Incidentally, the seventh international symposium will be held May 24-27 in the year 2000 in Scottsdale, Arizona at the Camelback Inn Resort. We are putting together a world-class program, and the title follows nicely from the 1999 focus on intercellular communication. The theme of the 2000 symposium will be on metabolic energy, messenger molecules, and chronic illness from a functional medicine perspective. That is the energy medicine connection, intermediary modulators triggering mediation of various disease phenomena and how we prevent and manage disease using this paradigm. I urge you to put the 2000 symposium on your calendar now
I’m sure you sometimes read things that stop you in your tracks and cause you to laugh. You feel the material must be written facetiously or for shock value, because no one would seriously say it. I had such an experience recently when I read a book titled The Rise and Fall of Modern Medicine, by Dr. James Le Fanu, published this year by Little, Browni. Reviews of this book suggested it would tell where medicine was going in the 21st century. As I read the book, I wondered how this erudite, well-informed author could write something so ludicrous.
Dr. Le Fanu wrote, “The limited prospects of future medical advance should by now be well recognized.” He then argues, “The age of the optimism ended in the 1980s, when ‘the main pillars of post-war medical achievement—clinical science, medicinal chemistry …and technological innovation—were in trouble. …’ This fall in turn is accompanied by a ‘four-layered paradox,’ that in this age of modern medicine there are disillusioned doctors, the worried well, the soaring popularity of alternative medicine, and the spiraling costs of health care.”
How can anyone suggest we reached the zenith of medical science in the 1980s and are now turning the other way? New information is being revealed constantly. There is an explosion of information, only part of which we cover on FMU every month. We are recrafting, reforming, and remaking health care and bioscience as a whole new paradigm for the 21st century—a functional medicine paradigm built on the premise of molecular medicine, individualized pharmacogenetics, and all the things we have talked about. I do not know how anyone who is even slightly aware of the rate of change in the field of bioscience could make the preposterous statement that we achieved the zenith of all of this in the 1980s.
Clinician of the Month
Vern Cherewatenko, MD, MEd
JB: This month’s Clinician of the Month is working to change the way healthcare finance works and make it more user-friendly and “healthy.” It is a functional healthcare system. Dr. Vern Cherewatenko is a medical doctor in Seattle and a University of Washington graduate. I admire the way he has taken charge of what he recognized was a system of “Mangled Care,” his aphorism for Managed Care. He describes himself in the following way:
“I graduated from the University of Washington and am a board-certified family physician. I have owned five family practice/integrated medical clinics in the Seattle area and was very involved with all insurances, including Medicare, Welfare, L&I, and several managed care contracts, in addition to our own regular menu of insurance company patients. A colleague of mine had a similar practice with five clinics open 365 days a year. We both were extremely busy and never were at a loss for numbers of patients. We created and founded the largest IPA in Washington State to try to protect the practice of independent medicine and remain able to assure the continuity of the Medicare and Medicaid population of patients we had cared for over the years.
“Needless to say, we created a monster. The passion we had that gave birth to the IPA to keep us alive was the very entity that became the nemesis that began to eat us alive. On a Sunday morning about 18 months ago, my partner, David McDonald, and my associates sat down to figure out why, when we couldn’t be busier, we were losing so much money. We both had excellent business staffs and ran a very tight ship business-wise. Our combined practice billings totaled over $10,000,000, not a tiny operation, by any means. Why were we losing money on a monthly basis, and why were we rapidly flying our businesses straight into the ground, not to mention the usual where-has-the-fun-gone stuff?
“We calculated that we were losing approximately $7 per patient, or $80,000 per month. This could not be made up, obviously, in volume. The managed care line of you-just-need-more-patients-to-win-at-the-capitation-game couldn’t have been further from the truth. Believe me, we tried. Between the two clinic systems, we took care of approximately 75,000 patients with our 55 providers between us. This rapidly depleted our total net worth and assets over a two-year period.”
That sets the tone. Vern is a very creative guy who wants to continue to practice quality medicine, but he doesn’t want to go bankrupt or be controlled in the process. That is part of the story of Simple Care. Vern, what did you and your colleagues create at this turning point in your lives?
VC: Thank you for inviting me to appear on Functional Medicine Update.™ I became involved in treating obese patients about the same time that Managed Care came in. I learned how to treat obese patients in a very comprehensive way from you, your staff, and your affiliated companies. Obesity is the number one problem in the country from the point of view of a family practice doctor. In working with obese patients, I tried a very comprehensive approach and found that most insurance companies would not pay for these treatment approaches, many of which involved non-prescription products, programs, teaching, and education.
I ran straight into the face of insurance companies that said they were not going to pay for obesity, “or anything related to obesity.” As I explained to the major insurer in King County, that cut out almost all of my patients, whom they were telling me they weren’t going to pay for. It also set me up for fraud and abuse charges from the insurance company and possibly the FBI. That’s exactly what happened to my associate. He had a larger practice than mine and is now totally bankrupt. This physician, had 40 respected doctors working with him, covered all of South King County south of Seattle. In my opinion, he took care of patients in the best functional medicine sort of way. His practice is now extinct; he’s been exterminated, despite the fight. He could fight with about $350,000. That’s how much he spent on attorneys’ fees before his light went out. All of those clinics and those patients were removed from a functional medicine clinic system.
