What about gluten?

What is gluten? It’s hard to read nutritional information online or packages in a food store without thinking that gluten is another word for “arsenic.” Avoiding gluten is the newest big food fad, with some claiming that such a diet can cure autism or allergies or asthma or any of a wide variety of conditions. Is gluten something you should avoid? What is it, what’s it used for, and what’s it doing to us?

Someone has probably written a book about the history of bread and its importance to human culture (if not, I’m on it). Long before Superman lunchboxes and Wonderbread, bread made out of crushed corn or plant roots made it possible for people to carry their nourishment with them for long trips. But these early breads were crumbly and fell apart easily and likely tasted like packing peanuts.

Once we evolved to Farmer-man, we figured out that cultivated grains, like wheat, were much better out of the oven. These grains contain the protein gluten, which is a long, tough molecule that gives modern bread dough its bounciness and elasticity. These loaves didn’t fall apart, and could be transported great distances. It’s not a stretch the say that gluten, like salt or cod or gummy bears, played a vital role in the very development of our culture.

These days gluten is used in many other foods as well. It’s useful as a protein supplement, and as an all-natural way to add sponginess to foods. Products like ketchup and ice cream are commonly thickened with gluten. Almost all imitation meats and cheeses prized by vegetarians are based on wheat gluten. And gluten is not just limited to food. Its a key ingredient in some of the new bio-plastic materials as an alternative to petrochemicals, and is commonly used in cosmetics such as lipstick to add firmness or body.

But for mysterious reasons, there’s been a growing trend in recent years to view gluten in a negative light. It is true that a small number of people are born with gluten sensitivities that reduce their ability to tolerate it to varying degrees. Perhaps the thought is that if some people can’t tolerate it, it therefore must be generally bad for everyone? As a result, some promoters of fad diets and various health schemes are now advocating gluten free diets, and shady characters and certain food manufacturers are cashing in.

Gluten free diets actually are necessary for some people, and advisable for others. These situations are quite rare, but they are real. The first is celiac disease (CD), or gluten-sensitive enteropathy. This is an autoimmune disease of the small intestine that occurs in people with a genetic predisposition. It’s not caused by gluten and you can’t develop it by eating gluten, but if you’re one of the unlucky few born with the gene, and you go on to develop CD, eating gluten will cause an adverse reaction. The immune system inside the bowel tissue reacts to the gluten proteins, causing inflammation of the bowel tissue, and this interferes with your body’s ability to absorb nutrients from food. There’s no cure for CD, and the only way to live with it is to adopt a gluten free diet for the rest of your life. Somewhere between 1 and 8 in 1,000 Americans have this, give or take (the exact frequency is not well known).

A wheat allergy is very different, and can be harder to track down since there are many different components of wheats and other grains that it’s possible to be allergic to. A wheat allergy is not a single condition; it is any of a great number of possible allergies. The symptoms are similar to what we expect from most allergies: hay fever type symptoms, hives, asthma, and swelling. More serious effects in the worst cases can include anaphylaxis, palpitations, swollen throat, diarrhea, and even arthritis. Unlike CD patients, sufferers of wheat allergies need not necessarily avoid all wheat products. The allergy is usually pretty specific and only some foods may need to be avoided. Standard allergy treatment with drugs such as antihistamines may prove effective enough to allow the patient to live with a normal diet. You need not eat wheat to have an allergic reaction; some may react by simply coming in contact with wheat. It’s very difficult to attach a number to how many people have some level of allergy to some type of wheat related protein, but it’s probably somewhere in the single digit percentage points.

There’s also a third type of gluten sensitivity, and that’s gluten sensitive idiopathic neuropathy. Idiopathic means the exact cause is not known, and a neuropathy is a disease of the nerves. Symptoms can include numbness or tingling in the extremities, or problems with muscular coordination often evidenced when walking, or even spasticity resembling epilepsy. Diagnosing this neuropathy is difficult. The blood test frequently produces false positives. And sometimes, sufferers may actually have a mild case of celiac disease instead. The number of people with a gluten sensitivity neuropathy is not well-known, but it’s very small.

