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The Patient Whisperer

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The Patient Whisperer

Finding patients that fit

There’s a fundamental numbers problem facing practitioners in integrative medicine: most people aren’t buying what you’re selling.

Take naturopathic medicine. Good stats are hard to come by, but it’s not unreasonable to assume that less than 10% of the people in your area use an ND with any regularity. It’s probably closer to 3%.

at’s a pretty small slice of the pie.

e good thing about that slice, though, is that it’s tasty. It’s made up of people who already understand what you do and want what you have to off er. ey’re already on board. ey love you. ey need less educating, less convincing.

The downside of that small slice of the pie, though, is that it isn’t always enough to feed everyone. Most of us need to wade out into the vast blue ocean of opportunity that is the other 90% or more of the population. And that’s where the trouble begins: it turns out that the ocean is a big place, and not everyone in it is friendly.

The Problem With Skeptics

That unexplored area on the map represents the opportunity to grow your practice. It’s a vast, untapped mass of people who have often never heard of you or what you do, never mind actually considered trying it.

But strange territory has a way of changing how we behave. Faced with uncertainty and skepticism, we change our stance. We become less confi dent. We compromise more. In an eff ort to win over skeptics we cut fees, stay late, open early, and make a host of other concessions that impact our lives and the quality of the care we deliver.

In short, trying to win people over is when we become the Jackass Whisperer. We spend money trying to reach them. We give them time, and more time, and still more time. And worst of all, we let our confi dence hang on whether or not they’ll fi nally agree with us.

But the worse part of all of this is that chasing skeptics doesn’t work. It turns out that after all your eff ort, expense and agony, the skeptics are still the same way they were when you started: skeptical. And in the meantime, they’ve drained time and energy away from the people you love to help.

Worse still, it’s not even their fault. It’s yours. e problem with skeptics, it turns out, is not that they’re skeptical. It’s that we keep pouring energy into them. But that leaves us with a dilemma. Your fans currently aren’t enough to feed you. But the people that aren’t your fans can be an enormous drain of resources to market to. So how do you grow?

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1. Understand the Cost of a Lost Skeptic…is Almost Nothing Before you can truly let go of the people that don’t fi t, you need to understand how little you’re actually giving up. ere’s often a little voice in your head that speaks up when you start pandering to skeptics. It’s a voice that says, “ is person isn’t a great fi t. Let them go.” en, of course, another voice speaks up that says, “Who do you think you are? You can’t aff ord to be so picky.”

That second voice is often the squeaky wheel – it gets all the attention. But the problem with that voice is that it’s terrible at math. It’s the voice of fear, and it believes that every lost opportunity is also lost income.

It turns out, though, that patients who don’t fi t simply don’t have that much value to your practice. ey often can’t be pleased. ey consume resources. ey don’t refer. ey don’t comply, and then they complain to others.

Let them go.

2. Define Who Fits Once you know what you don’t want more of, it’s important to defi ne the patients you do want.

In our clinic, the people who need our help the most and make the best patients have one or more of these three things in common:

• A health complaint that no one else could help resolve

• An intolerance to conventional options, or the need to reduce or eliminate a conventional care dependency

• A desire for better health care service. Th ings like more time, accessibility, no waiting, respect and informed consent.

That’s it. If someone meets one or more of those criteria, we can help. It’s that simple. Your criteria might be far more specifi c – what’s important is that you have criteria. Your criteria help strain that big, unwashed slice of pie, fi ltering out who doesn’t fi t, and leaving behind the people that we can best help.

3. Start Fan Whispering ose rules also serve an even more important purpose: they help other people understand who we can help. at’s critical, because even when you defi ne who you do want, there’s still a barrier to be surmounted: the people you want don’t know you. You may have what they want, but you may not have the credibility to bring them in.

But who does have the clout? e people connected to them – their friends, family, colleagues, service providers and more. And guess where they are? In your practice.

Tapping into new patients, then, begins not by trying to fi nd the people you want to be your fans, but by speaking to the ones who already are. ey’re your levers to help shift others. ey’ re the ones with the infl uence and the reach to step out into that big ocean and attract the people you’re looking for.

But how do you do it? What does it mean to focus on your fans?

