How is your practice doing?
Is it everything that you dreamed of and imagined it could be?
Are you booked 4–6 weeks in advance?
Are your employees all superb at what they do?
Are you providing your patients with the ultimate customer service?
If you are like me, and I suspect that many of you are, your practice is a work in evolution.
Some of the time you’re pissed off and thinking that you’d be better off if you fired everyone and started over again. There are some among us that literally go through employees on a weekly basis. Alternatively, you may think that things are going along pretty well and you’re reasonably satisfied with the course that you are persuing.
Do you enjoy what you do and look forward to seeing patients in you practice every day? Are there aspects of patient care that you would change or hope to get away from? For me, this would be getting rid of the drug seeking narcotized patients.
Do you look forward to walking into your practice every day or do you run into your office, shut the door and turn on the computer? Are there staff members that suck your will to live, bringing you and everyone else down? Why haven’t you fired them? Aren’t they sabotaging your efforts with their negativism?
I certainly don’t have all the answers. Like many of you, I am quick to hire and slow to fire (which is just the opposite of the way it should be).
Are you risk adverse? It’s hard to grow a practice if you are afraid to take risks. This may mean temporary sacrifices and inconvenience, but potentially long term benefits. As Kenny Rogers would say, "You have to know when to hold them and know when to fold them".
Is your practice efficient? Theoretically, in the best of all worlds, you would be treating patients and doing nothing else. Time spent filling out scripts, forms and dictating may be necessary evils, but they take you away from your ultimate purpose and could be kept to a minimum.
Have you enlisted outside help in the form of consultants to come in and make suggestions on improving your practice? There are many different types of consultants out there and their approaches can be quite diverse. Often, benefits can be garnered no matter what the consultant’s perspective.
Are there colleagues that you should be courting, meetings that should be arranged and talks that should be given? What’s stopping you? Are you getting in your own way?
Do you have a vision for your practice and both short and long term goals which are not necessarily financial? Consider making them and putting them to paper. It’s surprising what can happen when you make this tangible.
Finally, and I mean finally, do you accept mediocrity or do you constantly strive for excellence? This is applicable for your patient care, your employees and how your office functions. Be honest about what kind of grade you would give your office staff, your physical plant, and your efforts at marketing, educating your colleagues, patients and potential patients. If it’s not an A, invest the time and figure out how it can be changed.
There are many great business books out there; most of which I have not read, but a few I have read. I really enjoyed reading Good to Great by James C. Collins which explains who should be on the bus and why. A book entitled, The Dip, by Seth Godin has had particular relevance to the evolution of my practice within the last year as we have transitioned from predominantly intervention pain to more of a regenerative/restorative practice.
Good luck to you all! It is a strange and wonderful journey.
Life does not always get better just because you are the boss!
The Australian Taxation Office suspected a fishing boat owner wasn't paying proper wages to his deckhand and sent an agent to investigate him.
ATO AUDITOR: "I need a list of your employees and how much you pay them".
Boat Owner: "Well, there's Clarence, my deckhand, he's been with me for 3 years. I pay him $1,000 a week plus free room and board. Then there's the mentally challenged guy. He works about 18 hours every day and does about 90% of the work around here. He makes about $10 per week, pays his own room and board, and I buy him a bottle of Bundaberg rum and a dozen Crown Lagers every Saturday night so he can cope with life. He also gets to sleep with my wife occasionally".
ATO AUDITOR: "That's the guy I want to talk to – the mentally challenged one".
Boat Owner: "That'll be me. What'd you want to know"?
Most everyone has heard the expression, "An apple a day keeps the doctor away". The country of origin of this phrase is said to be Wales as the earliest known example of its use in print was the February 1866 edition of Notes and Queries magazine. The original version was written, "Eat an apple on going to bed, and you’ll keep the doctor from earning his bread".
A new study, recently published by researchers from the British Heart Foundation Health Promotion Research Group at Oxford University, showed that an apple a day may keep the doctor away by preventing thousands of strokes and heart attacks. They even found that apples may prevent about as many vascular deaths as statins, particularly when you factor in the cases of diabetes that may be induced by the statin medications and the resulting myocardial infarctions and strokes.
