The Complete Patient

I’ve been in Sarasota, FL, the last week tending to my mother, who is 84, trying to help her decide whether or not she needs to move from her apartment in a senior citizen community into an assisted living facility. She’s had what seems to be a rapidly accumulating number of health problems, primary among them dizziness and edema in her legs that renders her nearly unable to walk. Still, she is understandably resisting the move. 

Part of my intention in coming down to Sarasota, aside from helping my mom assess a specific assisted living facility, was to help her explore switching doctors. Her existing physician of twenty years has told her that he can find no cause of her dizziness (which has sent her to the hospital a couple of times after actual fainting), and that her edema really isn’t getting worse, that it’s just something that can’t be treated and that she needs to learn to live with. I actually was with her on one visit to this doctor a couple years back, so I knew my mother’s reports of his detached approach haven’t been an exaggeration He’s had her on three or four different prescription medications designed to thin her blood and help correct possible heart beat irregularities.

My feeling has been that there may be some non-drug tactics she can apply to her problems (perhaps herbs or supplements) and that she may benefit from the insights of another physician. So, with help from my sister, who lives in the Sarasota area, I checked around and found a doctor trained in so-called functional medicine, which emphasizes prevention and comprehensive management of complex and chronic conditions. I arranged an appointment about a month before coming down, and last week my mother and I went in to visit the doctor.

We were both impressed. In listening to my mother’s heart, she thought she detected problems with her aorta. In examining her legs, she found fluid in her knees, and in her questioning figured out that there is likely a genetic factor contributing to the edema. None of these matters had ever been explored or raised by her previous doctor.

It turns out the new doctor has what’s known as a “concierge” practice—a new trend among doctors who want to increase the amount of time they can devote to each patient, and reduce their overall patient load by charging an annual fee above and beyond regular office charges. I had known about this in advance, and encouraged my mother to consider it, since it seemed as if she needed additional care, assuming the doctor was knowledgeable and appropriate to her. The $1,500 annual “membership” fee, as this new doctor called it, seemed okay—perhaps beneficial, since my mother tends not to take great care of herself in terms of diet, and she resists exercise. So if she’s paying, I thought, she might be incentivized to follow through on this doctor’s recommendations.

Before leaving the office, my mother signed a form requesting that her previous doctor send along her medical records to the new doctor.

An hour-and-a-half later, a call came in to my mother’s apartment from the old physician’s office. I answered the phone, since my mother was lying down, and the physician’s office manager said it was his practice to call any patients who were leaving his practice to find out why they were leaving.

I explained that my mother was concerned that some of her conditions continued to deteriorate, and Dr. XX had said there was nothing he could do. She wanted to get another physician’s input.

“If she wants to consult with another physician, Dr. XX can send her to a specialist—maybe a vascular specialist for her legs,” she said

I explained that my mother wanted to avoid being sent to specialists—that she wanted her primary-care physician to do as much as possible to oversee any treatment.

In that case, the assistant told me, if she leaves his practice, “she can never come back.”

I said she hadn’t made the decision to leave, but in any event, that sounded like a strange approach. Just because she was consulting with another physician, she was being kicked out of his practice forever?

. “Yes, since she is going to another internist, he won’t take her back.”

“Why is that?” I asked.

“It says to him that she has lost faith in him.”

“Hmmm, “ I said. I then explained that my mother hadn’t made any final decisions (since she hadn’t and, even though the decision seemed clear to me at this point, she had the final say). The office manager she she’d call back the next day to speak with my mother.

When I explained the situation to my mother, she was upset. She had heard stories that a number of doctors in the Sarasota area had closed their practices to new patients. “What if I don’t like the new doctor. Then I won’t have a doctor.”

The intimidation was working. I tried to reassure my mother that she would always be able to find a new doctor. In any event, any doctor who was using such scare tactics probably wasn’t worth being with. While I thought the new doctor offered some possibilities for more effectively understanding and treating her conditions, the final decision was hers, I said.