Delight them:

You’re not really competing with the ND down the street – unless you want to keep squabbling over that same small slice of pie. What you’re really competing with is the idea in our minds that health care should be free. To justify your fee-for-service existence, you need to thrill your fans, every time. Do that, and they’ll do the hard work of convincing their friends and family that you’re worth every penny.

Eliminate barriers to entry:

Your fans are already out their singing your praises. But occasionally they’re stumbling across the same roadblock you are: the cost of what you do. We hear stories all the time of people desperately trying to convince their friends and family to visit a naturopath, but the person in question can’t seem to get over the cost issue.

Why not just remove it? Just for one visit?

Empower your fans to remove that barrier. Selectively give out certifi cates for a complete fi rst visit to your best patients, and ask them to off er it to someone. ey’ll know who needs it most. And once that person sees what you’re really about, the money may be far less of a barrier than it once was.

Find e Fans With Reach:

In terms of their ability to deliver patients to you, not all fans are created equally. And not all fans are patients. Who can you partner with in your community that can reach the people you’re seeking? One fan with reach can go a long way to fi lling your practice. We’ve met more than one practitioner whose practice was built almost entirely on referrals from another provider who was a true fan.

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Patient Whispering Pays Off

Over time, the best quality and quantity of patients will come from inside your practice. ey’ll be delivered by the people who love you most, and fi t you best. Where they won’t come from is from people who don’t fi t. Spend your time speaking to the people who love what you do. When you meet a jackass – and you will – move on.

A randomized targeted amino acid therapy with behaviourally at-risk adopted children

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Increasing numbers of children are at-risk for behavioural and emotional disorders, a phenomenon contributing to increased use of pharmacological interventions for pediatric clients. Adverse side effects and other risks associated with pharmacological approaches have helped fuel interest in nutritional interventions for behaviourally at-risk children. The current randomized clinical trial evaluated the efficacy of a neurochemical intervention involving the glutamine and glutamate analogue L-theanine and 5-hydroxytryptophan, the precursor for serotonin, with children adopted from traumatic backgrounds. Results include significant increases in urinary levels of the biomarkers for serotonin and gamma-aminobutyric acid, coupled with significant decreases in parent reports of the children’s behaviour problems. While further research is needed, these initial findings are encouraging and are consistent with a growing number of studies indicating the efficacy of nutritional approaches to help behaviourally at-risk children. (Child Care Health Dev. 2010 Dec 20) PMID: 21166834.

Reduced expression of fatty acid biosynthesis genes in the prefrontal cortex of patients with major depressive disorder

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The expression of FADS1 (Δ5 desaturase), FADS2 (Δ6 desaturase), HELO1 [ELOVL5] (elongase), PEX19 (peroxisome), and SCD (stearoyl-CoA desaturase [Δ9 desaturase]) was determined in the postmortem prefrontal cortex of MDD patients (n=10) and non-psychiatric controls (n=10) by real-time reverse transcriptase polymerase chain reaction (RT-PCR). After correcting for multiple comparisons, FADS1 mRNA expression was significantly lower in MDD patients relative to controls (-27%, p=0.009), and there were trends for lower expression of FADS2 (-30%, p=0.07), HELO1 (-37%, p=0.02), and SCD (-43%, p=0.02). PEX19 mRNA expression did not differ between controls and MDD patients (-2%, p=0.92). There were no significant gender effects, and relative reductions in FADS1, HELO1, and SCD expression were greater in patients that did not commit suicide compared with patients that did commit suicide. Principal genes involved in LC-PUFA and monounsaturated fatty acid biosynthesis are down-regulated in the postmortem prefrontal cortex of MDD patients. Additional studies are needed to replicate and extend these findings in a larger sample that includes antidepressant-free MDD patients. (J Affect Disord. 2010 Sep 20.) PMID: 20863572.

