Practitioner Roundtable—Continued
Practitioner RoundtableIn the August 2023 print issue of Natural Practitioner (NP), an expert panel of practitioners talked trends they are noticing, technology news, patient- and self-care, as well as the future of complementary and integrative health. Here is a continuation of what they had to say.
Participants:
Jeff Anshel, OD, FAAO, Author of Smart Medicine for Your Eyes (Second Edition), Kapaa, HI, https://cvconsulting.com/
Dr. Nicole Avena, Princeton, NJ, www.drnicoleavena.com
Michael Edson, MS, LAc, New Paltz, NY, www.naturaleyecare.com
Marc Grossman OD, Lac, New Paltz, NY, www.naturaleyecare.com
Jason Napuli, DC, Adjunct professor at Logan University and Chief of Chiropractic and Complementary & Integrative Health; VA Residency Program Director, VA St. Louis Health Care System, St. Louis, MO, www.linkedin.com/in/jason-napuli-23431410/; www.logan.edu/faculty/jason-napuli-dc/
Jodi Perrin, DC, ND, Instructor of Naturopathic Medicine – Clinical Sciences, National University of Health Sciences, jperrin@nuhs.edu
Dr. Elizabeth Livengood, Owner, Livengood Health, Mesa, AZ, www.livengoodhealth.com
Holly Lucille, ND, RN, ONC, Los Angeles, CA, www.drhollylucille.com
Dr. Rosia Parrish, Boulder, CO, Naturopathic Wellness Center of Boulder (Virtual Practice Only), www.nawellness-boulder.com
Jacob Teitelbaum, MD, Kailua Kona, HI, www.vitality101.com
NP: How have you embraced technology within your practice? Do you use a patient portal, offer virtual visits, created an app for patients, etc.?
Napuli: The use of both a patient portal or PHR and Electronic Health Records (EHR) are important components of health care. With the evolution of EHR, we are now able to seamlessly have medical records that can be shared among many health care providers. PHR is increasingly important for patients to have access to their own health care records and have the ability to communicate with their health care provider.
Avena: Yes, but it different ways than people traditionally think about when asked this question. I have utilized advanced technology as a method to help educate others and provide continued updates on the latest science. I use social media to convey a lot of this type of educational information.
Anshel: Yes, technology has certainly penetrated the eyecare health field. However, remote or virtual visits are less than efficient since practitioners use high-powered magnification and deep penetrating views into the eye to examine appropriately. These techniques are not available in virtual visits. We need to emphasize to patients that reading “20/20” on a chart does not substitute for a complete eye health evaluation.
Perrin: I utilize EHR/EMR in my office. The company I use has a patient portal where patients can access their records and make their own appointments. As a solo practitioner that does not have any employees, it is a huge help that patients can schedule their own appointments. I do some virtual visits, which allows for easier access to care for busy patients, and patients that live a distance from the office.
Grossman: Yes, great diagnostic technologies for eye conditions.
Livengood: I started offering video telemedicine visits before COVID and it was not widely utilized, as it is now. I surveyed my patients regarding the use of an app, and most people said they would probably not use it, so we haven’t invested in that yet. Our portal is user-friendly and comprehensive. It offers secure email, document sharing, charting, billing, referral letters and inventory management. We also have VOIP phone service that patients can text, which they love and utilize frequently.
Lucille: I have yes, entered the age of EHR for sure. My patients do have their own portal and I am completely remote at this time. No apps yet.
Parrish: I am a naturopathic doctor with a 100 percent virtual specialty practice (specialty is fertility), I have fully embraced technology to provide comprehensive care remotely. I was initially hesitant about this change (that I made post-pandemic, in May 2022), but since making this decision, I have incorporated the following:
1. Patient portal: Secure system for health information, review test results, and communicate with patients securely. The portal ensures that patient data remains confidential and allows for convenient and efficient communication between appointments. This isn’t new for me, but increased communication within the portal has increased. In this portal, I keep digital health records to store patient information including medical history, labs, treatment plans, and more. This allows for easy access during virtual visits.
2. Virtual visits: I offer virtual visits consultations only. Through secure telehealth conferencing platforms, I can conduct thorough assessments, order labs and imaging, provide referrals, discuss treatment plans, and address any concerns or questions patients may have. Virtual visits eliminate the need for in-person appointments and provide flexibility in scheduling, my family, and my life. My quality of life has significantly improved since pivoting to virtual practice.
3. Online scheduling: An online scheduling system that allows patients to book appointments at their convenience or they can contact me or my office manager (virtual assistant) and we can do this for them. This feature simplifies the appointment process and saves time for both patients and me and my office manager.