She was troubled, and rightfully so.

The next day, when I called her at mid-day, I asked her if her old doctor had telephoned. Yes, the office manager had called at 9 a.m., and confirmed my report that if she left his practice, she was out for good.

So what did you say, I asked.

“I told her I was changing doctors,” she said, with more force than I’ve heard her say anything of late.

P.S. I spoke further with my mother’s new doctor today and told her about the old doctor’s reaction. “It’s partly about ego,” she explained. “Also, some of the doctors around here want to get rid of Medicare patients” because of its low reimbursement. The wonders of our healthcare system!

I was watching a report this morning on CNN that repeated what Kirsten notes in her comment on Friday’s post—that some thousands of pigs had apparently been given feed containing melamine, the poison responsible for the deaths of at least a dozen dogs and cats in tainted pet food. No problem, this report quoted government officials as stating, and other media reports have said the same thing. Even though the animals will supposedly be kept out of the food system, you know that if raw milk were found to have anything like contamination with a toxic industrial product, government officials would not be yawning the problem away. No, they and the media would be hysterical, saying, "We told you so." Of this I have no doubt, given the periodic outcries from the federal Food and Drug Administration, the Centers for Disease Control, and the attacks on Michigan, Ohio, and other raw milk producers around the country.

You can get a taste of the ongoing latent media hysteria in a report on raw milk presented by ABC’s Nightline on Friday evening. Major media had been showing signs of being more evenhanded in their treatment of raw milk, but this one seems to me to lean toward the governmental fear mongering. It refers to the growing number of people consuming raw milk as a "national movement," but the overall thrust of the report makes it sound more like a cult. All these people drinking raw milk when the CDC reports 1,000 or more illnesses (yes, yet another interpretation of CDC data) and various government officials condemn raw milk as worse than poison.

But maybe because the melamine contamination came from China, and thus is attributable to globalization, well, that makes it okay. With all the riches that occur from globalization, what’s a few poisonings here and there? All the more reason to buy local and know your producers.

While I’m on the subject of globalization and raw milk, there’s a fascinating report from the blog of Foreign Policy magazine, a highly respected publication, about the growing market for human breast milk. It suggests that while this milk thus far has come from American “wet nurses,” it speculates that demand is growing to such an extent that Americans will soon be importing breast milk from mothers in Third World countries, where it will, of course, be cheaper than the American version. So does that mean the FDA and state public health authorities will become involved in testing it for contamination? Will we have different grades, organic versus conventional, whole versus skim? In a global economy, anything is possible.

I’ve been trying to make sense of the exchange of comments following my “Resistance Tales” a few days ago, and I don’t mean that as a criticism. There’s just been a real lot of amazing discussion going on and it’s a lot to follow. A few reactions:

* If you want to learn something about the nature and dynamics of E.coli, and its role in food contamination, check it out. There is some fascinating information about E.coli, much of which challenges common perceptions about its origin, danger, and how it is spread. The discussion is about as micro as you can get, but is extremely interesting reading. Also, on a previous posting where there was much discussion about raw milk safety, I suggest taking a look at a new comment/statistical analysis of Centers for Disease Control (CDC) data by Greg Bravo underscoring the relative safety of raw milk.

* On the macro side, a few people make note of the media’s inadequate coverage of the government’s shutdown of Organic Pastures, the California raw milk dairy and probably the largest raw milk producer in the country, last fall. I did write about it for BusinessWeek.com, at a time when I knew much less than I know today about raw milk. I can tell you that it was (and is) a complicated story. A serious journalist has to make all kinds of decisions about the level of detail to include for a large audience, much of which isn’t all that interested in such details, all under the pressure of daily deadlines. All you have to do is review the comments about E.coli I just alluded to, and you’ll begin to understand the complexity of just the E.coli aspect of the case—to say nothing of the regulatory and business aspects. Add to that the fact that most journalists think raw milk is weird stuff, for kooks and about kooks, and you have a formula for poor journalism.