Open trial of L-5-hydroxytryptophan in subjects with romantic stress

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This open-label trial assessed the clinical efficacy of L-5-hydroxytryptophan (5-HTP) in non-depressed young subjects with high levels of romantic stress. A total of 15 healthy subjects (11 females and 4 males, mean age 23.3 ± 2.1 years) who experienced a recent romantic break-up or reported recent romantic problems took part in the study. The participants were treated openly for 6 weeks with L-5-hydroxytryptophan (60 mg Griffonia simplicifolia extract containing 12.8 mg 5-HTP twice daily). The subjects were evaluated at baseline, at 3 weeks and at 6 weeks using an adapted version of the Seiffge-Krenke’s Problem Questionnaire. BDNF and platelet serotonin content were determined at baseline, at 3 weeks, and after the completion of the 6-week trial. There were significant improvements in romantic stress scores from weeks 0 through 3 (p=0.007) but no further significant improvement was evident from weeks 3 through 6 (p=0.19). At 6 weeks, subjects had a significant increase from baseline in both BDNF and platelet serotonin values, suggesting that direct modulation of the serotonergic system with 5-HTP may be effective for improving psychological distress associated with romantic grief. (Neuro Endocrinol Lett. 2010 Nov 3;31(5).) PMID: 21178946.

Meta Analysis of Fish Oil for Depression

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A total of 241 studies were identified, of which 28 were included for meta-analysis. Overall standardized mean depression scores were reduced in response to fish oil supplementation as compared with placebo (standardized mean difference -0.291, 95% CI -0.463 to -0.120, p = 0.001). Subgroup analyses showed significant effects for: (1) diagnostic category (bipolar disorder and major depression showing significant improvement with omega3 LC-PUFA supplementation versus mild-to-moderate depression, chronic fatigue and non-clinical populations not showing significant improvement); (2) therapeutic as opposed to preventive intervention; (3) adjunctive treatment as opposed to monotherapy; and (4) supplement type. Symptoms of depression were not significantly reduced in 3 studies using pure DHA (p= 0.997) or in 4 studies using supplements containing greater than 50% DHA (p = 0.417), but were significantly reduced in 13 studies using supplements containing greater than 50% EPA (standardized mean difference -0.446, 95% CI -0.753 to -0.138, p = 0.005) and in 8 studies using pure ethyl-EPA (standardized mean difference -0.396, 95% CI -0.650 to -0.141, p = 0.002). The current meta-analysis provides evidence that EPA may be more efficacious than DHA in treating depression. (J Am Coll Nutr. 2009 Oct;28(5):525-42.) PMID: 20439549.

Pilot study of Injectable Methyl B12 treatment in children with Autism

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The study was a 12-week, double-blind, placebo-controlled, cross-over clinical trial of injectable methylcobalamin, after which subjects were given the option of entering a 6-month open-label trial. All subjects received 6 weeks of placebo and 6 weeks of methyl B12 at a dose of 64.5 mcg/kg every three days administered subcutaneously into the buttocks. Blood for GSH analysis and behavioral assessments were obtained at baseline, week 6, and week 12. Thirty (30) subjects completed the 12-week, double-blind study and 22 subjects completed the 6-month extension study. No statistically significant mean differences in behavior tests or in glutathione status were identified between active and placebo groups. However, 9 subjects (30%) demonstrated clinically significant improvement on the Clinical Global Impression Scale and at least two additional behavioral measures. More notably, these responders exhibited significantly increased plasma concentrations of GSH and GSH/GSSG. Although methylcobalamin was found to be ineffective overall in treating behavioral symptoms of autism, methylcobalamin may alleviate symptoms of autism in a subgroup of children. (J Altern Complement Med. 2010 May;16(5):555-60.) PMID: 20804367.

Dietary intervention in infancy and later signs of beta-cell autoimmunity

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In a double-blind, randomized trial, 230 infants with HLA-conferred susceptibility to type 1 diabetes and at least one family member with type 1 diabetes were assigned to receive either a casein hydrolysate formula or a conventional, cow’smilk- based formula (control) whenever breast milk was not available during the first 6 to 8 months of life. Autoantibodies to insulin, glutamic acid decarboxylase (GAD), the insulinomaassociated 2 molecule (IA-2), zinc transporter 8, and islet-cell antibodies were analyzed during a median observation period of 10 years. The unadjusted hazard ratio for having a positive test for one or more autoantibodies was 0.54 (95% CI 0.29-0.95) in the casein hydrolysate group compared with the control group; the adjusted HR was 0.51 (95% CI 0.28-0.91). The unadjusted hazard ratio for positivity for two or more autoantibodies was 0.52 (95% CI 0.21-1.17), and the adjusted hazard ratio was 0.47 (95% CI 0.19-1.07). In the per-protocol cohort the hazard ratio for incidence type 1 diabetes with casein hydrolysate was 0.40 (95% CI, 0.11 to 1.51), incidence rate 4% versus 8%. Use of hydrolyzed whey protein in preference to other formula types may reduce risk of type 1 diabetes. (N Engl J Med. 2010 Nov 11;363(20):1900-8.) PMID: 21067382.