Leveraging these technologies enables me to deliver high-quality care, maintain efficient communication with patients, and empower them to take an active role in managing their health. Virtual visits and specialty lab shipments to patients’ homes have changed the way consultations are conducted. Additionally, patients are responsible for obtaining their own lab orders (the ones I write up) and take it to the lab, and purchasing recommended supplements from my online pharmacy, requiring motivation and a proactive approach to their health.
Teitelbaum: I have designed a popular free phone app called “Cures A-Z” which is kind of like having my brain in your pocket, but less messy. It has had more than a million downloads. I also hold a U.S. patent for a computerized physician, which has been modified into the Energy Analysis Program (www.EnergyAnalysisProgram.com). This free program analyzes people’s symptoms and pertinent labs and guides them on how to optimize energy levels. It is especially helpful for people with CFS, fibromyalgia and long COVID.
NP: Do you work with testing labs? If so what types of tests do you use and how do you choose which labs to partner with?
Avena: I don’t work with any testing labs.
Anshel: The testing labs I usually work with are for the purpose of determining the presence and level of patients’ nutritional deficiencies. I review the labs and discuss with local nutritionists the kinds of programs with which they have experience—and I apply that to my work as well. Word of mouth is a good start. I also work with one lab that offers an online questionnaire (not a food frequency), and from that I also get a range of specific results from which to base my recommendations.
Perrin: I utilize various labs in practice. I mostly focus on the standard labs that can be done in most medical laboratories. There are a few specialized tests I find useful in patient cases that would benefit from that type of testing. I like to utilize stool testing, salivary and urinary hormone testing, nutrient testing and food sensitivity testing. When deciding on a lab to partner with, I look for good customer service, client and provider support, access to learning materials for the practitioner, and validity of the tests.
Grossman: I look for labs that check glucose levels and inflammation levels that may contribute to eye conditions.
Livengood: We run basic labs through insurance (which means LabCorp and Sonora Quest in my region). The same labs can be run inexpensively for people with no insurance or Medicare (through Ulta Labs). We also use specialty labs for more in-depth testing of hormones, cortisol, food sensitivities or gut issues.
Lucille: I do and now with this platform RUPA, just like the Fullscript platform, you can more easily learn about more testing and other methodology.
Parrish: Yes, I work with testing labs to gather valuable insights into my patients’ health and guide their treatment plans. The types of tests I utilize depend on the specific needs and goals of each individual. Here are some examples of the tests I commonly use and how I choose which labs to partner with:
1. Day 3 and 7 DPO Bloodwork: These hormone tests are performed on specific days of the menstrual cycle to assess ovarian reserve, follicle-stimulating hormone, luteinizing hormone, estradiol, and progesterone levels. I choose reputable labs that specialize in reproductive hormone testing to ensure accurate and reliable results.
2. Semen analysis testing and comprehensive fasting lab work for the sperm donor and/or male partner. This helps me understand underlying causes that they might be bringing to the fertility landscape.
3. DUTCH Testing: The DUTCH test is a comprehensive hormone assessment that measures hormone metabolites in dried urine samples. It provides a detailed profile of hormone levels, including estrogen, progesterone, testosterone, cortisol and more.
4. Food Sensitivity Testing: Food sensitivity testing helps identify specific food triggers that may be causing inflammation or immune reactions in the body. This test helps me pinpoint potential trigger foods without the use of an elimination diet and to create personalized dietary plans for my patients.
5. Antioxidant Testing: Antioxidants are vital for reproductive health, protecting eggs and sperm from oxidative stress. Testing for antioxidant levels can provide insights into a person’s antioxidant status, which is incredibly important for fertility.
6. And more! I test for mycotoxins/mold exposure, environmental toxins, autoimmunity, and more.
When deciding which lab companies to partner with as a health care practitioner, I consider several factors:
1. Test quality and accuracy: I look for lab companies with a reputation for accuracy, reliability, and adherence to quality control standards. I consider their certifications, accreditations, and participation in testing programs.
2. Turnaround time: This has been an issue for several reputable lab companies lately. If they don’t continuously have adequate timely results, and if I hear from others about their track record for meeting turnaround time commitments, I reevaluate if I am going to order with them.
3. Insurance coverage: My services as a naturopathic specialist aren’t always covered, so I do like to order labs that are covered by insurance when possible. Fortunately, my patients can usually be covered by companies like LabCorp or Quest Diagnostics, but it is not typical for smaller ordering companies. I do like using companies like Reimbursify and others to see if patients can get reimbursed for visits, supplements and lab work.
