With the New Year right around the corner, it has given me cause to pause and reflect. For some reason this year, I find myself reflecting more than in past years. Maybe it has something to do with the fact that I am in my 30th year of practice or that changes in medicine and for that matter the rest of the world seem to be occurring so rapidly. Maybe it has to do with the loss of some very dear patients this past year; two of which were over 100. The longer I practice, the harder I find it to compartmentalize these inevitable life/death events.  

 

The Past

It was July 1985, two weeks shy of my 27th

birthday when I started practice in Aurora. For those of you trying to make the math work, I completed college and medical school in six years as part of a relatively new "six-year program" at LSU Medical School in Shreveport, Louisiana.  

I wasn't really sure when I applied for the program at age 17, after graduating valedictorian of my high school class, whether or not I yearned for a career in medicine. Most days I don't regret the decision and, in fact, I feel it has been one of the most personally and professionally rewarding careers I could've hoped for.

 

When I started practice I was pretty much a "traditional" practitioner. I took care of patients in the office and also when they were hospitalized. Back then we didn't have hospital-based physicians. We took care of the patients in the hospital, and the intensive care unit, managing some for weeks at a time on the ventilator. And I would have to break the news to family members when a loved one left us.

When the hospitalist movement started around 1997, I gave up my hospital practice reluctantly as did many of my colleagues who were in the same boat. We were somewhat forced to do so at the time by the HMOs who felt that hospital-based physicians were more cost-effective dealing with patients who were hospitalized. I liken this change to the OB/GYN who at some point in his or her career gives up obstetrics.

Many patients were not happy with the fact I wouldn't be taking care of them in the hospital, but as it turns out the new paradigm makes more sense. I can recall many times having to reschedule an entire afternoon of office patients to tend to someone who was crashing in the ICU. I am reminded of this when I hear a patient grouse today because we're running behind (something I hate to do). They have no idea how often "in the old days" we would have to reschedule entire blocks of patients or alternatively wait for a few hours if I had to drop everything to tend to someone crashing in the hospital.

Looking back, I wonder how I did it. Going into the hospital at 2 AM to admit a critically ill patient and trying to decide when done whether to drive back home or just catch some Z's in the office before starting the new day.

In the "old days" at the commencement of my practice, the financial reimbursement system was much different. The doctor saw a patient, he or she gave them a bill, which they paid at the time of service. Then, they submitted the claim to their insurance company for whatever reimbursement they were due.

A lot of our current problems started when there became a disconnect between the person receiving care (also referred to as the patient) and the person paying for the care (the employer). Nobody really seemed to care how much things cost because "the insurance was paying for it."  Now, with much larger out-of-pocket deductibles and more individual policies and less employer sponsored health care, patients are becoming more in tune with the cost of services they receive and the perceived value or lack thereof. Patients are becoming reconnected with the often times outrageous costs of healthcare.

I was talking to one of our medical students the other day and recapping some of the diseases I can recall which came on the scene during my practice. I admitted and took care of the first HIV patient in South Carolina in 1983. This was about a month after the original article describing this new disease was reported in the medical literature. We had no idea at  the time how the disease was transmitted. We were scared to death. We looked like a hazmat team as we entered the patient's room.

Prior to 1983, we were taught that stomach ulcers were the result of too much stomach acid in people who were under too much stress. Thanks to the discovery in 1983 of the bacterium H. pylori by the Nobel Laureate, Dr. Barry Marshall, we learned that our previous assumptions were false. It wasn't until about 1992 that testing and treating for H. pylori in patients with ulcer disease became standard of care.

I'm hoping it will not take so long for "leaky gut", H. pylori being one of the many causes, to become accepted. As one example, there are scientific publications linking nonalcoholic fatty liver disease (NAFLD), which is on the rise, with increased small intestine mucosal permeability-which is just a more scientific sounding name for leaky gut. I point this out to Dr. colleagues who  feel like leaky gut is a "quack diagnosis".