In the United Kingdom 5.2 million people currently take statins. Here in the United States, the American College of Cardiology and the American Heart Association recently issued controversial new guidelines addressing statin use that would increase the number of people who would meet the guidelines from 15% of adults to 44% of men and 22% of women.
Researchers at Oxford used data modeling tools to look at the most common causes of heart attacks and strokes for adults over 50. Using this data, they calculated the decrease in death rate if doctors prescribed a statin to those not already taking one. The researchers estimated that 17.6 million more people in the country would be prescribed a statin. Using a 70 percent compliance rate, they figured an additional 9400 deaths would be avoided. They then estimated the number of vascular deaths that would be prevented by the prescribed eating of an apple a day. If 22 million people, which is about 70% of the UK population, began eating one apple a day researchers estimated that 8500 vascular deaths could be prevented. The research group was surprised to discover that an apple a day had a similar effect as a statin on the population. However, because the side effects from statins could lead to thousands of cases of muscular myopathy and more than 12,000 cases of diabetes, when compared researchers stated "the apple may be a better choice". The study was published in the Christmas edition of the British Medical Journal.(1)
Thomas Shea PhD, of the Center for Cellular Neurobiology at the University of Massachusetts, has been studying the effects of apples on brain health and memory for many years. In a recent study on mice results suggests drinking two glasses of apple juice each day may help to prevent the development of amyloid plaques, commonly found in those who suffer from Alzheimer’s disease. Mice receiving the equivalent of two glasses of apple juice daily produced less beta amyloids. His study found that apple juice can push production of the memory chemical acetylcholine. "That is the way the popular drug Aricept works," Dr. Shea stated.(2) Previous studies have shown that increasing the amount of acetylcholine in the brain can slow the mental decline found in people with Alzheimer's disease.
R. Rui Hai Liu, an associate professor of Food Science at Cornell University, heads a team of researchers who extensively study apples. In 2009 the team published 6 studies that highlight the role of phytochemicals, known as phenolics or flavonoids, which are prolific in apples. The team also discovered a variety of new phenolic compounds that also have "potent antioxidant and anti– proliferative activities" on tumors. Their studies showed that fresh apple extracts significantly inhibited the size of mammary tumors in rats. Liu stated, "We not only observed that the treated animals had fewer tumors, but the tumors were smaller, less malignant and grew more slowly. Another study, published in the Journal of Food Science, found evidence that apples help "protect neuron cells against oxidative stress–induced neurotoxicity."(3)
A Finnish study, published in the European Journal of Clinical Nutrition, showed that eating apples, which are high in quercetin, can reduce the risk for thrombotic stroke.(4)
A Florida State University study found that apples are a "miracle fruit" lowering the LDL cholesterol of older women by 23% and raising HDL by 4% in just six months.(5) Another large study revealed that apples could help lower your risk of diabetes.
While eating a Fuji apple and researching the current scientific literature evidencing the many health benefits of consuming apples, I came across far too many studies to list. (I have eaten two apples already today!)
Over 2500 years ago Hippocrates, known as the father of medicine, knew that food can act as medicine. He stated "Let your food be your medicine and your medicine be your food". And today studies are showing this to be true over and over again. Food can act as medicine and the apple is truly a superfood.
Legislative and FDA update on stem cell and cellular medicine therapy. A update from Chris Centeno, MD about the use of a person’s own stem cells being classed as a drug.
You may or may not have seen that on Monday the DC Federal Circuit decided in favor of FDA in our landmark lawsuit challenging that our patient’s own cells could be classified as drugs. While we may ask for clarification of a few points, we won’t appeal to the Supreme Court at this point. This long battle has taken 5 1/2 years. On the plus side, since we haven't cultured stem cells for clinical use in our Colorado practice since 2010, not much changes for us.
As many of you know, while we were challenging the regulations that made cultured stem cells drugs, we never stopped treating patients and innovating with the same day stem cell procedures that the US allows. We will continue to perform these procedures in Colorado and continue our research so that our cultured technology can continue to be licensed into countries that permit it as the practice of medicine. For example, we just published on–line the results of our now 1,500 patients and counting who were treated with the allowed stem cell procedures and we’re seeing remarkable results in many body areas. We will submit two more scientific publications this month, one a case series of patients with full thickness ACL tears healed through same day stem cell injection and the other an n=1104 treatment registry report of knee and hip OA patients treated without culture. We also have four Randomized Controlled Trials that we’re funding and that are recruiting now. Our practice remains healthy and our ability to discover new therapies for our patients has never been stronger. As many of you know, our team and others is involved in birthing a new medical specialty, one that will see many existing surgical treatments for orthopedic problems morph to the non–surgical.
