Adaptogen Lecture (Wonder Herbs: A Guide to Three Adaptogens)

Going to post this on Blog IV for more folks to appreciate.

Electromagnetic Fields and Your Health

The Dangers of EMF

 

by JP Saleeby, MD

Like the ancient Romans before us who drank their wine out of pewter goblets unaware that the sweetness those metal vessels bestowed upon their wine was the toxin some historians consider contributed to their downfall. Yes the acidic wine leached out enough lead from their pewter drinking vessels to effectively sterilize Roman nobility. Today in the 21st century we live our lives unwittingly damaging ourselves with what we hold in high quarters as advanced technology making our lives richer. Slamming our bodies with mega doses of Electromagnetic Fields (EMFs) has become this millennium's poison of choice. Are we willing to give up the convenience of calling a friend while stuck in traffic. Are we to put on hold whipping out our laptop computer while waiting for a lay-over at the airport. No I think not. Even going "green" and replacing our incandescent lightbulbs with the energy saving florescent lights has some evil EMF repercussions. Many are unwilling to give up these conveniences so easily as the latency of the harm they produce are so remote to use we make no real time correlation. Should we see a "heavy cell phone user" drop dead in front of us as he talks and texts away, it may give us pause. Unfortunately, much like mad cow disease, it is a smoldering slow process that likely takes years to manifest. We must pick out technology wisely and use those for daily living judiciously and sparingly.

Even when we know the dangers of smoking, nicotine addicts cannot put their cigarettes down. Alcoholics aware of their liver swelling have a hard time keeping dry. Will it take a golf-ball sized tumor to force us to stop holding the cell phone so close to our brains? Going without our lickidly-split communicators is too much for some technofiles to bear. But you have been warned. There is mounting evidence showing rather significant harm from EMF. In 2007 an international collaborative effort occurred with scientists from the US, Sweden, Austria and China that released a 650-page report evaluating some 2000 studies pointing the finger at the public health risk of EMF. The group's report sited a variety of cancers, immunity disruptions and ailments ranging from dementia to heart disease as having an etiology in EMF. Several countries in the European Union have dismantled wireless networks and cell towers near schools and public buildings for fear that there may be overexposure to children. In Israel there is a ban on the placement of cellular antennae on residential buildings and in Russia the government has advised children under the age of 18 against the use of cell phones. Now we hear that the state of Maine is trying to legislate a ban of cell phone use amongst youngsters.

Besides cell phones we have to concern ourselves with WiFi transmitters, microwave communication towers, the power transformers we all use to recharge our cell phones and computers, and the increasingly ubiquitous fluorescent bulbs (compact fluorescent lightbulbs (CFLs)) that Lowes and Home Depot are hawking as an energy saving alternative to incandescent bulbs. Of course, there are the detractors who say this is all hog-wash, but they tend to be funded by the cell phone and utilities industries. The jury is probably still out on how much EMF we as humans can really tolerate and why some are more sensitive than others, but it appears that there is really something to it and whether it pans out or not, it would be prudent to protect ourselves best we can to limit exposure to EMFs. Recommendations are to avoid wireless when possible (use a land line or put your cell phone on speaker and get it away from your head). Pick a safer lightbulb, stay away from circuit breakers, give up the Bluetooth headsets, don't use your cell phone when service is spotty as cell phones give off more radiation to compensate for low tower strength. Don't wear your cell phone as an accessory, don't put your laptop on your lap. Unplug your rechargers when not in use and pick LCD over plasma screens.

source: www.prevention.com/health

Using Bioidentical hormones over synthetics: Why it is such a good idea.

 

Bioidentical Hormones & HRT

by JP Saleeby, MD

All the rage today is the use of bio-identical hormones.  We are seeing bioidentical hormones use for the replacement of insulin, thyroid hormones, and gonadal (sex) hormones, and the trend continues to be natural.  For our insulin dependent diabetics the last decade saw a transition away from using porcine based insulin derivatives to that of recombinant human forms.  With thyroid disorders there are those doctors who would rather see their patients on a natural bio-identical thyroid replacement of bothT3 and T4 in the correct ratios, rather than the single synthetic-T4 drugs offered.  And there are those physicians that would rather see their patients taking natural compounded sex hormones such as estrogen, progesterone and testosterone when the need arises rather than a synthetic blend offered by some pharmaceutical companies. 

