Author: Kaley Burns

Kaley is a fourth year Naturopathic Medical (ND) student at National University of Health Sciences in Chicago, IL. She completed her undergraduate studies in kinesiology at the University of Wisconsin-Madison. After graduation next year she is interested in collaborating with medical doctors as a member of an integrative healthcare team. Kaley has a special interest in veteran's health, nutritional medicine, and sports performance. As a research fellow, she has participated in clinical studies and furthered her appreciation for evidence-based clinical practice. Kaley is a certified triathlon and endurance coach and a member of the Timex Factory Racing team. In addition to endurance training, Kaley enjoys playing the piano, catching up on reading and cheering on the Badgers. As an ND she plans to aid in the movement towards a medical system with a broader vision and enhanced capability to create and sustain health in our communities.

Categories
General Pharmacology

A Quick Lesson in Supplement Quality

An increasing number of patients are now taking nutritional supplements on a daily basis, believing that they are boosting their health. Choosing the best supplements to take can be nothing short of overwhelming for the majority of patients. It’s not only a question of supplement type, but also of knowing how to identify which product is safest and most effective.  As more patients are taking their health into their own hands, vitamin sales are expected to grow by 8% to a total of $9.2 billion over the next year, according to Nutrition Business Journal.1

It is important for patients to be aware that the U.S. Food and Drug Administration (FDA) does not analyze the content of dietary supplements. However, the FDA has issued Good Manufacturing Practices (GMPs) for dietary supplements. These are a set of requirements and expectations by which dietary supplements must be manufactured, prepared, and stored in order to ensure quality. One of the best ways to know if a supplement contains what the label says it does is to choose a product that has been manufactured at a GMP facility. The GMPs are in place to prevent the inclusion of the wrong ingredients, the addition of too much or too little of an ingredient, contamination (i.e. by pesticides, heavy metals, bacteria, etc.), and the improper packaging and labeling of a product. A GMP facility must comply with the same standards required of pharmaceutical companies, as mandated by the FDA.2

Additionally, it is best if the supplement manufacturer has a Certificate of Analysis (COA) for each ingredient. Having a COA means that the raw material has been tested by an independent lab and determined to be contaminant-free.

Another sign of high supplement quality is for a product to be National Sanitation Foundation (NSF) certified. NSF is a respected third-party quality assurance organization. It verifies that a facility complies with GMPs and takes proper steps to ensure product safety and accurate labeling.

There are four “grades” of supplements/vitamins:3

  1. Pharmaceutical grade –The highest-quality grade, typically sold by a health care provider and may require a prescription.
  1. Medical grade – Still good quality but not as high as pharmaceutical grade.
  1. Cosmetic or nutritional grade (“consumer grade”) – Mostly “over-the-counter” products sold through health stores, pharmacies and grocery stores. Consumer-grade supplements are optimized for extended shelf life.
  1. Feed or agriculture grade – Not recommended for human consumption.

One good resource is the Dietary Supplement Label Database (DSLD). This site contains label information from thousands of dietary supplement products available in the U.S. It can be used to search for a specific ingredient in a product, a particular supplement manufacturer, text on a label, or a specific health-related claim.

Patients and doctors alike want to know whether a supplement has been clinically proven to support health. In general, it is a good idea to encourage patients to check with a healthcare provider before taking nutritional supplements. Dietary supplements may not be risk-free under certain circumstances, such as during pregnancy or for those who have a chronic medical condition.

Although this piece is about supplements, it is important to keep in mind that we all can benefit from improving our diets naturally, rather than by adding pills and powders. Supplements can be beneficial, but should not be used to replace a well-balanced, healthy diet.

References:

  1. “Nutrition Business Journal.” New Hope. http://newhope.com/nutrition-business-journal
  1. “Office of Dietary Supplements – Frequently Asked Questions (FAQ).”Frequently Asked Questions (FAQ). https://ods.od.nih.gov/Health_Information/ODS_Frequently_Asked_Questions.aspx
  1. “Fool-proof: How to Choose the Best Quality Supplements/vitamins.” Virginian-Pilot. http://pilotonline.com/life/fitness/quick-tips-for-wellness/fool-proof-how-to-choose-the-best-quality-supplements-vitamins/article_353a05ec-a4ed-5b6e-a3f7-01f14cd7bbd6.html

 

Featured Image:
Pills by Jamie

Categories
Clinical Reflection

Could I be wrong?