In summary, this battle has certainly taught me that fighting city hall is tough–the deck is definitely stacked very heavily in their favor. Having said that, my family, friends, and others have been great throughout. I’d like to throw out special thanks to the Manhattan Institute, AAOM, and AMMG who threw their hat in the ring. In addition, I’d like to thank the group Patients for Stem Cells as they have been a tireless supporter of my efforts.
Integrative Medicine is playing an enormous role in the correction of Medicine. As such, the status quo "incumbents" are not surprisingly rejecting the concept. In fact, they may literally be instituting a "War on Integrative Medicine" for which 3 links are provided over viewing these efforts to derail the "disruptive" innovations of Integrative Medicine.
Harvard Business School, Boston, USA.
It's no secret that health care delivery is convoluted, expensive, and often deeply dissatisfying to consumers. But what is less obvious is that a way out of this crisis exists. Simpler alternatives to expensive care are already here–everything from $5 eyeglasses that people can use to correct their own vision to angioplasty instead of open&ndahs;heart surgery. Just as the PC replaced the mainframe and the telephone replaced the telegraph operator, disruptive innovations are changing the landscape of health care. Nurse practitioners, general practitioners, and even patients can do things in less–expensive, decentralized settings that could once be performed only by expensive specialists in centralized, inconvenient locations. But established institutions–teaching hospitals, medical schools, insurance companies, and managed care facilities–are fighting these innovations tooth and nail. Instead of embracing change, they're turning the thumbscrews on their old processes–laying off workers, delaying payments, merging, and adding layers of overhead workers. Not only is this at the root of consumer dissatisfaction with the present system, it sows the seeds of its own destruction. The history of disruptive innovations tells us that incumbent institutions will be replaced with ones whose business models are appropriate to the new technologies and markets. Instead of working to preserve the existing systems, regulators, physicians, and pharmaceutical companies need to ask how they can enable more disruptive innovations to emerge. If the natural process of disruption is allowed to proceed, the result will be higher quality, lower cost, more convenient health care for everyone.
Don't Forget About Prolotherapy
An overview of the most up to date list of the world literature on Prolotherapy.
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Highly Paid Medical Specialties Sometimes Leave Patients With
Big Bills, Many Questions.
In a 3,700–word installment of its series "Paying Till It Hurts," the New York Times (1/19, A1, Rosenthal, Subscription Publication), on its front page, examines how much money some medical specialists are making and how some patients end up incurring high fees when they believe less–expensive rocedures would do. The Times follows the medical treatment of a history professor in Arkansas who underwent Mohs surgery to remove a small basal cell carcinoma near her eye, generating bills in excess of $25,000 in "a daylong medical odyssey."
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Opening the FDA Black Box
Steven N. Goodman, MD, MHS, PhD1; Rita F. Redberg, MD, MSc2
JAMA. 2014;311(4):361-363. doi:10.1001/jama.2013.283946.
The US Food and Drug Administration (FDA) is sometimes described as the most powerful regulatory agency in the world, its decisions affecting billions of both lives and dollars. The agency has this distinction not just because of its legislative mandate or governmental role but in part because of its reputation.1 This reputation has been shaped by how it makes its decisions, by its "conceptual power" in the language and methodologic standards it uses for drug and device approval, and by its ability to gain legitimacy among multiple audiences via a combination of scientific rigor and flexibility.1
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Study: FDA’s medicine approval process lacks uniformity.
The Washington Post (1/22, Dennis) reports the FDA’s certifications of medicines being "safe and effective" are based on widely varied data, citing an analysis by researchers at Yale University’s School of Medicine. Nicholas Downing, the lead author of the study, "which examined nearly 200 new drug approvals between 2005 and 2012," said, "Not all FDA approvals are created equally." For instance, the study says, the FDA required that many new medicines "prove themselves in large, high–quality clinical trials," however, about a third received approval based on one clinical trial, while "many other trials involved small groups of patients and shorter durations."