That’s it for the poor souls that need to or may want to avoid gluten. But some people would have us believe that many more of us should avoid it. Of course, these people are generally the people who sell gluten-free products. For example, GlutenFree.com claims their products help people with autism or ADHD, which is completely untrue according to all the science we have. The autism claim in particular is broadly repeated across the autism activist community. The treatment of autism with a gluten free diet has been studied a number of times with varying results, but so far no well designed studies have shown any plausible benefit. A 2006 double blinded study published in the Journal of Autism and Developmental Disorders tested children with and without autism, on gluten-free and placebo controlled diets, and found no significant differences in any group.

In addition to those that seek profit from the fad, many well-intentioned naturopaths routinely list gluten as a potential cause of disease. This is a bizarre and unfortunate claim. Proteins are essential for nutrition, and there is certainly no evidence that disease has increased worldwide since wheat grain became a staple. Indeed, prior to this, life expectancy was probably something like 16.5 months, give or take. It’s true that bread itself is a rich source of carbohydrates, which are not essential and can be safely minimized in the diet, but this is true of gluten-free breads as well. By no logic should the strategy of avoiding carbohydrates be misconstrued as avoiding gluten.

Given this fad, I have heard from many people that a gluten-free diet has helped them recover from various maladies. In my own observations, it is not uncommon for people to say they feel better since going gluten-free. Is this all placebo? And if it is, isn’t that okay? I mean, if someone is paying closer attention to their diet, and they feel better, is there reason to encourage such actions?

I think there is a good reason why the science and these perceptions are not contradictory. When you try to cut out gluten what are you cutting out? Let’s look at food that are high in gluten, foods like processed cheese, chocolate milk, ice cream, baked goods, cereals, pastas, breaded meats, lunch meats, gravy, jams, fruit-filled pastries, French fries, and flavored potato chips.

I propose that anyone that cuts the above foods from their diet will feel better! This is not because these foods contain gluten, even high levels of gluten. It is because these foods are also loaded with simple sugars and fats.

So think of gluten sensitivities in the same way you’d think of bee stings or peanut allergies: of great and very real concern to a small number of people, of some concern for a few more, and of no concern to most of us. Don’t let anyone tell you that gluten is harming you in some way that’s so far not supported by science. And yet, look at your diet with the vigilance of those that are aggressively cutting out gluten and find ways to balance your diet with complex carbs like fruits and veggies, healthy proteins, be they from animal, soy or even gluten sources, and fats. Eat food. Not processed imitations. Eat local whenever possible. But eat less overall. And you will indeed treat and prevent disease and just plain feel better!

The Scales of Karma

Since my announcement yesterday, I am so happy to hear all the positive “way to go!” comments. But one comment spoke to me by bringing up an important point, one that gave me great pause in making this decision.

Im sorry to say – this all would be very cool but ultimately it excludes poor people and there is nothing about that which addresses the health care crisis – as far as I can see you are just doing what they do on the TV show “Royal Pains” – being a concierge doctor and just because you’re doing it at home doesn’t make it folksy -perhaps you should consider barter and give less fortunate folks a chance to have a doctor’s care that doesn’t make them feel like a number – otherwise everyone is still a number – the number that you charge!

There is a large national Concierge Medicine company based in Florida that has recruited me for several years in a row. This company charges patients anywhere from $2000-5000/yr to sign up with their doctor. The doctors agree to limit their panel sizes to 200-300 patients, and they still charge insurance companies for services that are covered. Frequently the offices are in high rent districts in big cities and wealthy suburbs. To justify the prices, the physicians provide additional services, such as aesthetics or “executive” physicals, running every unneeded test available once a year. That, to me, is Concierge Medicine.

By comparison, Direct Primary Care practices are usually retainer-based only, or monthly retainer plus small per visit price. They’re often focused towards patients that are underinsured or uninsured, offering primary care at a much lower rate than insurance premiums. They typically focus more on wellness and prevention and don’t try to sweeten the pot by adding extra, unnecessary services.

Now, ultimately, Concierge. Boutique. Direct Primary Care. It’s all just semantics. Either way you look at it, I will no longer participate as an insurance provider and will be holding my knowledge and ability for ransom, asking people to pay for it at a time when every dollar counts. Call it what you want.