Physician overconfidence is thought to be one contributing factor to diagnostic error, and occurs when the relationship between accuracy and confidence is mis-calibrated.1 The relationship between diagnostic accuracy and confidence is still indefinite, but it is hypothesized that if confidence and accuracy are aligned, then appropriate levels of confidence could cue physicians to deliberate further or seek additional diagnostic help.2

A recent study by Meyer and colleagues, aimed at evaluating the relationship between physicians’ diagnostic accuracy and their confidence, found that physician confidence was related to how often they requested a critical additional resource. Additionally, the study found that diagnostic accuracy decreased when physicians were faced with more difficult cases, while confidence decreased only slightly with difficult cases. They noted that diagnostic tests were requested less often when confidence level was higher, regardless of whether or not that confidence was correctly employed. “In essence, physicians did not request more second opinions, curbside consultations, or referrals in situations of decreased confidence, decreased accuracy, or when diagnosing difficult cases.”3 The findings from this study suggest that physicians might not request the required additional resources when they most need it.

Students are often so sensitive to criticism that they are reluctant to give any to their colleagues. This is one area where the culture of medicine can be improved. By using feedback from others and self-reflection, we may be able to improve our diagnostic reasoning.

We are taught to think that everything needs to be rechecked and reconsidered when it comes from an outside source. But what if we turned that clinical skepticism inward? When you are right, you are going to save lives and figure out the patient’s problem. When this happens, it’s always going to be a wonderful thing. But how many more times can we get it right if we make it a habit to ask ourselves, “how could I be wrong here?”

Jason Benham said, “Your greatest weakness is often the overextension of your greatest strength.” Essentially, when a strength is over-extended, you get breakdown. But when a strength is turned into a stretch, and you’re flexible enough to bend, you will not break. Take time to occasionally step back from a difficult case, consult a textbook or run a different test, and make sure you are solving the correct problem. Mistakes will happen. When errors occur, acknowledge them, discuss them with colleagues and the patient, make efforts to correct it, and move on. In medicine, where the consequences of shortcomings and misjudgments can be dire, we can all benefit from encouraging more of these types of discussions.

References:

  1. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5)(suppl):S2-S23.
  2. Graber ML, Berner ES, Suppl eds. Diagnostic Error: Is Overconfidence the Problem? http://www.amjmed.com/issues?issue_key=S0002-9343%2808%29X0007-5.
  3. Meyer, Ashley N. D., Velma L. Payne, Derek W. Meeks, Radha Rao, and Hardeep Singh. “Physicians’ Diagnostic Accuracy, Confidence, and Resource Requests.” JAMA Internal Medicine JAMA Intern Med 173.21 (2013): 1952.
  4. Schiff GD. Minimizing diagnostic error: the importance of follow-up and feedback. Am J Med. 2008;121(5)(suppl):S38-S42.

Featured image:
superhero by snapp3r

Categories
Clinical Narrative

Did you hear any zebras in there?

“Every child you encounter is a divine appointment.” – Wess Stafford

I made a new friend today. He was sitting on the floor organizing puzzle pieces. I took a seat beside him to take in his perspective. It had been awhile since I joined a patient on this level, but it set the tone of our relationship immediately.

I made a new friend who was excited to share with me. He looked over at me and asked if I wanted to help him sort. “It’s more fun down here, isn’t it? I can teach you where these go,” he offered.

I made a new friend whose favorite things about himself are his freckles, despite what the kids at school say about them. He winked at his mom as we continued to sort the puzzle pieces. “I think your best thing is your smile. It is almost like my mom’s!” he remarked.

I made a new friend who is stronger than most adults I have met. He pointed at a puzzle piece and told me that he has “been sick since he was as tiny as this puzzle piece.”

I realized my new friend just wanted someone to include him in his case. As he recounted his story with vigor, he nodded toward his mother and critiqued, “Usually people like you only want to know what she has to say.”

My new friend showed me the scar on his head and the one across his chest. “I am proud of them,” he stated. “Mom told me I am the superstar of the family… but I think she does more than I do.” He shrugged.

I made a new friend who saw me as an ally. I was amazed at how quickly he trusted me; after all of the doctors he had met before me. “I am not afraid of you,” he said. “Mom says that you want to help me feel better, and mom is always right.”