Now, taking a step back—I appreciate the introduction you read because this is from the heart and it’s very factual. The current system of managed care and health care in general is undermining the background of functional medicine and the goal you are trying to accomplish. It is also making it very difficult for patients even to access care of doctors who think as you and I do—a functional medicine approach, a proactive approach, a preventive-medicine approach. These patients can’t even get in for the acute care, let alone anything preventive.
Something rubbed me wrong two weeks ago. It concerned a very popular internal medicine group that practices on the same floor as I do. A 73-year-old diabetic patient came in because he refused to go on insulin, and that was what the internist offered to him. In addition, he told me they had a sign on the inside of their door that basically says not to ask to be treated with preventive medicine because they won’t do that anymore. I couldn’t believe it until we sent one of our staff down to that office to check. Indeed, a sheet on the inside of every exam room door said not to ask about preventive medicine; they don’t refer anybody to preventive medicine.
- Le Fanu J. The Rise and Fall of Modern Medicine. London: Little, Brown, 1999.
- Rubinsztein D, Easton DF. How large is the role of apoE genotype in Alzheimer’s disease susceptibility? Dement Geriatr Cogn Disord. 1999;10:199-209.
- Tiroshi O, Sen CK, Roy S, Kobayashi MS, Packer L. Neuroprotective effects of a -lipoic acid and its positively charged amide analogue. Free Rad Biol Med.1999;26(11/12):1418-1426.
- Schipper H, Goh CR, Wang TL. Shifting the cancer paradigm: must we kill to cure? J Clin Oncol. 1995;13(4):801-807.
- Whelton PK, Appel LJ, Espeland MA, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons. JAMA. 1998;279(11):839-846.
- Stamler J. Setting the TONE for ending the hypertension epidemic. JAMA.1998;279(11):878-879.
- Labay V, Raz T, Baron D, et al. Mutations in SLC19A2 cause thiamine-responsive megaloblastic anaemia associated with diabetes mellitus and deafness. Nature Genetics. 1999;22:300-304.
- Fleming JC, Tartaglini E, Steinkamp MP, Schorderet DF, Cohen N, Neufeld EJ. The gene mutated in thiamine-responsive anaemia with diabetes and deafness (TRMA) encodes a functional thiamine transporter. Nature Genetics. 1999;22:305-308.
- Diaz GA, Banikazemi M, Oishi K, Desnick RJ, Gelb BD. Mutations in a new gene encoding a thiamine transporter cause thiamine-responsive megaloblastic anaemia syndrome. Nature Genetics. 1999;22:309-312.
- Taylor DW, Barnett HJ, Haynes RB, et al. Low-dose and high-dose acetylsalicylic acid for patients undergoing carotid endarterectomy: a randomised controlled trial. Lancet.1999;353:2179-2184.
- Parker JD, Parker JO. Nitrate therapy for stable angina pectoris. NEJM.1998;338(8):520-531.
- MacAllister RJ, Vallance P. The L-arginine:nitric oxide pathway in the human cardiovascular system. JIFCC;1996;8(4):152-158.
- Adamson DC, Wildemann B, Sasaki M, et al. Immunologic NO synthase: elevation in severe AIDS dementia and induction by HIV-1 gp41. Science. 1996;274:1917-1920.
- Schaffer MR, Efron PA, Thornton FJ, Klingel K, Gross SS, Barbul A. Nitric oxide, an autocrine regulator of wound fibroblast synthetic function. J Immunol. 1997;158:2375-2381.
- Brisinda G, Maria G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. A comparison of injections of botulinum toxin and topical nitroglycerine ointment for the treatment of chronic anal fissure. N Engl J Med. 1999;341(2):65-69.
- Scherrer U, Vollenweider L, Delabays A, et al. Inhaled nitric oxide for high-altitude pulmonary edema. N Engl J Med. 1996;334:624-629.
- Kurose I, Miura S, Higuchi H, et al. Increased nitric oxide synthase activity as a cause of mitochondrial dysfunction in rat hepatocytes: roles for tumor necrosis factor a . Hepatol. 1996;24:1185-1192.
- Vamvakas S, Schmidt HH. Just say NO to cancer? J Natl Cancer Inst. 1997;89(6):406-407.
- Xie K, Huang S, Dong Z, Juang SH, Wang Y, Fidler IJ. Destruction of bystander cells by tumor cells transfected with inducible nitric oxide (NO) synthase gene. J Natl Cancer Inst. 1997;89(6):421-427.
- Kiberstis PA. Mitochondria make a comeback. Science. 1999;283:1475.
- Gray MW, Burger G, Lang BF. Mitochondrial evolution. Science. 1999;283:1476-1481.
- Yaffe MP. The machinery of mitochondrial inheritance and behavior. Science.1999;283:1493-1497.
- Wallace DC. Mitochondrial diseases in man and mouse. Science. 1999;283:1482-1488.
- Yakes FM, Van Houten B. Mitochondrial DNA damage is more extensive and persists longer than nuclear DNA damage in human cells following oxidative stress. Proc Natl Acad Sci USA. 1997;94:514-519.
- Lonsdale D, Shamberger RJ, Stahl JP, Evans R. Evaluation of the biochemical effects of administration of intravenous nutrients using erythrocyte ATP/ADP ratios.Alternative Med Rev. 1999;4(1):37-44.
- Chen D, Ma H, Hong H, et al. Regulation of transcription by a protein methyltransferase. Science. 1999;284:2174-2177.
- Siegfried Z, Eden S, Mendelsohn M, Feng X, Tsuberi BZ, Cedar H. DNA methylation represses transcription in vivo. Nature Genetics. 1999;22:203-206.