Good Workups

Everyday I met new people and hear their stories, both what’s going on in their life and their medical history. Every once in a while, I am astounded at what I hear. They tell me stories of how doctors have managed their cases, and I am appalled – what is medicine coming to?

In medical school you are taught about the “standards of care.” These are guidelines about how to treat conditions like PCOS, migraines, hypertension or diabetes, to name a few examples. Knowing the standards of care for each condition is important, because if you deviate from them, you need to let your patient know, but also, if a doctor hasn’t followed the standards of care, especially when working up a patient to investiage if they have xyz condition, it raises some red flags because they need to be worked up accordingly – it’s a doctors due dilligence.

As a Naturopathic doctor, I don’t have a Naturopathic standard of care to follow – we learn the same standards of care that DOs and MDs use. I am happy about this (while some of my colleagues believe we should establish and teach just ND standard of care), because knowing what’s going on in conventional medicine is very important to manage some emergencies and also to work up a patient accordingly before using my alternative therapies to treat them.

When it gets interesting, however, is when a patient comes into my office and they claim they have seen 5, 10 or more doctors, that they have xyz symptoms, and that they had xyz testing. While the patient believes they have been appropriately worked up for a typical list of differential diagnoses (list of possible diagnoses based on the patient’s symptom picture), I usually find they have not.

Generally what happens is, when a patient walks into the office, a doctor will then create a DDX based on what the patient tells them, then the doctor investigates using the standards of care and any other diagnostic tricks they’ve learned throughout their practice, the results of these tests then narrow down the DDX and eventually get the practioner to one or two possible diagnoses. Then it’s time to refine, and begin treatment.

Typically when patients visit me, they have been worked up. I ask them questions to make sure I understand what their previous practioners have done (one rule in medicine is that you always do your own investigating, even though a patient claims they’ve had a thorough workup), and then if they have had an appropriate workup, we move on to what I do best – the natural therapies and figuring out the root cause. But too often, and especially recently, I discover that the patient hasn’t been appropriately worked up, and I am either left to work them up, diagnose the condition and figure out what’s truly going on behind their medical diagnosis (putting my detective hat on!), or I need to recommend that they see xyz type of practioner to the standard workup for me.

This is unacceptable. While doctors do not know everything, why is there this pretense that we have to “know” it all? We are human. We do our best with what we’ve been given. Sometimes that makes our job difficult, especially when patients are poor historians. But to not do all the appropriate investigations while using the standards of care, baffles me. If that condition is on your DDX, then you need to investigate!

Patients, ask questions of your doctors. If they brush you off or aren’t able to fully explain something to you, find another doctor. Your health is important and their unwillingness to explain their thoughts about your case, is a big red flag.

Doctors, ask questions of your patients. Don’t assume they’ve had the appropriate workup. Make a long DDX and have reasons why you cross conditions off the list. Think about the medical dangers, the zebras and the horses. Include them all. If you can’t work them up (some states limit what us NDs can do, because each state has it’s own set of rules and scope of practice), send them to someone who can. If the need for workup is urgent, make sure you explain this to the patient and get them to a specialist in an appropriate amount of time.

I went into medicine because I hate the mediocrity that I sometimes see in the profession.

Be the medicine, and stay curious!

— Dr. Meg

The Rate-Limiting Step

Have you ever noticed how life seems to be like one big decision? We are all faced with decisions – every day, every hour, every minute, and every second. How do you navigate these decisions, and how to do you decide which move is the best to make?

It all comes down to what I call the “rate-limiting” step. This is actually a phenomenon that comes from biology. You see, your body is a huge network of cells. These cells work together to acheive common goals, and create functions, vitamins, enzymes, movements so that we can BE a healthy, alive, functioning human being. Biochemically, your cells are all working very hard. They are signaling between eachother, talking, sending messages, and being affected by messengers that travel throughout your blood, most commonly known as “hormones.” Enzymes are what we call catalysts of chemical reactions – they actually help the reaction happen! Enzymes are usually protein molecules, and these molecules “have needs” if they are to function properly, in order to later carry out the process they were created to catalyze. Enzymes “need” things like co-factors, which include vitamins and minerals, and also they need other parts in the biochemical pathway to work properly, otherwise the system gets gummed up with one type of molecule, or substrate, the enzyme cannot work with just yet. So if there aren’t the right cofactors, or the rest of the system is not functioning fully, the enzyme can’t work. Often, when the enzyme is dependent on other substrates in order to carry out it’s action, this is called a rate-limiting step, because the enzyme has to wait for the substrate to be available in order to do it’s thing. If the substrate isn’t around, the enzyme can’t work, and the biochemistry stops there. The rate limiting step is always that part of the biochemical pathway, where, if the substrates and enzymes do not come together in the right amount OR with right timing, the reaction will not occur.

This idea is applicable to human behavior. For example, this morning when I woke up, I had a choice, do I go to the gym like normal, even though it’s a Saturday and I woke up late intentionally, and I know the gym will be busy, and I’m slightly tired because I’m fighting a cold my roommate is trying not to give me? OR do I go to the gym regardless because I love the gym?

That moment when you wake up and have to decide is the moment that determines the momentum for the rest of your day.

As I was contemplating what I was going to do, I thought about this concept of the rate-limiting step. I thought about the pros and cons of going to the gym. I realized the rate limiting step of me wanting not to go, was fact that it was late (8 am for me is late), and I was starting to get hungry. I prefer to do my morning workouts fasted, but I didn’t have a real dinner before going to sleep, so naturally I was feeling low on food. I decided to get up, have a small protein bar (just tried these – love the ingredient list!) and get to the gym. It was 100% the right decision at the time, and now as I am typing this, I am so happy that it’s 1230 and I’ve already gotten in my workout, showered, breakfasted, and have some laundry in process.

As a doctor, I am often talking to clients about their lives – how they make decisions, what goes on day to day, and in general, figuring out how their brain works — because that influences their choices, both mentally, physically, emotionally and spiritually — AND whether they are going to do what’s on their treatment plan OR make changes in their lives. I’ve found that once I tell them about this idea of the rate-limiting step, they are easily able to identify areas in their lives where they are stuck and can’t move forward.

It’s been game-changing for them, and I’m sure it will be game changing for you!

How will you apply this idea of the rate-limiting step in your own life?

Until next-time,

Dr. Meg