Hand in Hand -- Forging the Provider/Community Partnership

Janice Werbinski, MD


October 09, 2003

This 2-day women's health conference, jointly sponsored by the Santa Fe Community Center of Excellence in Women's Health, The American College of Women's Health Physicians, and the New Mexico Women's Foundation, was held in Santa Fe, New Mexico, against the beautiful backdrop of the Sangre de Christo Mountains. The idea of a conference that combines healthcare providers and patients as partners seems to capture the new universal concept of "total women's healthcare." The conference was designed to inform both healthcare providers and consumers about comprehensive, cutting-edge ways for women to become, and stay, healthy. Several total-group plenaries were interspersed with individual workshops crafted to highlight specific illnesses and conditions unique to women. The breaks were welcome and gave options of exercise, dance, and gentle movement, as well as healthy nourishment in keeping with current ideas of patient and provider self-care and well-being.

The opening plenary set the "partnership" tone. Family physician, Dr. Joseph Gallagher, FP, along with Betsy Najjar, presented a thumbnail view of a service they developed in Santa Fe to begin to break down the walls between providers and patients. Gallagher and Najjar facilitate Sunday morning "debriefing" sessions that allow both parties to express the frustrations, challenges, and crowning glories associated with their healthcare experiences. The goal is to "break down the barriers to the provider/patient relationship and promote closer collaboration between them." The physicians in the program find a place to "debrief" their anxiety, confusion, and frustration concerning their daily work. And the consumers resolve some of the angst they have acquired trying to sanely access the healthcare system. The debriefing sessions also set out to address issues around the notion that providers often blame patients for unhealthy behavior as well as the consequences of providers being overworked, a phenomenon that has only been exacerbated by managed care, which has "sped up the belt" on the provider production line. The sessions allow both doctors and patients to identify unhealthy behaviors and expectations in order to initiate change and promote healthier interactions. The sessions often become support groups that bring both parties to a deeper understanding of the healthcare experience, and the participants leave the sessions with renewed energy and vitality.

Having set the "partnership" tone for the conference, the rest of the first day consisted of several presentations and workshops. Participants could choose from various topics, depending on level of sophistication and interest. A few stand out as illustrative and representative.

Outstanding presentations on alternatives to hormone replacement therapy were given by Dr. Tieraona Low Dog, Clinical Assistant Professor, University of New Mexico, Albuquerque, and Medical Director of the Tree House Center of Integrative Medicine, Albuquerque, and Dr. David Riley, editor of Alternative Therapies in Women's Health. The underlying theme of the presentations was that menopause is not a disease, and no woman has ever died of it. Menopause is a bio-psycho-socio-cultural phenomenon similar to puberty and needs to be viewed through a complex lens to be understood and managed.

Dr. Low Dog critically discussed the medicalization of menopause. By way of example, she remarked that pharmaceutical ads exaggerate the impact of hot flashes on women and overestimate the number of women who experience them at all. She gave a comprehensive presentation on various supplements and herbs commonly used by alternative providers, outlining the basic science supporting each element, and giving a great slide show about doses, side effects, costs, and procurement. She promotes Tai Chi or yoga together with calcium supplementation for prevention of hip fracture, with judicious use of pharmaceuticals if DEXA scanning reveals critical bone loss. The other products she promotes are whole foods, soy (to alleviate hot flashes), black cohosh (to alleviate hot flashes), chastetree (to treat abnormal bleeding), ginseng (to improve mood or combat fatigue), and St. John's wort (to elevate mood or counteract depression), all of which have been shown in clinical trials to be significantly more effective than placebo at controlling specific symptoms of menopause. Scientific data to support use of some of the other products that are on the market, such as motherwort (to treat palpitations), kava (to reduce anxiety), and dong quai (to manage hot flashes), are limited or conflicting, although she points out that these agents may still be effective in combination, as usually used in Chinese medicine. One should note, however, that kava is banned in Canada and in some European countries because of its potential hepatotoxicity. In addition, studies have shown that wild yam actually contains no active ingredient that is effective and does not convert to a progesterone, as had been thought. Dr. Low Dog also mentioned that although red clover (used to relieve hot flashes), with its isoflavonoid content, should in theory be effective, studies so far have not supported its effectiveness against hot flashes relative to placebo.