The Wall Street Journal (1/22, Loftus, Subscription Publication) provides a response from the FDA, which said it set specific requirements for each individual medicine but applies the same standards in giving the green signal for safety and efficacy of all medicines. The Federal agency also said it has set higher standards for approval of major modifications to some implantable cardiovascular devices over the past few years, including new studies aimed at finding any problems with devices.Modern Healthcare (1/21, Rice, Subscription Publication) notes the authors said "the purpose of the study" was "not to suggest that the FDA is not rigorous in its approach to drug reviews." One of the authors, Dr. Joseph Ross, assistant professor of general internal medicine at Yale University School of Medicine, said "the regulatory flexibility allows for a customized approach, and the agency can rapidly approve potentially effective therapies for life–threatening diseases." Bloomberg News (1/21, Edney), Forbes (1/21), New Haven (CT) Register (1/21), Medscape (1/22) and AFP (1/22) also cover the study.
Scientific and Regulatory Reasons for Delay and Denial of FDA
Approval of Initial Applications for New Drugs, 2000–2012
Leonard V. Sacks, MBBCh1; Hala H. Shamsuddin, MD2; Yuliya I. Yasinskaya, MD2; Khaled Bouri, PhD, MPH3; Michael L. Lanthier, BA4; Rachel E. Sherman, MD, MPH1
Original Investigation|January 22/29, 2014
JAMA. 2014;311(4):378-384. doi:10.1001/jama.2013.282542.
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Importance: Some new drug applications fail because of inadequate drug performance and others are not approved because the information submitted to the US Food and Drug Administration (FDA) is unsatisfactory to make that determination. Resubmission of failed applications is costly, delaying marketing approval and the availability of new drugs to patients.
Objective: To identify the reasons that FDA marketing approval for new drugs was delayed or denied. Design, Setting, and Participants: A retrospective review of FDA documents and extraction of data were performed. We examined all drug applications first submitted to the FDA between 2000 and 2012 for new molecular entities (NMEs), which are active ingredients never before marketed in the United States in any form. Using FDA correspondence and reviews, we investigated the reasons NMEs failed to obtain FDA approval.
Main Outcomes and Measures: Reasons for delayed FDA approval or nonapproval of NME applications.
Results: Of the 302 identified NME applications, 151 (50%) were approved when first submitted and 222 (73.5%) were ultimately approved. Seventy–one applications required 1 or more resubmissions before approval, with a median delay to approval of 435 days following the first unsuccessful submission. Of the unsuccessful first–time applications, 24 (15.9%) included uncertainties related to dose selection, 20 (13.2%) choice of study end points that failed to adequately reflect a clinically meaningful effect, 20 (13.2%) inconsistent results when different end points were tested, 17 (11.3%) inconsistent results when different trials or study sites were compared, and 20 (13.2%) poor efficacy when compared with the standard of care. The frequency of safety deficiencies was similar among never–approved drugs compared with those with delayed approval (43 of 80 never approved [53.8%] vs 37 of 71 eventually approved [52.1%]; difference, 1.7% [95% CI, –14.86% to 18.05%]; P = .87). However, efficacy deficiencies were significantly more frequent among the never–approved drugs than among those with delayed approvals (61 of 80 never approved [76.3%] vs 28 of 71 eventually approved [39.4%]; difference, 36.9% [95% CI, 20.25% to 50.86%]; P .001).
Conclusions and Relevance: Several potentially preventable deficiencies, including failure to select optimal drug doses and suitable study end points, accounted for significant delays in the approval of new drugs. Understanding the reasons for previous failures is helpful to improve the efficiency of clinical development for new drugs.
Study: Lack of Gray Matter May Make People Perceive Pain More Intensely.
HealthDay (1/21) reports a recent Wake Forest Baptist Medical Center study indicates people’s brains may determine their level of sensitivity to pain, finding that "people with less gray matter in certain areas of the brain perceive pain more intensely." For the study, investigators "asked the" 116 "participants to rate the intensity of pain when a small area of skin on their arm or leg was heated to 120 degrees Fahrenheit." Following "this pain test, the participants underwent MRI scans to examine their brain structure." The researchers hope the findings will lead to improved pain diagnosis and treatment.