My new friend had many questions and I did my best to explain why we were meeting. He looked at me with trusting brown eyes and asked, “So are you going to listen to my insides with your special headphones?” I nodded and he held his shirt up for me.

I made a new friend who found humor in a hard situation. “Did you hear any zebras in there?” His eyes were wide with excitement as I put my stethoscope back around my neck.

My new friend challenged me to adapt my exam routine and inspired me to work on my creativity. I let him try my “headphones” out on me. “I think you have some monkeys in you! Let’s see what mom has!” he cheered.

I made a new friend whose heartbeat was weak, but whose heart was full of kindness. As he held the bottle of gummy vitamins above his head, he exclaimed, “These are way cooler than the pills my mom tries to hide in my applesauce! I am going to make you my favorite snack sometime. I won’t put anything bad in it, don’t worry.”

When it was time to say goodbye to my new friend, he gave me a big squeeze and told me he thought we would be good friends. “Next time I will feed the zebras before we come so you can hear them better!”

Featured image:
zebra by SigNote Cloud

Categories
General Lifestyle

Nutrition 101

A 2011 Consumer Report found that 9 out of 10 Americans consider their diet healthy.5 People have become accustomed to reading product labels, estimating portion sizes, fashioning colorful meals, and some may even have a grocery list stored on their phone. Yet many still find themselves eating too much or too little. How many nutrients are we really getting and what are they doing once they enter the body? Are we sufficiently addressing nutrition with patients?

It has been rumored that people lie about what they eat 100% of the time. Consequently, it’s likely that patients’ eating habits are holding them back from health. According to a recent poll1, fewer than one-eighth of physician visits include any nutrition counseling and fewer than 25% of physicians believe they have sufficient training to discuss diet or physical activity with their patients.

These statistics have created a demand at the national level for reform. A few recommendations from the American College of Sports Medicine and the Alliance for a Healthier Generation include developing a standard nutrition and physical activity curriculum for medical and health professional schools, increased testing on nutrition and exercise for licensing and certification exams, and better insurance reimbursement for preventive care.2 While this will be a long-term shift, these are important strides in a beneficial direction.

Because of the relative neglect of nutrition in medical education, physicians tend to either ignore the subject or offer limited advice. For example, gastroenterologists may focus solely on fiber content, while nephrologists may focus on sodium intake.

“As long as the healthcare marketplace undervalues preventive care, health care professionals will lack financial support to address these issues with their patients and medical schools will have less incentive to train their students accordingly,” the report notes.1,2

Compared to the 20 hours devoted to nutrition in allopathic medical schools, Naturopathic medical students receive roughly 200 hours through courses such as nutritional biochemistry, science of diet and nutrition, and clinical nutrition.  This uniquely positions naturopathic doctors as physicians who not only specialize in preventative healthcare and chronic disease management, but also lifestyle and nutrition counseling.

For those looking to delve more into their patient’s nutrition status, one simple place to start is using a diet questionnaire for evaluation at baseline and to track changes over the course of treatment. Furthermore, there are an increasing number of online nutrition education programs directed towards practicing physicians. An example of one such resource is The Nutrition Source.

Why nutrition matters:

As one of my professors says, “You can be lean and mean with the illusion of health, but inside you can have raging inflammation.” The foods we eat turn on or off certain pathways and subsequently cause the release of chemical mediators. Over time this process lays the foundation for low-grade inflammation. Our enzymes convert dietary acids into prostaglandins, some of which create inflammation and pain. Therefore, based on these basic concepts, when we eat foods like sugar and flour that create these mediators, we are creating pain. Simply put: the food we eat changes our body chemistry. The more nutrients we can obtain through our food, the more building blocks are available to support the chemical reactions that take place in order for us to be alert and create energy.  While drugs like Tylenol and NSAIDS can be necessary and may help to reduce diet-driven pain, they do not treat the underlying cause.

As a naturopathic student, I hope to educate and inspire other medical professionals to learn more about nutrition in order to deliver more optimal clinical care to patients. Continuing medical education should include topics in nutrition research and instruction on how to critically evaluate new evidence in the field of nutrition. Physicians are simply one element of the much larger system necessary to promote health and wellness through nutrition. By emphasizing the influential role of nutrition in medical training and practice, we can further our ability to reduce suffering in patients.