* The “Grand Canyon” Miguel alludes to separating the bacteria-phobes from natural process advocates also comes up repeatedly. While Melissa’s rejoinders may seem repetitious, she does a good job of playing the bacteria-phobe role and standing up for her viewpoint.

While Melissa is very much in the minority in this particular discussion, I was reminded by a number of developments over the past several days that they remain a force to be reckoned with.

Mary Zanoni, an expert on the National Animal Identification System (NAIS) informs me that there is a new move in Congress for creating a single agency—now divided between the U.S. Department of Agriculture and the Food and Drug Administration—for overseeing food safety. What’s especially intriguing is the mechanism being pushed for this new agency to do its work. The Congressional proposals, she says, “contain a provision which, if enacted, would grant authority to the proposed new agency to create not only a mandatory NAIS, but in essence, mandatory tracking for all food products, apparently including produce, grains, virtually any food or food-producing animals. This is NAIS on steroids. In fact, it would subject local, small-scale producers of vegetables and fruits to the same regulatory hell that NAIS would impose on livestock owners.”

And if you want a taste of how the government can push NAIS on farmers, consider what’s happening in Wisconsin. There the state government has set a May 1 deadline for farms to complete “premises registration.” For the apparently significant number of farmers resisting registration (the state’s Department of Agriculture, Trade and Consumer Protection on Wednesday held a packed meeting to discuss resistance by farmers), Wisconsin has come up with a tough stick. (I’m not sure it ever had a carrot).

It has sent out letters to dairy plant operators ordering them to, “Please inform unregistered producers that premises registration is a condition of licensure. All milk producers, new and existing, must have a registered premises to avoid jeopardizing their milk producer’s licenses.” (In Wisconsin, dairy plants pass out milk producer licenses.) So Wisconsin joins Michigan in pushing the USDA’s NAIS agenda. (Michigan made registration mandatory for all cattle as of last March 1, though it hasn’t come up with the cute dairy licensing trick of Wisconsin.)

One final note: Pete Kennedy, a lawyer for the Weston A. Price Foundation, informs me there is a federal move afoot to outlaw the herdshare approach for making raw milk available in states that ban retail sales. Such a ban, which will apparently be on the agenda for dairy industry governing bodies (not known for being raw milk enthusiasts), could then easily be adopted by state agriculture deparments, and effectively make raw milk distribution illegal in as many as 40 states, he says.

So there you have it: federal and state governments gearing up to be able to track down and get rid of every single E.coli in the country. We’re going to be so well protected…

As Linda Diane Feldt points out in her generous acknowledgment on my most recent post, Steve Bemis played a huge role in helping mediate a highly favorable settlement for Richard Hebron in his tussle with the Michigan Department of Agriculture (MDA). I didn’t do Steve justice in my previous posting about the case, but I think you’ll get a fuller understanding of his role in a new BusinessWeek.com article I’ve written about the case.

I should add that Linda’s description of the case as “strange” is quite apt.

One of the things that made it strange has been the disconnect between the nature of the possible “crime” and the official force applied. A lingering question for many Family Farm Cooperative members and others has been why the MDA felt compelled to organize the equivalent of the cavalry to go after a lone farmer hauling food products. Even if his products were legitimately suspect, is that how such enforcement should be carried out?

I asked Katherine Fedder about why so much force was applied, and she launched into “bureaucratese”: “Issues related to food safety are very valid issues.” The tactics used to go after potential violators “are specific to that individual and that operation.” And so on and so forth.

While she wouldn’t discuss the specifics of the planning for the Hebron sting operation, she said something that seemed to clarify things a bit. “The action taken (against Hebron) was consistent with other actions that have been taken.” In other words, for the MDA, working with the state police, pulling vehicles over, executing search warrants, confiscating property, and other such enforcement actions “are not unusual,” in her words.