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I just underwent the humbling, ego–piercing, impersonalizing experience that is foreign travel. No matter whom we think we are, we immediately become equals in the eyes of the TSA. The AAOM mission to Mexico (Feb. 2014) provided a much–needed education and exchange of information and, as importantly, a refocusing of reality, both professionally and personally.
The task of rearranging our unnecessarily complex work schedules began months ago. We probably didn’t realize why we were compelled to "go to all that trouble" until the moment we walked through the outdoor patient waiting area into that clinic in Mexico that sweltering Sunday morning. I saw simultaneously both desperation and acquiescence in the eyes of a subset of that nation’s population, as they sat awaiting our return to provide them care that, otherwise, is unavailable to them. As the week went on, after we had treated each of God’s children, I saw not only appreciation in their eyes, but also a glimmer of hope.
Please tangent–hop with me for a moment. Is it possible that hope is a paradoxical emotion when posited in the wrong circumstances? In a recent movie, Batman’s nemesis, Bane, breaks Batman’s spine during their initial encounter, then throws him in a dungeon. The dungeon has a chimney through which sunshine is visible. Legend has it that long ago one prisoner had actually escaped through it. Batman asks Bane, "Why don’t you just kill me?"
Bane responds, "Your punishment must be more severe." Bane believes that if he kills Batman, or imprisons him with no hope of escape, the punishment is lighter than being held at bay, with a potential escape route just out of reach. In Mexico, I began to wonder if we might be giving hope to people who had previously managed and coped just fine without it.
At the end of that week–long odyssey, as the plane returned me to a world I’ll never again see in the same way, I stared out the window, as Mexico and a thousand grateful faces faded into the distance. I felt the souls of others intermingling with mine.
The blur, din, and distortion of my life from a week ago were evaporating. Everything was becoming clear, especially that glimmer of hope I’d been given from an unlikely source. As in the saying "less is more," one doesn’t have to be a lighthouse; it’s enough at times to just be a candle. The feeling we shared in that emotion–laden clinic was powerful medicine indeed, and the lessons learned will spread far beyond their source.
The workshop came off without a hitch, stitch, or inappropriate needle stick. The visiting professors and physicians learned injection techniques from the AAOM instructors, and much more. As importantly, they learned something about the character and interpersonal skills they will need going forward. These courageous physicians will return to their homes, where they will commit daily acts of courage, as they institute our shared mission.
Toward the end of the week, the "Wizard of Pez" (Dr. Lenny Horwitz, our foot and ankle specialist) delivered an important and timely lecture to the visiting physicians. When confronted with an arduous, imperative task, we all need a little encouragement.
The skills of the Instructors surpassed the experience of most of the visiting physicians. Thus, a pep talk was in order to head off potential discouragement. You could have heard a pin drop when the Wizard proclaimed to the visiting physicians, "You are all geniuses–at least your mothers thought you were!" He encouraged them not to let the enormity of regenerative injection therapy (RIT) overwhelm them. He reassured them that we all develop these skills at our own speed and should introduce RIT into our practices over time, based on the advancement of our skill sets.Three key personality traits have been identified that are shared by most successful people:
As the Wizard astutely pointed out, all the brave souls who ventured to Mexico to learn about this profession–shaking paradigm shift were all exceptional individuals. But, despite their outstanding credentials in their various specialties, they all must have felt a little insecure when confronted with the enormity of the task of learning the relatively new specialty of regenerative injection therapy.
Who among us has not felt insecure in our pursuit of regenerative and cellular medicine in the face of dissenting family and "colleagues," skeptical medical societies, and mischievous government agencies? When I started my journey down this path less taken, my technical skills far surpassed my clinical skills. So for me, the technical aspects of injection therapy were not as challenging as learning to perform the all–important clinical and physical examinations.
