Part IV_Jeffrey Bland_Town Hall Seattle_6_2_2008

Through our different docs, through the functional medicine model. So I want us to share something that I thought this weekend when we were meeting with some doctors might be useful to share with you. So these are some personal histories of people who are all being managed in midlife with proper medicine. And again, I want to emphasize I'm not a medical critic. I'm just trying to talk about what tools to use. If everything you have. I'll say it another way, if all you have is a hammer, then everything is a nail, right? So what you want is more tools in your toolkit. So if you want to do watch repair, you probably don't want to do it with a hammer. If you want to do very heavy work, you might want to use a hammer. So what are the right tools for the right application? So let me give you just a little kind of summary of some. So what do these guys do? These are all people on medication. They're all getting the right therapy based on their diagnosis, but the trajectory they were heading on was still the slow slipping, slippery slope. What happens is they start looking at their function with some good counsel, some people who know what they're talking about, and people sit down and talk with them, which is a kind of a rare experience often in our healthcare system that's compressed in the six minute office visit, as you probably heard from John Graufman's book, How Doctors Think. He's a Harvard medical professor and he came to the conclusion after doing some studies that were done and doctors that because of the time compression they have in their practice, often they come up with their diagnosis within the first 18 seconds in the visit with the patient, which generally leads to the power of the prescription pad. I call that communication interruptus. Because in the past we have felt as long as we got a prescription, we genia flecked to the east, that we were getting the appropriate transaction and we would go and there would be some magic event that would occur that would rescue us from whatever malady that we had experienced taking us to that practitioner's office. And what we're now starting to recognize as a culture is that we may have less symptoms when we fill that prescription and take it, but it may be that the trajectory of that dysfunction is still continuing because maybe what we did is uncouple the smoke detector rather than really deal with the fire, because maybe the fire is related to something that's deeply rooted in physiological dysfunction that just taking the battery out of the smoke detector didn't fix. So this whole model that these four people are describing is a very simple, tried and proven model. And it's a model where you sit down and you talk about your life. In functional medicine, we have what we call the differential assessment model. We start with antecedents in the patient. Antecedents are the history and the physical information and the genetic history and your personal health history. And you listen carefully to little triggers as a skilled practitioner to what the clues are in this Sherlock Holmes novel. It's that person's life about things that may have been mitigating factors or things that were precedence to their onset of their complaint. Then you next look after antecedents, you look at triggers. Were there triggering events? Was it a traffic accident? Was it a high stress environment? Was it they got exposed to pesticides? Did they have an infection traveling to India? Was there a triggering event that worked on their antecedents to create? Then what? Through the triggers, the mediators, the mediators that shift the web of physiology over into a new state. And that new state is the state that they reported. Because that new state with those mediators produces the signs and symptoms of different duration, frequency and intensity of dysfunction, not disease. Disease is a tiny place to put this, but we all know that every diabetic is different one from the other. Every heart disease patient is different one from the other. So because we can call a person by a name of a disease doesn't mean we understand the origin or the pathophysiology of that disorder. So maybe it's understanding the history of that dysfunction that leads us into understanding its origin. So we treat the cause, not its effect. Now, if you think that I'm waxing too philosophically here, let me, if I can go back and just show you something that's, that's happened in the literature recently that I think is quite dramatic. So as I said, life expectancy is suggested to be shorter for our children than that of ours. This is on average, which is kind of discouraging in the face of all this wonderful, heroic medicine that we have available today. And by the way, I don't want to leave any impression that I am not absolutely supportive of the job that our health providers are doing in our culture today. This is a hard job. It's a hard job to be in managed care and be compressed into seeing 40 patients a day. It's a hard job to know that you're always behind, you have a waiting room filled with people all who want their questions answered and they want them answered quickly and they want complete remediation of their ills, even though the Ills may have come on for decades. They want them fixed tomorrow. These are difficult challenges. I recognize that. But something is going on underneath the surface to create these changing prevalence patterns with regard to disease. So that leads me then to James Wright, cardiologist, head of the pharmacology department of the University of British Columbia in Canada. And Dr. Wright, who is anything but a heretic, very responsible investigator, medical school professor, also a cardiologist in clinical practice. His PhD is in pharmacology, his MD is in cardiology. He decides because one of his jobs is he's the chairman of the board in Canada, being a socialized medical system that selects what drugs are going to be allowed on formulary to be reimbursed for the treatment of certain conditions. So he is in a position at a committee of very high importance. So he and his colleague, who's a cardiologist at Harvard Medical School, made the decision that what they wanted to do was go back and reread all of the studies that have been published, the large randomized clinical control trials on statins. Statins, as you probably know, the biggest single pharmacological agents used for preventive medicine. It made cardiology into a preventive medical discipline when statins were developed. Now, if you think of your blood screen, those of you who are not necessarily students of medicine, you get your blood analyzed, you get a whole bunch of numbers from your blood. Analyze most of those numbers the physician uses to see whether you have a disease. Like if your liver enzyme numbers are elevated, they would say you might have hepatitis or you might have cirrhosis, or if your levels of glucose were elevated, they might say you have blood sugar problems associated with diabetes. But there's one number on your blood screen that has nothing to do with any specific disease. It's not a diagnosis to any disease. That's cholesterol. Cholesterol is not a diagnosis for any disease. When it's elevated, it's a prognostic marker for the risk to a disease. Right. Would you agree with me on that? So we say elevated cholesterol a certain associates itself as a surrogate marker with the major cause of illness in our culture, which is heart disease. Now, with that in mind, what Wright and his colleague did is go back and evaluate the eight large randomized clinical control trials on the use of statin drugs to lower cholesterol in primary prevention. Now, what do I mean by primary prevention? I mean for people that are asymptomatic that go into their doctor's office for their routine health evaluation, they have their blood drawn, they have their cholesterol analyzed, and it comes back a high number. So the doc says you are at risk to heart disease or stroke. Therefore, we need to lower your cholesterol. And the agent of choice is a statin. And there are many variations on the theme of statins. So we use those drugs in primary prevention. Now, in the year 2001, you probably know the statin. Let me say it the other way. The cholesterol guidelines for the use of statins was modified. It went from a level of cholesterol in your blood that was above 220 for use of statins to a number that was lower to 200. Now, when that happened, as this data says, that suddenly, because of lowering it from 220 to 200, the number of people that were candidates to be on statins went from 13 million to 36 million US residents. Now that, if you're in the market of selling statins is a really good news right this. Now, the question that Dr. Wright wanted to know is what is the benefit of those statins? Because we know there is some adverse side effect from statins, limited as they are. We get myopathies. In the extreme case, you get what's called randomolysis, which is where your muscles actually undergo very severe breakdown. But a lot of people get these, what are called zips and zaps, these little pains in their muscles and so forth associated with statins. So if you could avoid status, it would be disarmed. Right. But we've used them as a primary prevention tool. Now, the question that one asks is in the eight randomized clinical controlled trials, which sum together to constitute hundreds of millions of dollars of clinical research, the most studied drugs in our present culture, what are the outcomes?