathic treatments is thereby perpetuated by a Catch-22.

Physicians receive little or no training in health, almost entirely in disease, and so they are very poor at intervening in a manner that improves health. Indeed, the conventional system is financially invested in the perpetuation of illness. Healthy people who do not need intervention would put the system out of business. A system such as the legendary Chinese health care system of yore, where doctors would get paid only when their patients were healthy would make more sense, if we truly valued health. A system where doctors are paid mostly when their patients become sick would be threatened by healthier patients. So why invest in what will be financial disastrous to you?

With apologies to readers of my last blog article, I openly confess that I did not tell the whole truth about health care reform in that particular piece. I did not because what I omitted would be even more radical and less easily digested than what I did put out. The truth hurts, and our health care reforms are likely to do everything to avoid it.

Sunday, July 19, 2009

In Defense of Real Health Care Reform

After a nearly 7 months absence, 2 new twin girls, born March 6th, and more sleep deprivation than I have ever thought it possible to survive, I return at long last to reveal to those who wish to listen the callings of my homeopathically inspired muse.

The fever of health care reform has infected the nation, and like so many others, I too am gripped by the controversy that surrounds this topic. While virtually no one views the mishmash of legislation currently being being debated in congress as the be all and end all of health care reform, we all love to argue about what would be better than what has been proposed. There are those who wish for nationalized health care and those who consider that to be anathema and wish to promote greater competitive forces in the medical marketplace, eschewing any kind of increase in government involvement. While most arguments seem to be recognizably couched in a particular political viewpoint, only a few seem to comprehend the realities of the systemic problems that drive up health care costs. I can not resist tossing my hat into the ring too at this heated moment: what kind of a blogger would I be otherwise?

I humbly submit that real reform of the health care reform can occur only by addressing the causes of the problem, not by addressing the symptoms alone. And so, inspired by Michael Pollen's In Defense of Food, I am here to defend real reform, as opposed to the ersatz
band-aid type that politicians are haggling over in the hallowed chambers of the legislature.

Any real reform must address the following problems:

1. There is little or no accountability among doctors or patients for their medical care. Choices are made without regard for cost, and sometimes without regard for effectiveness. Reforms must make doctors accountable for the amount of health care costs they generate, and patients responsible for the amount of health care costs they utilize. Otherwise we will continue to have the race to the bottom that taking no responsibility necessarily creates, and which characterizes our present system.

2. The excessive costs of medical education must be reduced. Doctors must be compelled to enter medical school with the understanding that in exchange for tuition and expense free education, they must commit 4 years of their post-residency lives to working in an underserved area, or with the uninsured or poor. The former prerequisite avoids the financially catastrophic costs of training that drive doctors to try to make more money than they need to live on, because of the high levels of debt they graduate medical school with. It also helps to solve the problem of treating those who lack access to service, which depending on how you tally it, amounts to at least 16% of the population (if you include only the truly uninsured) but may be at least double that if you consider the underinsured. For these four years of service doctors would be rewarded fairly, higher than they were paid as residents, but considerably less than the generally prevalent rates for doctors in the immediate post-residency years. This would save dollars, and help to pay the costs of educating our physicians.

3. Medical schools need to be mandated to graduate more primary care doctors as a percentage of their classes. This may be through direct law or by making taxpayer supported funding contingent on a school graduating a class with a minimum predetermined per cent in primary care residencies, and perhaps certain other undersubscribed specialties. This would hold down costs and help to make available the type of medical care our society needs most. In addition, primary care needs to be more equitably reimbursed compared to specialized care.

4. Malpractice needs to be reformed. Rather than cash awards, suspensions from practice or non-monetary reparations would be preferable. The costs of rewards for pain and suffering simply can't be born. Having doctors exempted from lawsuits during the time of public service would also help, although other forms of oversight of the quality of care would need to be substituted during that service period.

Another way of reducing malpractice costs would be to have doctors identified to the public as "high, medium, or low" intervention doctors, based on the amount of medical costs they generated in their practices. Doctors who generated the highest costs would also have the highest vulnerability to law suits and those who generated the lowest costs would have the lowest vulnerability to law suits. In other words, you can sue less if you choose a doctor who practices more conservatively. Your reward for choosing such a low intervention doctor would be lower insurance premiums. This boils down to making the right to sue something you have to pay for. Your doctor's reward for holding down costs would be lower malpractice rates, and reduced likelihood of being sued.