4. Customer service and support: I like companies that are responsible, accessible, and have top-notch customer service including the ability to have a medical consult.
5. I also consider cost and pricing structure. I prefer lab companies that have multiple methods of payment from paying in full, using insurance, or having payment plans.
6. My main priority when choosing a lab company is their compatibility with a virtual practice. This includes drop shipping capabilities for direct lab shipments to patients, access to local phlebotomists for bloodwork, and seamless remote collaboration without the need for an in-office lab test.
I would be remiss if I didn’t say that I prefer lab companies that are peer recommended and have a good reputation. Trusted colleagues and health professionals insights and recommendations are very valuable and help me inform my decision as well.
Teitelbaum: I find it much more effective to simply listen to the person’s symptoms, and then look at the response to treatment. Tests can be helpful, but the normal ranges often cannot accurately be used to determine treatment. Most normal range is simply telling you if the person falls in the lowest or highest 2 percent of the population (two standard deviations). For example, a normal range for shoe sizes would be size 5 to 13. This does not mean that a size 7 shoe fits everyone. But most physicians would act as if it did.
NP: Do you carry (or recommend) supplements in your practice? If so, how do you vet the companies you work with?
Napuli: Recommending supplements is an important part of practice. It is also important to know your patients and the potential for interactions with medications. Working closely with a patient primary care provider or specialty provider, you can ensure that you recommendations for nutritional support does not conflict with current medication regiment and planning.
Avena: I recommend supplements when necessary, and I am very selective about which brands I will recommend. I look for quality ingredients, third-party testing, and avoid companies that make lofty or non-scientific claims.
Anshel: When I was in practice, I absolutely did! I have a list of “what to look for in a supplement” ingredients and talk to different companies about their respective manufacturing processes, their ingredient sourcing, and their marketing efforts. I must always feel comfortable and knowledgeable in making any recommendations to patients.
Perrin: Supplements are a big part of what I utilize in practice. Since I have a limited amount of space, I work with an online dispensary and carry the bare minimum essentials for urgent cases. When picking the companies I want to work with, I look at the quality of the products the most. I also take into consideration the cost, customer service, provider education and support, and the companies involvement in research and development.
Grossman: Yes I do carry supplements in my clinic. I have developed my own line of specific nutrients and herbal formulas to be part of my protocols for vision conditions such as macula degeneration, glaucoma, dry eyes etc. I did this to make sure that the quality was good and that the therapeutic dosages according to research were met. [I] usually [go] through Emerson Ecologics.
Livengood: Yes, we carry a small inventory of basic supplements such as multivitamins, probiotics and immune support. We also create “prescriptions” in Fullscript for nearly every patient. I only utilize nutraceutical companies that confirm their ingredients and excipients and reveal how they source their herbs.
Lucille: I don’t necessarily carry supplements, but I make them available via Fullscript to be honest. I set my margin to zero, so I don’t make revenue from my recommendations. Mostly through reputation but more recently, through clinical studies and transparency of quality.
Edson: All the companies we work with are recognized on the health care industry as having high standards.
Parrish: I am a virtual practice so all supplements I recommend are within online pharmacies where I personally create a tailored supplement prescription to my patient, and they can retrieve it within the online pharmacy portal.
Beware of purchasing supplements from unauthorized sources (including Amazon!) It’s important to be aware of the potential risks associated with purchasing supplements from unauthorized sources, such as Amazon or unknown websites.
To ensure your safety and the effectiveness of the supplements you take, consider the following guidelines:
1. Choose companies that adhere to good manufacturing practices (GMP) and NSF standards, which prioritize quality control measures.
2. Look for supplements that undergo third-party raw material testing to verify their authenticity and quality.
3. Opt for products that undergo batch testing, which involves third-party testing of each batch to ensure consistency and potency.
By following these guidelines, you can have greater confidence in the safety and reliability of the supplements you consume.
Teitelbaum: It seems that some companies have their products put together largely by the marketing department, with precious little regard to the science. Others are science-based, or based on solid clinical experience. I have found that EuroMedica has created a superb line of products that use the cutting edge research.
NP: What advice do you have for someone looking to get into the field of complementary and integrative health?
Napuli: CIH continues to be a growing field that is evidence based and can offer a person-centered approach to care. By adopting these practices, you can ensure that you are offering your patients the best care possible. Understanding the collaborative nature of CIH and the importance of working tother remain the center focal point for CIH. Having an increased understanding of the role that a CIH provider plays in conventional approaches is important. Recognizing that it is not how many CIH approaches that you are versed in, it is understanding that becoming an expert in the evaluation and management of chronic conditions is important rather than a provider who promotes being well versed in CIH and able to deliver these modalities entirely. Understanding limitations and also your passion for success remains important.
