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|Do You Need a Medical Detective?
An Interview with Brian Bouch, MD
with Janice Hughes, Share Guide Editor
Brian Bouch, M.D. is an expert in medical research, patient advocacy, and complex treatment options, and founder of Hill Park Medical Center in Petaluma, CA. He has 30 years experience in family practice, emergency medicine, and integrative medicine. He earned his medical degree from the University of Pennsylvania School of Medicine and obtained Board Certification in Emergency Medicine and Medical Acupuncture. Dr. Bouch is also an associate clinical professor at the UCLA School of Medicine where he teaches Medical Acupuncture to physicians. In 1988 Dr. Bouch founded Hill Park Medical Center in Petaluma, to offer patients the best in alternative healing therapies combined with high-quality conventional medical care.
After recovering from cancer several years ago, Dr. Bouch became interested in patient advocacy and research and created a second practice, Integrated Medical Solutions (IMS), a service that provides people who have complex or challenging medical diagnoses with a personalized medical detective/advisor to help them. Working with people mostly through the internet and telephone, Dr. Bouch specializes in helping to navigate through the maze of workups and treatment options that can be very confusing. Dr. Bouch also helps people seeking ways to integrate alternative healthcare with conventional care or wanting to look at cutting-edge treatments.
The Share Guide: Dr. Bouch, what inspired you to start doing this kind of research and advocacy work?
Brian Bouch: In 1997 I was diagnosed with a mysterious form of cancer which appeared in my neck. Medical opinions differed vastly on the best way to approach treatment because the location of the primary tumor was unknown, only the metastases were visible. I contracted with Mark Renneker, MD to help gain clarity and look at options. Through intensive literature review, Mark found clinical research that had been done with my exact kind of cancer at a well-known cancer center in Texas. They said no to surgery, and the concurrent chemotherapy and radiation recommended was used and resulted in cure.
After my recovery, I became interested in offering the same kinds of service that Mark had provided to me, and so I spent a year training with him. This sharpened my skills in conducting literature searches and directing research assistants. I created Integrated Medical Solutions (IMS), which offers a fundamental difference in terms of how the physician/patient relationship works. Rather than the professional telling the patient what is best for them, I work together with the patient as an equal partner, encouraging them to put together a healing program that works best for them. Before this, if someone came into my office with an interesting condition, I would want to do some research, but I would get a few minutes into it and realize that I could spend several hours, and I wouldn't get reimbursed for it, and didn't really have the time to do it anyway. So I would stop, and that's what most physicians do.
The Share Guide: In our current managed care system, many doctors are only allowed 10 minutes per patient. How much do you think this impedes good medical care?
Brian Bouch: I think that it impacts it tremendously. The model in which most physicians were trained was designed around doing an extensive initial intake, and then being able to spend enough time during follow-up visits to hear the person's complaints, look at possible side effects of medications, and assess how well the treatment is going. But 10-minute visits really don't serve anybody. They have been forced on the medical community and patients by the insurance industry. The doctors are frustrated by it, the patients are underserved by it, and altogether I think it makes for a poor quality of medical care. I just saw a piece on the internet yesterday rating the health care in 20 industrialized nations, and the United States was dead last. This issue was pointed out in Michael Moore's movie, Sicko. Our system is just not geared towards taking comprehensive, long-term care of the entire population.
The Share Guide: Do doctors resent you because your advice to patients may make more work for them?
Brian Bouch: Yes, some doctors look at my work as a pain in the ass. It could potentially create more work for them--work that they might not be reimbursed for. For example, let's say a doctor has a patient with a complex condition and that patient consults with me. Then I tell them that there's another way of looking at the situation and if this test were done and that test were done and this potential treatment were tried, it might be beneficial. Then they call their doctor, but say the doctor is in an HMO, so they have limited time to be able to spend with the person. Now they're being presented with something new that they're going to have to spend time doing a little research on, and it's more work for them. I've been yelled at on the phone by some specialists: How dare I push them to do stuff that is not necessarily part of the standard of care!