But. If I do this right, in addition to providing better care for those that sign up, I think I can save money overall, as I have no doubt that I will be able to keep people OUT of the ER and OUT of the hospital by being there when needed and by proactively managing chronic disease. I think I will be avoiding burnout that is causing a lot of my colleagues to just drop out of the profession all together, worsening the doctor shortage, which is so extreme here on the island. And, hopefully, such an arrangement will give me the time and ability to do exactly what you talk about , to work for barter and to work for free for those that need it. I have already been in contact with community health centers on the Cape to try and learn of ways to better meet needs here on the island.

The ethics of this are important to me. I feel like it came down to deciding between providing good, ethical care to a small number of patients who can pay for it or providing mediocre, inadequate care to a large number of people, rich and poor, and continue focusing more on the entities that control the money in healthcare (employers, hospital systems, health insurance companies, the government) than on patients. It’s estimated that for every scheduled visit, a primary care physician spends 7 minutes face-to-face with a patient and then, along with staff, spends 45 minutes on managing the patient’s payer needs, i.e., on getting paid. That, to me, is unethical.

Do Over. Part Two.

New practice. What should it look like?

A couple of weeks ago, I posted a “Shoot for the Moon” Facebook question asking my friends and contacts what they would like from their physician’s practice. I posted the not so surprising results here: Shoot for the Moon.

Dusting off the ashes of burnout, I decided that if I did return to practice, I would have to be true to myself and return to the roots of why I became a doctor in the first place—to interact with people in a meaningful way and try to be their guide in the pursuit of wellness. (I need to go back and check my Med School application to see if those were the exact words.) As such, I need to open a practice that is as much the opposite of my former one as possible.

It turns out that a lot of what people asked for in my Facebook poll are the kinds of things that should only facilitate such interaction. Things like online access to your medical records, same day appointments, decreased (even rare) waits in a waiting room (in fact, I’m not planning to have one), after hours and weekend access and appointments, and no robo-telephone answering service. These aren’t just patient-friendly enhancements designed to market a practice, these are the kinds of changes needed to help patients stay involved in their healthcare, to break down the current barriers to getting any healthcare at all (i.e., appointment availability), and to refocus towards wellness and prevention, instead of just “treat and street” medicine.

In the Facebook thread I am referring to, after about 180 messages of people talking about how to re-engineer the typical current doctor’s office experience, including non-sense requests like “home-cooked meals,” a colleague and friend of mine chimed in.  Janet Chaffee, a wonderful, experienced island nurse wisely replied:  “You are going to need one heck of a staff. Coming from 30 + years in an office, it would be wonderful to do all these things, but is it impossible? I think yes. Doctors are people with lives. No one can expect 24/7 and be upset if they don’t get it. Evening hours? Weekends?? Deliver babies. When do you sleep or see your family. Sorry, I’m coming from the other end.”

She’s right, of course. But…

I am going to work out of the cottage on our property and open up initially with a skeleton crew–me. I’ll be answering the phones, seeing the patients, and shoveling the steps if it snows again.

I am going to offer online access to medical records, same day appointments, online self-scheduling of appointments.

My patients will have my cell phone number and email and will be encouraged to use them when needed.

I will be available for appointments outside of the usual 9am-4pm timeframe, most days of the week.

I will offer housecalls as well as online visits for when you just need a simple follow up visit and don’t need to miss a day’s work.


I am hoping to provide this better, more personalized care and improved customer service by seeing a lot less patients (the roster will be limited to 500 patients total, a number that might fluctuate depending only on how easily I can meet these promises) and by ignoring health insurance companies–the myriad of their regulations and the frustrations of their denials and the armies of personnel needed to interact with them!

I am opening a Direct Primary Care practice. It’s a new model, gradually catching hold around the country. The idea is that a practice stops billing health insurance companies and instead bills patients directly for the enhanced care, often using a monthly retainer and/or nominal visit fees to cover all services.

“Ahhhhhhh. The Catch.”