Avena: Find something you are interested in for yourself, and then takeoff with it as a complement to what you already do/ the populations you serve. If you are passionate about it, you will succeed.
Anshel: Realize that when you graduate from your school or program, your education has really only just begun!
Perrin: I think the best things someone can do is to be a patient in the so they can experience the medicine, shadow practitioners in their field(s) of interest to see what practice is like, and then visit as many schools as they can to find the one that is the best fit. I was a patient of chiropractic for many years and when I first became interested in being a chiropractor, I decided to follow a few doctors and then worked as a chiropractic assistant to see if chiropractic was really what I wanted to do. I had a similar path when I became interested in naturopathic medicine.
Grossman: There are many good programs. [For] example, The Institute For Functional Medicine to study integrative medicine or naturopathic colleges.
Livengood: I suggest they experience and observe many modalities to find which ones resonate the most with them. Not everything requires a doctorate. Many people are very successful in a niche practice of reiki or nutrition counseling. They should also consider whether they want to simultaneously be an entrepreneur or if they prefer the security of an employee position. This can have an impact on job opportunities in their chosen field.
Lucille: Go for it! People need you and there are so many recourses to set you up for success.
Edson: Attend introductory lectures as the specialized schools to get a feel as to what form or integrative medicine appeals the most to them.
Parrish: If you’re considering a career in complementary and integrative health, here is some valuable advice to help you navigate your path:
• Research and explore: Take the time to thoroughly research and understand the field of complementary and integrative health.
• Familiarize yourself with different modalities, practices and approaches. Explore various educational paths, certifications, and licensing requirements to gain a comprehensive understanding of the field.
• Choose accredited institutions: Ensure that the educational institutions you consider are accredited and regulated. This ensures that you receive a quality education that meets industry standards and prepares you for professional practice.
• Financial considerations: Compare the costs of different schools and programs, and also inquire about financial assistance options. Talk to current and former students to gain insights into their experiences with financing their education.
• Pursue relevant education: Once you’ve identified the educational path that aligns with your career goals, pursue your education diligently. Depending on your chosen field, you may need to complete pre-medical coursework or other specific requirements. Stay focused and committed to your educational journey.
• Seek mentorship and networking: Connect with experienced practitioners in the field who can serve as mentors and provide guidance. Attend conferences, workshops and professional events to network with like-minded individuals and expand your professional connections. Mentors can offer valuable insights and support as you navigate your career.
• Gain practical experience: Seek opportunities to gain practical experience in complementary and integrative health. Consider volunteering or interning alongside practitioners to deepen your understanding, refine your skills, and establish a solid foundation for your future practice.
• Stay informed: Keep yourself updated on the latest research and developments in complementary and integrative health. Subscribe to reputable journals, join state and national professional associations, and engage in continuing education to stay informed about emerging trends, evidence-based practices and regulatory updates. Continuous learning is essential in this field.
Teitelbaum: When I entered medicine in 1972, getting an MD or DO degree was the only pathway that legally allowed you to diagnose or treat. Fifty years later this is no longer the case. Most often, I recommend people who are interested get an ND degree instead, from one of the certified naturopathic colleges that offers the ability for licensure. Be sure it is one that allows them to diagnose and prescribe.
Unless their heart is calling them to other branches of CAM. But then they need to realize that they will have to follow a legal “Texas Two-Step” Dance to be able to treat people.
NP: Is there anything else you would like to add?
Anshel: If we are going to succeed when it comes to improving patients’ outcomes as a whole, then we need to incorporate lifestyle medicine, nutrition, exercise, mental support and other similarly complementary-oriented modalities into a fuller system of diagnosis and treatment. It’s up to us.
Grossman: As science and technology improves in both the diagnostic and treatment of medical conditions, it is more important than ever to treat the person behind the eyes and not just the eyes.
Livengood: I would love to see individuals in our field being more supportive and communicative rather than competitive and secretive. There are plenty of patients for everyone. Providing healthcare services while running a profitable business can be daunting, and we would all benefit from supporting each other in these challenging areas.
Edson: It is really important to let people know that lifestyle considerations play an important role in both short and long term health, and that they have the power to make these decisions.
Teitelbaum: Especially important? I encourage practitioners to “follow their bliss.” Take the time to notice what feels best to you. Our intuition speaks to us through feelings more than thoughts. Combining intuition and logic, with a healthy dose of skepticism, can lead you to authenticity and effectiveness. And happiness.