References:

  1. Alliance for a Healthier Generation; American College of Sports Medicine; Bipartisan Policy Center. Teaching nutrition and physical activity in medical school: training doctors for prevention oriented care [white paper]. June 2014.
  2. Bernstein, Lenny. “Your Doctor Says He Doesn’t Know Enough about Nutrition or Exercise.” Washington Post.
  3. Devries S, Dalen JE, Eisenberg DM, et al. A deficiency of nutrition education in medical training. Am J Med. 2014 Apr 19.
  4. Katz, M.D. David. “Why Holistic Nutrition Is the Best Approach.” The Huffington Post. TheHuffingtonPost.com, 1 Apr. 2011.
  5. Ward, Tricia, and Stephen Devries. “Doctors Need to Learn About Nutrition.” Medscape, 4 Sept. 2014.
  6. http://www.consumerreports.org/cro/diet-plans/buying-guide.htm

Featured image:
National Nutrition Month Book Display by The COM Library

Categories
General Lifestyle

Medical Grind

It’s 6 a.m. and your hand doesn’t quite make it to the alarm clock before the voices in your head start telling you it’s too early, too dark, and too cozy to get out of a bed.

Another voice says that there’s a reason your alarm is going off. You take a deep breath, sit up, put your feet on the floor, and get to work.

This is the grind. You have a commitment. The words normal and comfortable have been traded for unexpected and demanding. You’re in a fight towards a finish line without a ribbon and the reward outweighs any medal around your neck.

On this journey to achieve a challenging goal, it’s OK to negotiate with yourself. You’ve wanted to quit many times, but you don’t surrender. Believe the voice that says “it’s OK you didn’t do as well on that exam” or “you will eventually get through to your noncompliant patient” and “you can survive these last two hours on shift.”

Keep focused on what it takes to reach the next step in the journey. Now that you’ve headed down this path, the transformation is taking place. Don’t lose heart. Remember that this is the grind.

Featured image:
vintage alarm clock / thermometer by H is for Home

Categories
General Lifestyle

Semper Fi

In early medical practices, the translating of ailments into Latin and Greek amalgams created a language that set doctors apart from the general society. This boundary signified the value that doctors provided and created a group that could identify with each other because they held similar values and had comparable educations.

The use of the phrase “Semper Fidelis” in the Marine Corps serves a similar purpose.  More than just a slogan, it is a way of life for a select population. United States Marines are admired for their dedication to each other, their service, and their country. Marines are a group that is separate and unique from any other. “Semper Fi” translates to “Always Faithful.” This statement symbolizes the ability of common people to become part of a brotherhood that demands more of its members than any other comparable group.

We don’t have to be Marines to achieve the same discipline. As medical students, we can make this a practice as we transition into our careers. Marines are trusted to make significant, split-second decisions in an environment more dangerous and confusing than those in which most doctors operate. The battlefield is chaotic and information often unreliable. In a medical environment it is important to develop effective means of communication balanced with ongoing decision-making. In practice, however, this standard of communication is rare. Empowering front-line practitioners is vital to the success of the medical system. This is parallel to what Marines do. The Marines have standards; a reputation of excellence. There is a sense of being part of something much bigger than simply an organization. What the Marines understand is the same thing that the best doctors understand- success happens through failure. There is a sacrifice that comes with joining the Corps or becoming a physician. Not only must we surrender our weekend plans and sleep to meet the physical and mental demands of our chosen paths, but we are weighted with the notion that our everyday activities affect the lives of others. No matter how good our intentions, as doctors or Marines, we will not be able to overcome the problems caused by poverty, war, the spread of infectious disease, famine, or climate change. That doesn’t mean we can’t try to help people afflicted by these events. 

Why do we do all of this? Because we take pride in what we do.  Moreover, Marines and doctors alike truly care for the welfare of the human race. Veterans Day was November 11, a celebration to honor America’s veterans for their patriotism, love of country, and willingness to serve and sacrifice for the common good (Dept. of Veterans Affairs). 

 

Featured image: Marine Week Boston, 2010: A Bell UH-1N SuperCobra attack helicopter flies by in front of pinkish cloudy blue skies by Chris Devers

Categories
Clinical Emotion Lifestyle Narrative

A letter from a patient with anorexia nervosa

Dear Doctor,

What I need from you is validation that what I am experiencing is real; recognize this is more than just a burden for me.