The Share Guide: Many people suffer from fear and depression due to illness and that can impede the healing process. It seems like the work you do allows people to feel like they're taking positive action so they can have some hope.
Brian Bouch: Yes, that's true. I feel like an important part of the work that I do is exploring some of those other dimensions of healing with patients and not just doing symptom checklists and coming up with a conventional Western diagnosis. I also focus on looking at the person's psychological life, what their resources are, what their spiritual connection is, if they have some kind of a mind/body practice. I think an important part of what I do is get people connected in those realms.
The Share Guide: In our culture, we've been taught to think that the doctor always knows best and we shouldn't question it. When we interviewed Dr. Rachel Remen she said "Diagnosis is an opinion, not a prediction." Isn't part of your protocol to question the diagnosis and get a second opinion?
Brian Bouch: Yes, it is. I can give you a good example of this from a recent patient that I worked with. It was a man who had received a diagnosis of prostate cancer. The best local opinion was that he had a moderately aggressive cancer and there's currently just three typical treatment choices for somebody in his age group with early stage prostate cancer. They are surgery, conventional radiation therapy, or radiation seed implants into the prostate. And all of them have morbidity associated with them. And so he came to me initially because he wanted help in trying to choose which of these three choices would be the best one for him and try to understand the pros and cons because they hadn't been adequately explained to him. But when I looked at his medical records, I felt that it was important to get a second opinion on the pathology slides and have a second reading.
So I sent him off to Johns Hopkins Medical Center in Baltimore, which is considered to be a major center of excellence, specifically for prostate cancer. We had his slides read by the head urologic pathologist there, and he said this is not cancer. Then just to make absolutely certain, I had the slides sent to the Mayo Clinic as well. And the Mayo Clinic agreed with Johns Hopkins and said this is not cancer. So the local pathologist was wrong. Unfortunately, they don't have anything in place to double check readings like this. Therefore, I think that anytime anybody is diagnosed with cancer, they should go out to a separate department for an independent reading to confirm it. In this man's case, it saved him a huge amount of physical discomfort, medical costs, and the potential complications--the whole spectrum of having cancer was completely turned around.
The Share Guide: Was it because of your connections that you were able to get experts like that to look at his pathology slides and give another opinion?
Brian Bouch: No, in this case it was not because of my connections. It was because I'd done my own research, so I knew what the center of excellence was for prostate cancer and the best place to go. There's a whole way of doing that: scanning through the medical literature; seeing where most of the articles in the mainstream journals come from; looking at editorials; even calling around and asking other specialists that I know.
The Share Guide: But even if you know where to go, is it hard to get their attention because they're very busy and you're not their patient?
Brian Bouch: No, it doesn't work like that. The places that are the real centers of excellence will make themselves available, often more quickly than your local facility. For example, there's a patient that I'm working with right now who I saw in my office last week for the first time. He had a new diagnosis of head and neck cancer, and he had all his treatment planning already. He had it initially at UCLA and then came up to Sonoma County because he had family here. But I felt like there were some things in the treatment plan that looked a little irregular and maybe too aggressive. I thought maybe he was going to be treated too hard with chemotherapy as well as radiation. So I wanted him to be evaluated at MD Anderson Cancer Center, which is a known center of excellence for his type of head and neck cancer, which originated in one of his tonsils. I was able to call over there because I do have a connection, and I talked to the head of the department on Monday and my patient flew out there last night and is being seen today. So sometimes it does have to do with connections, but sometimes it just has to do with doing the appropriate research and knowing where to look.
The Share Guide: Some conventional doctors have a mechanistic attitude and see our bodies as just machines needing to be fixed. Doctors like this will often counsel their patients to stay away from alternative therapies. Does this inhibit your work?