I am hoping that with today's technology and the Internet, it won't take so long for information regarding new discoveries to become reported and accepted. Example, for those of you who think that gluten-free is a fad-it is not. Some experts predict that within 10 years 30% of the population will be gluten zero, 30% gluten-free and the rest will be eating the same diet they are today.  

The incidence of celiac disease (an autoimmune disorder and the worst form of gluten reaction) has gone up 400% in the past 30 years and this is an indisputable fact I always like to point out to the naysayers. Then, you have the issue of non-celiac gluten sensitivity, a new clinical syndrome described in 2012, of which many practitioners are still unaware.  

Here are some other examples of other relatively new diseases (if you consider the past three decades relatively new). So we mentioned HIV, H. pylori, and non-celiac gluten sensitivity. Let's not forget Lyme disease, Clostridium difficile, Ebola, Hanta virus, SARS virus, community acquired methicillin-resistant Staphylococcus aureus (a "flesh eating" bacteria) and swine flu. Note how many of these are infectious diseases and some experts foresee infectious diseases outpacing heart disease and cancer as leading causes of death in the future. Many infectious diseases were leading causes of death in the pre-antibiotic era.

 

The Future

The number of healthcare practitioners working for hospitals and health systems has increased exponentially over the past 10 years and I see this trend continuing as many private practitioners become overwhelmed with the burdensome business aspects of running a medical practice. The solo physician practice is going the way of the local hardware store or neighborhood pharmacy.

For those of you worrying that I might be going down that same path, I have no immediate or future plans to do so. I feel fortunate, in that I have recently entered into a relationship with a management company that will allow me to spend more time focusing on the clinical care of patients. The old days of "an office manager" who possessed all of the skills required to run a small practice is not realistic in today's complicated world of medical practice. In much the same way, there needs to be a team approach to patient care. This is why we have skilled medical assistants, nutritionists, nurse practitioners and physician assistants on staff.

I am often asked how "Obamacare" (a.k.a. the affordable care act) has affected the practice. I can't say that I have really noticed any significant changes other than the fact that many patients who didn't have healthcare previously now do and this has put a larger burden on the shrinking ranks of primary care practitioners such as myself. There needs to be a push to encourage medical students to go into primary care (pediatrics, internal medicine, family practice).

The other big change is the reconnection I mentioned earlier in terms of those who are receiving and paying for healthcare-the patient. Patients are and should be paying attention. Unfortunately, in our practice we have seen a rise in uncollected payments for services, coincident with the increased out-of-pocket responsibility for our patients.

On a positive note, I see a rising trend toward a more functional/integrative approach to patient care. The Cleveland Clinic recently entered into a relationship with Dr. Mark Hyman, who founded the Institute for Functional Medicine. Many other large and prestigious medical institutions are also creating functional medicine departments.  

I am often asked how I became interested in functional medicine and it really wasn't a single, seminal event. I did attend a three-day functional medicine meeting in Houston several years ago and came home realizing that I needed to practice more "why" medicine and less "what" medicine. In other words, why does this patient have this particular set of symptoms and not necessarily what is the diagnosis defined by the set of symptoms.

We need to get away from the disease-drug model and begin to look for the root cause of the problem and use natural treatments whenever possible. As an example, probiotics are very effective for helping many digestive disorders and certain types of magnesium are very effective for lowering blood pressure and treating constipation etc. etc.

At its essence, functional medicine is about removing what's making you sick and replacing anything in which you are deficient. Eating the right macronutrients (fats, protein and carbohydrate), eliminating anti-nutrients from the diet (gluten, junk food, GMO's), and making certain you get adequate micronutrients (vitamins, minerals). Look at the whole patient from a mental, physical and spiritual perspective. Engage the patient so that they may become an informed participant in the pursuit of their own health and well-being.   

 

Wishing you all optimal health in 2015!