Part of the implication of her admission is that employing such tactics isn’t generally a problem for the MDA because it’s so unusual for the details to wind up in the national media and being followed in detail on the Internet. I don’t know enough about the ongoing enforcement actions of the MDA, except to see from its web site that much of its activity has to do with quarantining farms, enforcing bans on certain animals and plants, and going after retailers possibly violating food safety regulations. It certainly does make me wonder: Does the MDA throw its weight around because few outsiders are paying attention?

Six months after launching an elaborate sting operation against Michigan farmer Richard Hebron while he delivered raw milk to cow-share owners in Ann Arbor, and a follow-on investigation that spanned at least three other states from Pennsylvania to Missouri, Michigan walked away from the entire mess by giving the farmer little more than a slap on the wrist.

You could almost hear authorities from Michigan’s Department of Agriculture (MDA) and county prosecutor offices in Cass and Washtenaw counties breathe a sigh of relief this morning as they wrapped up the embarrassing case by agreeing to a settlement with Hebron whereby he can continue distributing raw milk to members of the Family Farms Cooperative and approving in principle the validity of cow share agreements. In exchange, all Hebron needs to do is refrain from distributing raw milk through any retail establishment (which he hasn’t been doing since the sting operation), “come into compliance” on a number of food preparation and processing matters on foods apart from raw milk, and pay a $1,000 “administrative fine,” according to Katherine Fedder, head of the MDA’s Food and Dairy Division.

The MDA’s soft and reasoned approach demonstrated today is a far cry from previous talk of a trial of Hebron on felony charges for supposedly violating state rules against sale of raw milk.

The sting operation, which had state police and MDA officials pulling Hebron’s truck over on the morning of Oct. 13, confiscating his $7,000 of raw milk, butter, kefir, meat, and other products, and executing search warrants on his home and the storage facilities of Morgan & York, an Ann Arbor food and wine store, created outrage in Michigan. Local politicians were inundated with emails and letters of protest, which caused them to complain to the MDA.

Nearly 300 members and supporters of the Family Farms Cooperative wrote testimonials on behalf of Hebron to the Cass County prosecutor’s office, which took the lead in determining whether to bring charges against Hebron. Many of the letters were touching accounts of how families had come to rely on the raw milk Hebron delivered to help improve their immune systems and relieve chronic health conditions like asthma in children. Steve Bemis, the Ann Arbor lawyer and FFC member who represented Hebron in negotiating the settlement with the MDA, presented copies of the letters to Fedder.

Fedder, for her part, says the letters in that pile, along with more than 100 her office received “certainly enhanced my knowledge of who the advocates are and where they come from. I have a greater understanding of their concerns.” She also credited this blog for having “done a service” in informing people about the many facets of the raw milk issue. Hey, I’ll take that praise, especially coming from a public official who has been on the receiving end of a lot of criticism.

Hebron, for his part, isn’t overly ecstatic about the settlement. He not only lost the confiscated produce, but many thousands of additional dollars in revenues from people scared off by the government action. He says co-op sales have just in the last few weeks rebounded to pre-sting levels—driven in part by the media attention to his case, as well as by a realization by some that “they haven’t been eating as well, and are starting to see health issues return.” But he worries about “six or eight regulations and codes they now want followed…They want to get me under their thumb with all these regulations.”

Also still outstanding is a warning letter to the co-op's milk producer, Indiana farmer David Hochstetler, from the federal Food and Drug Administration, accusing him of violating prohibiltions against selling raw milk across state lines. Hochstetler has appealed the warning letter, arguing that he is fulfilling contractual obligations of the cow share agreements and not selling milk.

So while there are still some important loose ends in this case, it is clear that public outrage and media attention did play a role in helping" educate" public officials and encourage them toward a more reasonable approach than they started with. It was certainly an expensive lesson.