Some of the most useful information Dr. Low Dog provided related to her use of black cohosh. She recommended dosages of 20-60 mg twice daily and said that up to 1 g daily can be used safely. She said that this product has proved superior to placebo in 11 of 12 clinical trials. In addition, in vitro data have shown no estrogenic effect on breast cancer cell lines. She referred the audience to her review of studies of black cohosh published in Menopause, which concluded that black cohosh has a positive safety profile when used for as long as 6 months.[1]

Dr. Riley's presentation expanded on that of Dr. Low Dog, again emphasizing the importance of diet and exercise in maintaining health. He addressed other modalities, such as homeopathy, biofeedback and massage, bioidentical hormone creams, garlic (to decrease cholesterol), red rice yeast (which has now become a patented medication to lower cholesterol and is distributed by a large pharmaceutical company), and guggul (which is derived from a tree indigenous to India and is used to treat hypercholesterolemia.) He predicted that guggul will soon also become the active ingredient in a patented pharmaceutical.

In keeping with a midlife theme, Dr. JoDean Nicolette, Clinical Professor of Family Practice at the University of California, San Francisco, presented a fascinating look at menopause from a historical and sociocultural viewpoint. She started with an enlightening look at sexist historical views of "the change," from those of Hippocrates to those of Dr. Robert Wilson, author of Feminine Forever. She also noted that Dr. Wilson's book was financially supported and orchestrated by a large pharmaceutical company (Wyeth-Ayerst). She then attempted to define menopause and noted that, globally, there are only 2 universal symptoms to define this physiologically changing state: (1) cessation of menses, and (2) senescence of pregnancy potential. Dr. Nicolette also discussed the overarching effect that culture has on the interpretation of menopause, remarking that in some cultures there is not even a word in the language to express the phenomenon of the hot flash, because the symptom is not reported. This is the case in the Mayan culture, for example. She also reported on the Study of Women Across the Nation (SWAN), which gives us insight into experiences of 14,906 midlife women in 7 major US cities, analyzed according to ethnic group. This study found wide variability of symptoms from 3 categories: somatic, mood, and vasomotor. Some women had no symptoms; some had symptoms from all 3 categories. Of interest is that the most universal symptom was headache and stiffness (54%). On average, 52% of women across all ethnic groups had mood changes (tenseness, irritability, or depression) in early perimenopause, but this was often correlated with interrupted sleep. On average, 28% of women had hot flashes, but the range was 10% to 60%. Japanese and Chinese women reported similar premenopausal and menopausal rates. Dr. Nicolette pointed out that all of these symptoms vary by culture and are influenced by beliefs and expectations, sensitivity to symptoms, diet and health behaviors, and roles of women in the culture. Her concluding statement sums up the presentation: "Cessation of menses is a 'snapshot' in the complex life cycles of women."

Staying with the focus on midlife and its management, Dr. Stacie Geller, a researcher at the University of Illinois Center of Excellence in Women's Health, Chicago, reported on a study called "Survey on Dietary Supplements and Herbal Medicines (DS/HM)" that was conducted in conjunction with the National Centers of Excellence in Women's Health. This survey's purpose was to assess the knowledge, attitudes, and behaviors of medical providers on the use of DS/HM in midlife women. One hundred nineteen providers were surveyed who were either affiliated with the University of Illinois in Chicago or worked in the community of Santa Fe, New Mexico.

Dr. Geller noted that use of DS/HM by women has increased by 380% in the past 10 years, and more than 100 new menopausal products have been introduced to the US market in that time period. However, 70% of women do not inform their provider that they are taking any of these supplements. The study found that in general, age (older), provider type (family practice), practice setting (community), and site (Santa Fe) were predictive of increased knowledge, positive attitudes, and proactive behaviors toward DS/HM. The survey also revealed that belief in the efficacy of herbal approaches was quite low, with only 1% to 2% of healthcare providers considering such options for their patients, suggesting the need for educational opportunities for the providers.

While interesting concomitant workshops were in session on traditional native foods and diabetes, elder wisdom and grandmothers' circles, healthcare issues for the homeless, and living well with arthritis, Dr. Kate Patterson-Neely, Assistant Professor, Drexel University College of Medicine, Philadelphia, Pennsylvania, presented a spellbinding session called "Introduction to Concept Mapping." She outlined a new learning theory, which distinguishes rote learning from meaningful learning using the concept mapping tool, a learning tool that is being introduced into many institutions of education. The principle behind the tool is connecting new knowledge to previous knowledge and applying the integrated knowledge to new situations. Dr. Patterson-Neely used the American College of Women's Health Physicians definition of women's health ("A sex- and gender-informed clinical practice, centered on the whole woman, in the diverse contests of her life, grounded in a sex- and gender- informed biopsychosocial science"), and constructed a concept map as a new way of looking at, and teaching, women's health. She gave the attendees a recommendation of software to facilitate personal and professional use of concept mapping (IHM Concept Map Software at https://cmap.coginst.uwf.edu/). The remainder of the session was used to allow participants to construct concept maps in their areas of expertise.