I’m sorry. I’m sorry the system is so broken as to make me buck it like this. I’m sorry that you have health insurance that purports to cover services like mine; maybe you even purchased it yourself at great costs (as opposed to having it provided for you by your employer). So Sorry.

Ask yourself this:  how well does my insurance cover the primary care services I need? Most plans have a $15-25 copay. Often there is a $2,000 deductible that is out of pocket. Most plans have a $150-250 ER copay, and making multiple trips to the NCH ER every year is almost a given these days, given our extreme shortage of doctors and appointment slots. It is not uncommon for a family of four to spend $1,000 on ER copays and another $250 for office copays. So what if you could redirect that money in a way that allows you to mostly avoid ER visits, to see the same physician every time you need to see one and who answers your phone calls at night when you just want to know it’s okay to not go to the ER, and gives you the convenience of making an appointment that best fits your schedule?

I have not completely settled on the price yet for this service. Most DPC practices charge anywhere between $60-120 a month for such services. And, if there is enough interest, and the practice matures (allowing me to bring more services in-house, e.g., nutritional counseling, on-site lab tests, a health coach), I can see a price point that falls somewhere on the lower side of that range. (I am going to focus harder on controlling overhead than raising revenue.)

As way of introduction, however, especially as I work the kinks out, I am going to charge less. I am considering $50/mos with a family cap of $125/mos. This will include everything. I will not ask for a co-pay or per-visit fees. If you need an ECG or a strep test, it will not cost extra.

I should point out that this plan is in no way a replacement for health insurance. Your health insurance will still work, and be needed, for example, if you need a $6,000 knee MRI at NCH, or a $300 Lyme test, or a $15,000 Medflight transport, or $55,000 worth of treatment for a cat bite. But, given my non-participation, it is unlikely that health insurance will cover my monthly fee.

So, there you have it.

What’s next? I have to renovate our cottage, turn the turn ground floor bedrooms into consultation rooms. I have to buy some equipment. I need to get a license to work out the building. I have some important decisions to make when it comes to Medicare and how to handle people who have managed care plans.

In the next week or two, I am going to redesign this website and blog and flesh out the details of how it will all work. I’m sure there will be many questions, so I’ll need an FAQ section. There will be a sign-up if interested page.

Still a lot to think about. But I think I can start seeing people within 4-6 weeks though!

Please feel free to comment below or email me at info@ackdoc.com if you have questions or comments. Be nice.

Do Over. Part one.

I am opening a new medical practice. Soon. This is the first in a series of posts in which I will explain the whys and hows and what-fors of this new practice. Bear with me, I’m still working on the business plan, but I have decided that the best way to handle it all is by being honest and transparent about the whole process. I’m looking to do something new.

In the summer of 2001 I moved here with Amy, James (who was 3) and Jack (only 2 mos old) for what has been an amazing island journey. No one is going to write a book about it or make it a movie; I’m not Robinson Crusoe. But Defoe’s novel is in some ways an interesting metaphor for living as a physician on Nantucket. Crusoe could barely make out a distant continent on the horizon and, but for Medflight and technology, we’re similarly isolated. And, unlike when we first arrived, there are now cannibals to worry about, for certain. Medicine has changed a lot since 2001. Romneycare. Obamacare. Health maintenance organizations. Pay-for-performance. ACOs, PCMHs, and Meaningful use certification. E&M coding. DRGs. HIPAA.

I started my practice with Sally as my assistant and Annie as receptionist. I had a delivery the weekend before I opened and had 25 patients on my first day. The practice had been Dr. LaRochelle’s, and the hospital had maintained it after his departure with locum tenens physicians (including Dr. Hartmann filling in at times). Back then, I outsourced the process of billing and managed the practice myself. Since then, the practice of medicine has evolved (in futility) in the name of cost control and improved care, and it is more and more difficult to get paid.