Brian Bouch: Yes, it really does inhibit the work and it's a problem. Actually, the biggest interference comes from conventional medical and radiation oncologists, because there's been a long-standing bias in the cancer community that antioxidants (Vitamin C, Vitamin E, Vitamin A, beta-carotene, etc) can interfere with the treatments for cancer. They feel that antioxidants that are recommended for fighting cancer can somehow block the effects of the radiation and chemotherapy that they're providing. And so, almost across the board, oncologists will tell their patients not to do any of that stuff because it can possibly make the cancer worse. But there's not a shred of evidence anywhere that this is true! There's several good articles that have been published reviewing all of the individual studies that have been done, and in the vast majority of cases the alternative treatments, including using antioxidants, have no negative effect on the cancer treatment. In fact, they often improve the patient's quality of life while they're going through chemo and radiation treatments by staving off some of the side effects. In some cases, it's actually been shown that alternative treatments enhance things so that people have better outcomes.
The Share Guide: Where did that idea come from, that antioxidants would interfere with chemotherapy and radiation?
Brian Bouch: It has to do with free radicals, which are responsible for most of the breaks in DNA sequencing that prevent uncontrolled cell growth, which is what cancer is. So free radicals have a lot to do with creating the cancer to begin with. When you give chemotherapy or radiation, there are tremendous amounts of free radicals that are generated as part of the process--the treatments are toxic to cells and they cause a lot of cell death. And so because of that you get free radicals that are liberated. About 12 years ago, one of the oncologists at Memorial Sloan-Kettering in New York said that because all these free radicals are generated, it must be the free radicals that are allowing the chemotherapy and the radiation to work. According to him, that's where the therapeutic effect must be coming from, so we can't let anything happen that's going to block those free radicals.
The Share Guide: So it was just one guy who said that?
Brian Bouch: Yes, it was one man's theory, but it was published in the New York Times, and the entire oncology community basically accepted it as true. Because of that one article, it created a sea change in the thinking about free radicals--but there's never been any good evidence to back it up. So that kind of advice and thinking from the mainstream oncology community really interferes with people's ability to access alternative treatments and to be able to use them both to improve quality of life and also potentially to have better outcomes with their cancer treatment. Now many patients ignore that advice, and will do what they feel is right anyway, which is to use antioxidants such as Vitamin C and Vitamin E and Vitamin A. There's really good evidence that those things really do help.
The Share Guide: Haven't a lot of conventional doctors branded all alternative medicine as quackery, whether it's antioxidants for cancer or anything else?
Brian Bouch: Yes, that's true. I'll give you another good example from the non-cancer realm. DHEA, which is an adrenal steroid hormone, has anti-inflammatory properties and anti-autoimmune properties. The rheumatology department at Stanford did a study on DHEA about 10 years ago. They took a large cohort of patients with lupus, which is an auto-immune disease, and they put half of them on DHEA and half of them on placebo, and many of them were being treated at the same time with conventional steroids, like Prednisone, to keep their disease under control. The evidence was crystal clear that the people who took DHEA were able to reduce and sometimes eliminate the Prednisone. These people were able to get by without having all of the side effects of steroid therapy--the puffiness, the bone loss, and all the other things that happen. So DHEA worked great, but it's not patentable as a pharmaceutical.
So in spite of that very excellent study and several studies since then that have confirmed the data and also shown DHEA's effectiveness in other autoimmune conditions, the mainstream medical community has never taken it on as a treatment. This is mainly because it's a supplement, and you can buy it over the counter in the drugstore or natural foods store. It's not part of what doctors can prescribe, and so they feel like they don't have a level of control with it.
The Share Guide: Plus there's no money in it for drug companies.
Brian Bouch: That's exactly right. There's no money in it for the pharmaceutical companies because they can't patent it. Plus it's cheap; a 30-day supply of DHEA costs about $10-$12.
The Share Guide: How much do you think fear of malpractice lawsuits inhibits the advancement of health care in this country?