In another vein, different from the usual academic presentation, was an eye-opening look at "Pharmaceutical Marketing and Women's Health", presented by Dr. Morgan Camp, a family practice resident in the UCSF program. Dr. Camp presented well-researched data showing the depth to which physicians' prescribing practices are influenced by marketing. He referred to a 2002 article published in The Annals of Internal Medicine reporting that 40% of the budget of pharmaceutical companies ($15.7B) is spent on marketing. About half of this ($8B) is spent on sample provision, 26% on "drug rep rounds," and 3% on journal advertisements. In addition, $2.5B annually is spent on direct-to-consumer ads.[2] He noted that the American Medical Association provides physician data to pharmaceuticals at the cost of $9000/MD/year. Physicians can have their names removed from these lists by calling 1-800-262-3211, ext. 5213. To give an immediate sense of the scale of monies entailed, Dr. Camp pointed out that in 2002, the budget spent on marketing the nonsteroidal anti-inflammatory drug rofecoxib (Vioxx, Merck and Co. Inc. was higher than that spent on either Budweiser or Pepsi and that Wyeth-Ayerst had made approximately $1B annually on their menopausal hormone therapy conjugated equine estrogens (Premarin) during the 1990s.

Dr. Camp mentioned that "methods of influence" used by pharmaceutical companies to influence provider prescribing habits rely on gifts, appeals to authority, exploitation of social biases, fear, and surrogate end points. In his discussion on the medicalization of menopause, Dr. Camp also remarked that nonmedical variations (problems) become defined as medical problems or "diseases," so that corporations can sell more medications. Examples he gave were menopause, baldness, erectile dysfunction, premenstrual dysphoric disorder, and female sexual dysfunction. At the end of his presentation, Dr. Camp provided a most useful list of Web sites (see below) where physicians can obtain unbiased information about prescribing standards and ways to eliminate bias.

Finally, there were 3 academic presentations at the conference that deserve mention. One of these was on renal disease in women, presented by Dr. Benjamin Fritz of Santa Rosa, California; another was on diabetes and the stroke-heart connection in women, presented by Dr. Naushira Pandya of Nova Southeastern College of Osteopathic Medicine, Fort Lauderdale, Florida; and a third, on metabolic syndrome, was presented by Dr. Janice Werbinski, Associate Clinical Professor of Obstetrics and Gynecology, Michigan State University, College of Human Medicine, Kalamazoo Center for Medical Studies.

Dr. Fritz reviewed several aspects of renal conditions from a women's health perspective. He noted that women have a 70% greater chance of being started on dialysis later in their disease (when filtration rate is < 5 cc/min); they are more likely to be severely anemic when starting dialysis, more likely to have hypoalbuminemia, and less likely to receive erythropoietin. He postulated possible reasons for these differences, including limited access to care, late referral to nephrology, and nephrologists' failure to estimate accurately the rate of disease progression. He said that "eyeballing" the creatinine level is a much less specific way to estimate kidney failure, and that glomerular filtration rate (GFR) calculation is critical in estimating the degree of failure in women, because the GFR is more dependent on height, weight, and size than the creatinine level. A case in point is that a large 24-year-old man can have the same serum creatinine as a small 74-year-old woman, but their actual measured renal function can be markedly different -- the young man's normal, and the elder woman's severely compromised. Dr. Fritz gave us a very useful formula to calculate GFR at the bedside, which takes height, weight, and age into account. This is the Cockroft-Gault formula: (140-age) x weight (kg) x 0.85 (women)/serum creatinine x 72.

Dr. Fritz then presented a revealing discussion on gender differences in transplantation. He discussed a study published in 2000 in The American Journal of Kidney Disease by Wolfe and colleagues.[3] This study involving 228,000 people on dialysis, 46,000 of whom were awaiting kidney transplant, found that women were 16% less likely than men to be on a waitlist. And, blacks were 41% less likely than whites to be on a waitlist. Once on a waitlist, women were 14% less likely to receive a transplant than men. To try to explain these differences, Dr. Fritz noted that the United Network of Organ Sharing Point System allocates points toward acceptable donations according to various parameters, including time spent waiting, quality of match, age (pediatric patients get more points), and "sensitization," which refers to a reaction to foreign antigens. Sensitization is more common in women, probably because of pregnancy history, and increases the presence of foreign antigens. Sensitization makes transplantation more difficult because of the increased likelihood of rejection.