Omega-3 Fatty Acids Improve Function in Non-ischemic Heart-Failure Patients

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This study was designed to test the effects of n-3 polyunsaturated fatty acids (PUFAs) on left ventricular (LV) systolic function in chronic heart failure (HF) due to non-ischemic dilated cardiomyopathy (NICM). A total of 133 patients with NICM and minimal symptoms on standard therapy were randomized to receive n-3 PUFAs or placebo. For the first month, patients took 5 caps/d (~4250 mg combined EPA+DHA), after which they took 2 caps per day (1700 mg) for 11 months. Both groups were treated with an ACE inhibitor/angiotensin-receptor blocker, a beta blocker, and furosemide. LV function and functional capacity were assessed by echocardiography and cardiopulmonary exercise testing at baseline and at 12 months. After 12 months, the n-3 PUFAs group and the placebo group differed significantly (p <0.001) in regard to: 1) LV ejection fraction (increased by 10.4% and decreased by 5.0% respectively); 2) peak VO(2) (increased by 6.2% and decreased by 4.5% respectively); 3) exercise duration (increased by 7.5% and decreased by 4.8% respectively); and 4) mean New York Heart Association functional class (decreased from 1.88 ± 0.33 to 1.61 ± 0.49 and increased from 1.83 ± 0.38 to 2.14 ± 0.65 respectively). The hospitalization rates for heart failure were 6% in the n-3 PUFAs and 30% in the placebo group (p = 0.0002). (J Am Coll Cardiol. 2010 Dec 29.) PMID: 21215550.

Prevalence of celiac disease in autoimmune liver disease

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Prevalence of coeliac disease was assessed among 100 autoimmune liver disease patients in Iran and compared it with the prevalence in healthy individuals. The study also sought to determine if rates of celiac disease among autoimmune liver patients had been evaluated in Western populations. Among Iranian participants in the study, elevated prevalence of coeliac disease (10-15%) was observed compared to the general population (0.1-1%). To a lesser extent, the prevalence was high in patients with autoimmune hepatitis (2-4%). In our systematic review, prevalence of coeliac disease in autoimmune hepatitis in the majority of studies was 4% or more; several studies also reported such prevalence in primary biliary cirrhosis. CONCLUSIONS: Since coeliac disease is common among patients with autoimmune liver disease, screening autoimmune liver disease patients for coeliac disease is indicated. Although the magnitude of benefit from a gluten-free diet in reversing autoimmune liver disease in patients with coeliac disease is controversial, it may reduce the risk of further complications of coeliac disease. (Dig Liver Dis. 2010 Sep;42(9):620-3.) PMID: 20236872

Gluten- and casein-free diet for children with autistic spectrum disorders

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During stage 1, 72 Danish children aged 4 to 11 years were assigned to GFCF diet (A) or no-diet (B) groups. Participants were assessed at baseline, 8, and 12 months using the Autism Diagnostic Observation Schedule (ADOS) and the Gilliam Autism Rating Scale (GARS) to assess core autism behaviours; Vineland Adaptive Behaviour Scales (VABS) to ascertain developmental level; and Attention-Deficit Hyperactivity Disorder – IV scale (ADHD-IV) to determine inattention and hyperactivity. Based on per protocol analysis, data for 26 diet children and 29 controls were available at 12 months. At this point, there was a significant improvement in the GFCF diet group on sub-domains of ADOS, GARS and ADHD-IV measures. At this point, given the improvement seen in the treatment group (A), the control group (B) was also offered treatment. Data from18 group A and 17 group B participants were available at 24 months. Analysis based on inter- and intra-group comparisons showed evidence of sustained clinical group improvements with a possible plateau effect for diet. Further studies are required to ascertain potential best- and non-responders to intervention. (Nutr Neurosci. 2010 Apr;13(2):87-100.) PMID: 20406576