5. As an alternative to increasing taxes, a network of health care charities should be fostered by various financial incentives, to help those who need an even greater safety net than the system, even as reformed above would provide for. If people don't want to incur more costs through taxes to pay for the care of those who are sicker than themselves, let them voluntarily provide funds through charitable gifts that could be used for those how experience catastrophic illnesses that make their health care costs jump suddenly and dramatically. The difference could be made up in taxes, at the discretion of the individual states. This gives people more local control of their health care budget.

Too much care for too many people and too little of the kind of care that is needed are all parts of the problem. Doctors thrive on the perpetuation of ill health. How about rewarding them for improving health, rather than maintaining disease? As part of my first proposal, I would add that the health care costs generated in a practice (on a per patient basis) from year to year should be monitored, and doctors should be rewarded for reducing their per patient annual costs with higher reimbursement rates. For example, if a doctor has 1000 patients in his practice and generates costs of $1,000,000 total, for all of his patients (including the cost of referrals), and the following year, he reduces that to $990,000, for the same number of patients, his reimbursement rates would increase slightly. If they went up to $1,010,000 the following year (measured in inflation adjusted dollars), his reimbursements would go down for the following year. Naturally, the amount of increased revenue the doctor would be entitled to for reducing costs to his patients would have to be less than the amount saved, in order for the system to save money. However, this system would motivate doctors to think more before ordering tests, making referrals, or ordering expensive drugs. Some would argue that doctors must be free from these kinds of considerations. They must think only of what's best for the patients. I would counter that when you are in the jungle, you must think of what you have with you, not what the high tech options in another environment could do for you. We are now in a kind of jungle, since we see now that what we thought was available is actually a chimera. It will disappear just as Bear Stearns or Lehman brothers almost did, and just as the glaciers are doing, if we ignore the effects of over-consumption.

Some would say that by introducing financial incentives, doctors will reject sick patients, just as insurance companies have been doing for years. But this should not happen, since a patient who consumes a lot of resources can still help the doctor to increase his reimbursement if he cuts that patient's annual costs from say $50,000 to $49,000. Also, while it is true that doctors may find themselves in awkward positions at times, doctors personal interests are at least counterbalanced by a desire to help their patients and avoid vulnerability to lawsuits from delivering inadequate care. Besides, who would you rather have making decisions about what you can receive for treatment, government bureaucrats, insurance companies, or doctors themselves?

If patients were to be rewarded with lower insurance rates, or tax breaks for reducing their utilization of health care resources, this would encourage people to take more responsibility for their health. It would mean that people who choose more expensive options would have to pay for what they get. Isn't paying for what you recieve fair? Some may say that this discriminates against those with congenital or other "no-fault" illnesses. Individuals who reduce their health care consumption annually would receive financial benefits, whether they came down from $100,000/year to $95,000 per year, or from $2000 to $1900. This way people with congenital illness or other "no fault" would not be discriminated against because they need expensive treatments just to survive. And people with low costs would have an incentive to keep their costs low by not smoking, not using drugs, and exercising. It is known that at least 50% of health problems are caused by behavior and as such are modifiable without the need for conventional medical treatment.

Many physicians will look at less care as worse care. The notion is that you get what you pay for. However, studies on regional Medicare spending show that regions that have higher spending have no better health in their populations than regions with higher spending. Also, the notion that more spending results in better health is illogical. The healthier people are, the less their health care costs should be. The sicker they are, the more costs they will incur. This type of convoluted logic is itself a product of a diseased system, one that understands only disease and not health.

How does alternative medicine fall into all of this, you may wonder? Health care reform is very doctor-centric, and ignores the reality that large numbers of our population see practitioners of alternative medicine including chiropracters, naturopaths, acupuncturists, and so on. The numbers of these alternative health care practitioners are considerable. As a practitioner of alternative medicine myself, I am of course sympathetic to those who wish health care reform not to leave out these practitioners, and those who benefit from their work. Many fear that by expanding coverage to these practitioners, the health care costs of the country would just be increased further. I would propose only that these practitioners be judged by the same standards as physicians and other more conventional health care practitioners, nurse practitioners, physician's assistants, physical therapists and so on -- namely that their reimbursement rates be adjusted according to whether their patients show an increase or decrease in their collective health care expenditures for the time during which they were in treatment. This tends to reward those practitioners who are helping their patients be healthier and take away from those who are worsening or at least failing to improve the health of their patients.

In sum, we need to make doctors and patients more responsible for the health care costs they generate, support primary care, reduce built in medical education debts and malpractice costs that drive up the costs of care, add to the workforce that can affordably treat the uninsured and indigent, and let any treatment that helps hold down costs be justly rewarded. These are the kinds of proposals which I believe will move the system and those that it serves in the direction of health.