Brian Bouch: I think it's a major factor because doctors follow a standard of practice. If the physicians deviate from the standard of practice they are at risk of being sued. If a patient presents with a certain set of symptoms, there's an expected workup that's supposed to occur, and certain tests ordered to confirm or refute the diagnosis. And then once a biomedical diagnosis is arrived at, then there's a treatment formula that's supposed to be followed, which can be found in medical textbooks or many online sources. If doctors deviate from that standard formula and the patient has a negative outcome (either less results than expected or an adverse outcome) and they decide to sue the doctor, then the doctor is medically liable. In most cases their malpractice insurance will cover it, but then their rates are going to go up, and they have to go through the whole unpleasant process of being sued, which involves depositions, time in court, lots of anxiety, lots of self-recriminations. So who wants that?
Thus we have a huge problem in this country, and it's probably one of the main reasons why health care is so expensive. It's also why we're not doing well compared to other industrialized nations that have different levels of liability control, where physicians can't be sued so easily. The fear of malpractice liability really inhibits physicians from being able to practice in the way that they want, and it also forces them into a position of ordering way more tests than is necessary.
The Share Guide: Which tests are ordered unnecessarily?
Brian Bouch: CAT scans are a big problem. Recently in the medical internet press, there's been a lot of attention on CAT scans as a cause of cancer. This is because of the tremendous amount of radiation that's generated from a CAT scan. It's been estimated that 2% of all cancers diagnosed in this country are caused by cumulative X-ray from CAT scans. When I was doing emergency medicine 15 years ago, although CAT scanning technology was available, the number of CAT scans that I would order as an ER doctor back then was maybe two to three a month. It was very unusual and typically used in a really critical situation.
Nowadays, emergency room doctors often order two or three CAT scans during the course of one shift. If somebody comes in with a bellyache, instead of just getting an exam and having vital signs taken and maybe a stool test and a culture, they get a CAT scan. And CAT scans cost about $2,500 each, so it greatly increases the cost of the workup. It also exposes the patients to potentially damaging X-rays that most of the time weren't necessary. The problem is that as this becomes the standard of practice, then doctors are afraid they're going to be sued if there was a very small possibility that they might have missed something by not doing the CAT scan.
The Share Guide: In the protocol you recommend for patients, how important are lifestyle changes such as diet, exercise, and meditation?
Brian Bouch: I think they're extremely important. There are several components or pillars of healing, only one of which is the conventional medical treatment, which is the same thing we were talking about in terms of standard of practice. But patients who improve their metabolic status and get closer to their ideal weight by doing regular exercise and changing their diet, have a much better chance of improvement. What's really become clear over the last several years is that the healthiest diet for the majority of people is a low-glycemic diet--one that greatly reduces the amount of refined carbohydrates, such as white flour-based products, baked goods, white pasta, and sweeteners in all forms. This would include soft drinks and cookies and all the dessert treats that people like to eat. People need to focus on whole grains, vegetables, and healthy fats, including things like olive oil and avocados, healthy nuts like almonds and walnuts, and cold-water fish that are rich in essential fatty acids. Fish oil is extremely important and is now actually being used by some conventional physicians as a treatment for elevated cholesterol levels and to reduce people's risk for cardiovascular disease. That one's finally making it into the mainstream.
I also believe that the spiritual component is very important. The information is out there and lots of people are taking it on and starting to work with it. Being spiritually focused activates centers in the central nervous system that positively impact the function of the immune system. This puts us in a place where we're more resistant to infections, and we're more resistant to the onset of other degenerative diseases and cancer. It also greatly improves quality of life, and how people feel on a day-to-day basis.
The Share Guide: How much of a difference do you think the internet has made with all the information that's now available to people?
Brian Bouch: I think it's fabulous, but there's also a very dark side to it. There is so much information out there that if people don't have a good way of evaluating whether it's a credible website with well-vetted information, they can be led down a path of misinformation and be steered in the wrong direction. There are several alternative remedies that have had huge publicity online but there's not a shred of evidence that they work. In some cases there have even been negative effects associated with them. For instance, coral calcium, mangosteen juice, and zeolite. I'm sure that you're going to have readers that will totally disagree with me, but my medical opinion is that they are not effective. I think people should read Ralph Moss's information on mangosteen juice. Moss did a good job in his newsletter on discussing mangosteen juice. [See The Moss Reports at www.cancerdecisions.com] As far as I'm concerned, it has mild antioxidant properties and other than that it's just a total scam. Zeolite is a volcanic ash that's processed into a supplement, but there's nothing special about it. I think it's all marketing that's profit-driven.