At first it was a rush. The best feeling I’d ever had. I was getting compliments, attention, and my jeans felt wonderfully loose.  But it didn’t take long until it became everything; an obsession.  My eating disorder (ED) has become all I think about.  Every second of every day is consumed with what I eat, what I avoid, how I can avoid it, when I will exercise and for how long. I can’t escape.  Even if I actually wanted to gain weight back, it’s not that easy.

I know you might understand, but at least acknowledge that it’s not about the food. The truth is, when you say it’s about the food, it’s more tangible, easier to categorize, like a patient with a broken wrist.  People think that if I “just eat a sandwich” I will be fine, but this is far from accurate.

Sometimes ED hints at me, other times it screams. Either way, ED is a part of my life; it is a part of who I am right now. I have a deep connection to this diagnosis. Because of this, I will defend and validate ED, and conjure any excuse to hold on to this relationship just a little longer. For patients like me, ED becomes another member of the family, the third wheel in a relationship, or even another personality who needs attention.

I still struggle often, but I have good days too.  I am not just another girl with anorexia.  I’m a young woman who never takes life too seriously, loves road trips and playing the piano, and who fights back against anorexia every single day.  I know it’s your mission, but you cannot fix me. Only I can do that and I am going to need your support.

So right now, take a seat on my rollercoaster, listen to me, and let’s get to the end of this ride.

Sincerely,

Your ED patient

 

* Inspired by a loved one

Featured image:
Anorexia. by Mary Lock

 

Categories
General Opinion

You don’t belong here; are you even a real doctor?

Disclaimer: This is written with the sole purpose of increasing awareness.

Rare things are valuable.  They stand out.  They generate intrigue.  However, they can also make people apprehensive.

There is a misconception that naturopathic doctors are quacks who couldn’t get into “real” medical school, and don’t know what they’re talking about. But there is a big difference between naturopaths (online certification) and naturopathic doctors (four years at an accredited institution). At age 23 I had been to nearly 20 different MDs and was ingesting 10 different medications each day until I saw a naturopathic doctor (ND) who turned everything around. Not only did my health change, my career choice did as well.

Naturopathic Medicine is a distinct primary health care profession that combines natural healing techniques with modern science.  It is a whole-person approach tailored to each patient and focuses on finding the root cause of the health issue. NDs are well versed in treating chronic illnesses and emphasize preventative medicine, but can also aid in acute care. By combining natural healing methods with modern scientific principles and technology, naturopathic medicine genuinely embodies modern integrated health care.

There is a time and place for everything. NDs are trained to know when referral or higher intervention is needed. It is time to erase the battle lines because the “us versus them” mindset is not beneficial to patients. Furthermore, MDs and NDs are more similar than it may seem.

We all have the same ability to heal and treat our patients. Although the manner in which we go about treating our patients may be different, we are all trained in basic and clinical sciences, including biochemistry, anatomy, physiology, pharmacology, and even minor surgery. NDs have additional training in nutrition, botanical medicine, and counseling, while MDs have added training in pharmacology and more clerkship hours. Both cohorts complete clinical training and take board examinations in order to become licensed professionals.

We have similar struggles. We sit through hours of classes only to go home and study until we fall asleep. We sacrifice our social lives for our scrubs. We are more up to date on the latest neuroanatomy YouTube videos than we are on episodes of Game of Thrones. We go home at the end of the day smelling like dead bodies and bodily fluids.

But aside from these things, we have the same end goal. We are all detectives, trained to combine history, lab tests, imaging and physical examinations to understand the patient. While NDs typically don’t advocate drugs at the first sign of trouble, we are still trained to prescribe them.

There is an underlying assumption that only pharmaceuticals are “real” medicine, while nutrition, exercise, and lifestyle interventions are “fake” medicine. In actuality, real medicine is whatever works, and the most important aspects of patient care are things that cannot be quantified or measured, but can instead be conveyed and experienced.

Partnerships require a lot of work. Nonetheless, patients need and deserve the services of both MDs and NDs.  Therefore, we should work to understand and respect each other’s profession.  Our skills complement each other and by working together our patients will receive the greatest benefit.

Featured image:
Apple for Health – Apple with Stethoscope by Wellness GM