Another tangent–hop por favor, regarding trait numero dos, insecurity. Long ago, a younger version of me thought golf would make a good future. My father was a poor farmer when he was growing up, so I was probably thinking that I too could dig around in the dirt, but that, as a golfer, it might be more lucrative. Very early in that endeavor, I’d stand on the driving range and pound shots into a warm breeze for hours, feeling secure with my budding life decision. Sam, my mentor (and member of the Arkansas Golf Hall of Fame) brought me down to earth, pointing out that to become proficient at something, we have to practice the things we’re not good at.
For me that was the short game. I began to spend 80% of my time on my weaknesses, chipping and putting, and only 20% blasting drives and hitting seven irons off of perfect lies. This new approach was not particularly heartening; in fact, it made me quite insecure about my skills. But the way we learn best is by failing and studying our failures. Hard work in the hot sun paid off finally, and I was able to play golf all the way through college. However, I soon encountered others who’d practiced longer and harder than I, forcing me to alter my life course and revert to my plan B (Medicine).
When I joined AAOM, I realized my weaknesses. As an Intervention Radiologist, I was familiar with imaging guidance and needle placement. But Clinical Assessment and Physical Exam are as important as injection skills, if not more so. To make matters less secure for me, it became glaringly apparent that my cherished radiology "images" were not truly representative of the "patient." So when I ventured to Mexico on a regenerative injection therapy mission, I was not ashamed to admit to being a neophyte at physical exam, and I spent most of my time working on my weakness.
Radiology images have their place, but astute Physical Examination teaches us that without the correct diagnosis, we can’t administer the correct therapy. Am I a little insecure on these missions? Darned right I am. But isn’t this the best way to improve as a physician and a person? Darned right it is. I acknowledged long ago that to realize my potential, I have to practice the things at which I am least proficient.
My voyage ended with a lost piece of luggage. But I was spared the usual irritation of this experience. I wondered how one of my Hispanic patients would have felt. I flashed back to a night years ago, when my daughter was about to leave for college. She called me, with quiet tears in her voice. "Dad," she said, "I’m standing here looking at my whole life in two suitcases. And I just know that when I leave for school tomorrow, I’ll never feel the same way about home again." How could I be upset about temporarily being separated from a piece of luggage?
As for delayed gratification, most AAOM members realize at some point that something is missing in their Allopathic medicine careers. Although it’s a difficult paradigm shift, I believe we all come to understand that practicing medicine is not about acquisition of legal tender. We learn the importance of delaying materialistic and monetary reward and of building self worth along the way. We set out to right wrongs and do the right thing whenever and wherever necessary.
The "greed ethic" will stop only when AAOM and similar organizations take the position in Medicine that "the buck stops here." The host countries for our RIT Courses are often impoverished and struggling with fractured economies. Maybe we see ourselves in these people, and by doing what we can to help them, we are actually helping ourselves and our people. A great majority of the world's people are locked in poverty.
Could it be possible that the poor hold the key to surprising and considerable wealth, which if recognized, legally formalized and cultivated, could help the bottom billion overcome the plague of poverty? In our travels, we are learning that the developing world's underground, "informal" economies can be harnessed to benefit the world's poor. If we continue to make connections with those now small voices, they will soon become a thunderous chorus of hope; not just a glimmer.
PLEASE NOTE: Many of the Pre–Conference Workshops are close to Sold–Out so don’t hesitate to register now
Sports, Spine and Beyond – Latest Advances in Regenerative
Clearwater, Florida April 9–12, 2014
The AAOM annual meeting is not just the same–old topics that you can hear at every other medical conference. If you want "out of the box, cutting edge" thinking and information, come to the AAOM – you will not find this type of program and the camaraderie to share ideas anyplace else.
The field of Orthopedic Medicine is exploding! Though this explosion is quite positive for our burgeoning field, it is important to be able to navigate around the technological advances, to avoid the pitfalls and be able to get what you need to enhance your patients and your practice. To that end, I've worked to combine topics from the not so traditional Interventional Pain Medicine, Sports Medicine and Regenerative Orthopedic Medicine. We will also explore advances in Manual Medicine, Nutrition, Physical Examination and Physical Therapy. We will have several workshops that include Musculoskeletal Ultrasound, Stem Cell Extraction from Adipose, Prolotherapy 101 – A Primer, Bioidentical Hormone Replacement Therapy, to name a few. The goal of this conference is to bring you state of the art techniques and technologies that can help our patients now.