I think that it's really important to have at least some base of scientific data through studies showing benefit for particular conditions before you make claims for certain supplements. The gold standard for research in Western medicine is the randomized placebo-controlled double-blind study. This may be over the top, especially for integrative medicine treatments. But some level of scientific research and evidence is really important before you start making claims.
The Share Guide: Unfortunately, often you'll see brochures from companies that manufacture these products that say there are studies proving effectiveness. They might even quote something specific, but the average person can't evaluate it.
Brian Bouch: Yes, I agree. The internet has places to research things like this if you know how to get to them. You can often find good evaluations of various products. I'll give you one example. There is a company called Health Notes, which is a database that was started primarily by naturopaths. You can't get to it directly, because they need to make money, so they only license themselves by going through other portals. The way that I usually get to them is I go to the GNC website (library.gnc.com/healthnotes). Once you're in the Health Notes database, they have a huge listing of vitamins, herbs, and supplements, with the conditions that they're usually used for and a rating (one, two, three or four stars) in terms of efficacy and levels of evidence. They often cite the research in the study. Over the last few years I've found this to be extremely good in terms of the validity of their information and evidence, which is pretty up to date. There's also information on Medline (www.medline.com) and Consumer Lab (www.consumerlab.com).
The Share Guide: Do you include things like energy medicine, visualization, or prayer as part of the protocol that you recommend?
Brian Bouch: Yes. I try to find out if my patients have a spiritual practice, whether it's a conventional religious practice or a so-called alternative practice, such as meditation or Qigong. About two years ago, we adopted Qigong as the official mind/body practice of Hill Park Clinic, our medical center in Petaluma. We sponsor a class ever Saturday morning at the Bodyworks Yoga Studio. And about every 2-3 months we bring our teacher, Ming Tong Gu, to town for a 2-day workshop.
The Share Guide: Do you see evidence that Qigong helps your patients?
Brian Bouch: Yes. I recommend Qigong to almost every patient unless they have another practice that they're involved with. And of the patients that end up doing the Qigong regularly, I see way less of them in the office, which is the best sign of success in the world. If I can get somebody down from needing to seem me every 2-3 weeks for their chronic health conditions to maybe a few times a year or every few months, I consider that big success.
The Share Guide: Do you think the kind of patient advocacy that you're doing will become more common?
Brian Bouch: Unfortunately, without both the training considerations and insurance reimbursement, I don't know that it's something that can ever become widespread. There's only three other people that I know of in the country doing this kind of work right now. This is because it's so time intensive and it's potentially more expensive for the insurance companies--although long-term it would actually benefit them because they would be spending less money on patients if the patients had better outcomes and didn't need more high-tech care. But they don't see the long-term view. In the same way that they don't see the benefits of integrative medicine, even if it's something as simple as acupuncture, which the insurance companies still don't want to pay for, even though it could potentially save them thousands and thousands of dollars on an individual patient who might be able to avoid expensive surgery. So if the health plans don't pay for it and patients aren't getting reimbursed, it doesn't have a very bright future, the way that medicine works in this country.
The Share Guide: What about training others to do this service?
Brian Bouch: I'm actually so busy that doing that by myself would be impossible. But I am in conversation with a few other doctors about potentially trying to create something that would help to train other physicians to do it. Unfortunately, because it's not part of a recognized medical specialty and because there's no official academic pathway that would allow something like this to happen, it makes it pretty difficult unless you're just looking at an individual mentorship.
For more information about Dr. Brian Bouch and Hill Park Medical Center, visit www.hillparkmedicalcenter.com.
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