Conversely, in the area of donation of kidney organs, this study showed that wives are 28% more likely to donate a kidney to a spouse than husbands (36% vs 6.5%), and 80% of spousal donations come from wives.

While interesting workshops were being conducted on "How to Quit Smoking," "The Osteoporosis Revolution," "Gender-Specific Addiction," "Stroke: A Survivor's Journey," "Fertility Awareness," and " [Automated External Defibrillation] AED Demonstrations," 2 other academic lectures were presented at the conference.

Dr. Pandya presented an overview of the connection between diabetes mellitus, insulin resistance, stroke, and heart disease in women. Her comprehensive review considered the effects of aging, sex, and insulin resistance and commented on its rise in the United States and other countries. Sex-differentiated data show that the standardized mortality ratio is higher in women than in men; stroke is the second most common complication in women; and women have a lower risk of amputation, coronary heart disease, and gangrene than men.[4] Thirty-two percent of women with diabetes mellitus, as opposed to 15% of men, are unable to walk a quarter mile, climb stairs, or do housework.[5] In premenopausal women, type 2 diabetes eradicates any cardiovascular advantages possessed by age alone.[6] Dr. Pandya noted that we are not doing well at following the current National Cholesterol Education Program (NCEP) guidelines to help prevent and manage diabetes, and she reviewed the current recommendations and their potential impact on macrovascular disease, morbidity, and mortality. Her specific recommendations included nutrition therapy, weight reduction, and exercise to reduce insulin resistance; target of HbA1c to < 7%; intense pharmacologic treatment of dyslipidemia and hypertension; judicious use of aspirin and reduction of hypertriglyceridemia to normalize fibrinolysis; and potential use of agents to increase insulin sensitivity.

Dr. Werbinski presented her clinical success in the management of metabolic syndrome and insulin resistance. She is collaborating with colleagues in cardiology and integrative medicine. Together, they have created an interdisciplinary program to diagnose, manage, and reverse the consequences of the metabolic syndrome. This year-long program combines instruction and assistance with lifestyle changes, nutritional supplementation, diet education, supplemental nutriceuticals, exercise, and group therapy. The program has been registering remarkable success, with more than 400 patients participating. Referrals are made by primary care physicians as well as specialists, including cardiologists (reversal of heart disease) and gynecologists (management of polycystic ovary syndrome).

The diagnosis of insulin resistance is made mostly by collation of presenting symptoms, with the aid of some specific blood parameters. Dr. Werbinski remarked that a traditional glucose tolerance test may only diagnose the problem later in the progression of the disease, and that if a 2-hour postprandial (or post 75 g glucola) serum insulin level is measured, the syndrome can be diagnosed earlier along the continuum of the disease. There is some controversy regarding the normal parameter of this value, but an insulin level > 50 mcIU/mL at the 2-hour postprandial time is generally considered abnormal. Patients are accepted into the program on the basis of symptoms or obesity alone, but various blood parameters help to follow improvement and progression during the program. Some of the tests monitored include the following: fasting and 2-hour glucose and insulin levels; total, LDL, and HDL cholesterol levels; lipoprotein a, homocysteine, C-reactive protein, and triglyceride levels; weight, waist-to-hip circumference, and blood pressure; and symptom analysis.

The nutriceuticals prescribed in the program include omega-3 oils, conjugated linoleic acid, meta-lipoic acid, soy, vanadium, chromium, magnesium, and water-soluble fiber such as amylose. The diet proposed is 40% carbohydrate (weighted toward low-glycemic-index carbohydrates), 30% protein, and 30% fat (but very low in saturated fat and higher in Mediterranean, or mono-unsaturated, fat).

During her presentation, Dr. Werbinski also sang the praises of the new food pyramid, published in the January 2003 issue of Scientific American by Dr. Willard C. Willett and Meir J. Stampfer of Harvard University.[7] Most importantly, Dr. Werbinski stressed, Willett and Stampfer call for the discontinuation of use of the USDA food pyramid and the avoidance of packaged, "low-fat" (and therefore, usually, high-carb) convenience meals. She further noted that the US government has finally gotten the message that it is crucial to list types of fats and carbohydrates on food product labels, and that adding folic acid to foods will not only help prevent birth defects but also aid in prevention of heart disease. We need a means to be sure of the presence and availability of the actual nutrients in our food supply; in other words, we need to know whether the essential action of the nutrient remains (and to what extent) after any processing.

In summary, this 2-day conference certainly fulfilled the sponsors' mission of "Forging the Community/Provider Partnership" and presented an interesting, cutting-edge, woman-centered look at aspects of our present practice of medicine.


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