Electronic medical records have been installed in the majority of practices. These record systems were conceived to make it easier for physicians to get paid, to meet the difficult requirements for documentation required to justify the levels of complexity tied to reimbursement levels set by Medicare and health insurance company contracts. These inefficient systems, with clicks and checks and bullet points, have made it more difficult for a physician to see as many people per day, even as the pressure to do so is increasing. They make it easy to cut and paste records from visit to visit, patient to patient, which results in errors. (I used to chuckle when I received a consult note from a specialist about Mr. Jones that included, in the examination section, details about his breast and pelvic examination; now I just want to cry.) It’s not a surprise then that recent studies show that these systems are not saving money, as hoped for by policy makers, nor are they improving care, though everyone assumes that if records are digitized and easily communicated amongst healthcare providers, and hospitals, and pharmacies, and consumers, we should be able to provide much better and safer care. But this standard of interoperability has proven to be the Holy Grail so far and, instead, we have a splintered industry of hundreds of software providers, none of who have products that easily communicate with others (nor are they motivated to do this in as much as it is perceived is prohibitively expensive and/or as a threat to market share).

Since that time, healthcare reform has attempted to control and reform the costs and practices of health insurance companies (e.g., mandating certain coverages), to curb the need to use Emergency Rooms for primary or even urgent care, and to stop self-referrals to expensive specialists and use primary care providers as gatekeepers instead. A higher and higher percentage of health insurance products available are Managed Care policies, instead of the traditional fee-for-service policies.

This seems like a smart change. In an attempt to control costs and improve care, Managed Care tries to standardize the delivery of healthcare and ration resources. Consumers are not able to see a dermatologist about a simple Poison Ivy rash without being sent there by the PCP on record who, presumably, will see the patient instead—at a cost of $80 instead of $300—and prescribe the simple, needed treatment. PCPs won’t be able to prescribe the latest and greatest antihypertensive, available in the sample closet thanks to the nice drug rep that bought dinner last night, when hydrochlorothiazide at $4/month will work just as well, without getting the insurer’s permission first and needing to justify the increased expense. A well-meaning back specialist will not be able to order an MRI for uncomplicated low back pain just because a patient is insisting on it, without having the PCP call and ask for pre-authorization.

It is easy to see how these kinds of changes are good and necessary, if we are to control the way healthcare costs are threatening to bankrupt our country. But, to health insurance companies, concerned primarily with profit and dividends and astronomical CEO salaries, Managed Care is a means to cause confusion and preserve margins. If you require pre-authorizations and prior approvals, and you change the rules frequently, more things will get retroactively labeled as uncovered, resulting in consumers having to pay or healthcare entities having to eat the bad debt.

The detriment of all of these changes which are on the surface well-meaning but ultimately meant to save recently-created administrator, legislator or bureaucrat jobs and increase insurance company profit margins, was so apparent in my little practice. I started with Sallie and Annie and me. But I finished with Dr. Koehm as a partner, and the two of us being responsible for (and needing) a Nurse Practitioner, Sally in the front primarily on the phone with insurers getting tests and medications approved, 1.5 receptionists and a computer answering the phone, a full-time manager, two RNs, a medical assistant helping out in the back, a part-time translator, and a large billing staff in Boston that withdrew 11-15% of collections right off the top. (I gave this as a range because I cannot remember the exact number. I think it was 11% of collections and a 3-4% “management fee,” but I could be off by a point or two.) And, in the few months leading up to my departure I saw, on average, the same number of people per day. 25.

It does not take a Harvard MBA to see the problem.

The salary I paid myself in 2001 was $150,000. My salary last year as an MGH employee was $161,000, though my charge, for example, for 9 months of obstetrical care and delivery changed from $2,400 to over $6,000, and my charge for a medium complex office visit changed from ~$60 to ~$180. Over the 11 years, employee salaries increased in a manner more consistent with everyone else’s. In fact, in the new MGH practice, the employees were now mostly in a union, with contracted pay increases and a very generous benefits package. (This is a good thing, in my opinion, but it further explains the recent, difficult evolution of small medical practices.)

So, if my salary was relatively static, but the overhead increased as described above, and the number of appointment slots stayed the same, what had to give to keep the doors open? I’ll tell you what: my efficiency, my compassion, my abilities, and my sanity. That’s what.

And that is why I need a new practice and why it has taken me awhile to plan it. I have to make sure I don’t open the same can of worms.

I need a new can of worms.

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