The big issues (that remain controversial with physicians on both camps) are efficacy, reported well designed double blinded studies, cost and side-effects.  For me efficacy is a priori, by natural it goes without being said that what we replace in our bodies as the need arises should be of the same biochemical composition as what our own endocrine organs produce.  Replacement with a synthetic in theory opens up a can of worms to all sorts of untoward effects both short term and long term (as yet unrecognized or unrealized).  The paucity of controlled scientific studies for natural hormone therapy is due in part to the lack of financial support or underwriting of scientific trials on all things natural.  But that fact is changing as more studies are being published and there is growing acceptance of research outside the USA.  Cost is a factor as many natural and bioidentical therapies cost much less than the latest and greatest that the pharmaceutical industry has to offer.  Side effects is the last contested point.  If we take for a moment all the trouble realized with synthetic hormone therapy replacement for women in recent years with the use of horse estrogens and synthetic progestin compounds and the increase incidence of cancers, blood clotting disorders and gallbladder disease, it is no wonder many women choose the less insulting therapy found in bioidenticals .  My philosophy is that the closer we get to replacing hormones with an almost exact replica of what our own bodies once produced is the ideal situation.  Not only the biochemical components, but also the doses and timing (chronopharmacology) are important.  Appropriate testing do discern the need for HRT is the first step.  Once a deficiency is detected bioidentical hormone replacement (bHRT) is ultimately the best solution.  You can read in greater detail the types of hormones that should be tested and what type of bHRT is offered on my medical blog site:  www.DocSaleeby.blogspot.com.

For a limited time I will be offering free consultations for bHRT (a $300 value) to the first two new patients who qualify based on income and lack of health insurance status.

FAQ about choosing source of EFA

[an answer to a question about which source of EFA to choose]

To answer your questions regarding n-3FA and Flax vs Chia vs Fish oil.  Using ground vs unground flax and the reason n-3FA is important in diet are outlined below.  Some references are listed below.

First of all omega-3-Fatty Acids (n-3FA) are important in human diet for several reasons.  They make up the outer cellular wall of each of our cells as part of the bi-lipid layer (eating poor fats high in n-6 and n-9 with low n-3) will result in a poor cellular structure and poor hormone receptors which poke out through this lipid bi-layer.  Intake of higher doses of good lipids (n-3) will result in a better cell wall function in 28 to 30 days.  Also DHA and EPA which are constituent parts of n-3FA are "brain food" so to speak.

So what type of n-3FA should you take.  10 years ago the rage was Fish Oil.  But with issues of over fishing, toxins (Hg, PCBs, and other heavy metals making their way into our fish) non-pharmaceutical grade fish oil is falling out of favor.  There are plant sources such as Flax, Borage, Chia and Hemp.  However, there is an important enzyme that converts precursor EFAs (ALA) to EPA and this is delta-5-desaturase.  The problem may be that some folks don't have enough d-5-destaurase activity or any at all.  This EFAs get "stuck" in this precursor lipid and don't progress to what the body really needs.  When you take a vegetable source of EFA that is the chance you run.  ALA is converted to DHA at a rate of 2-5% and to EPA at a rate of 2-15% in the body in general.  DHA conversion from plant EFA is less than that obtained from animal sources (fish, etc.)  Finally EPA through an enzymatic pathway yields DHA.

So a "fish" or oceanic source of EFA may be of more benefit and eliminate certain enzymatic steps within our body.  Krill oil steps up to the plate as a very good alternative to fish oil.  It is lower on the food chain, thus not a repository for heavy metals and toxins.  It is very plentiful and over fishing of Krill should not be a problem.  Additionally, Krill contains the anti-oxidant Astaxanthin which is only available in large quantities in this organism and not in plant oils and has the unique property of crossing the blood brain barrier (protecting the brain, CNS and eyes).

The scoop on Flax seeds is this:  ... to store it for freshness keep in whole.  To get the most out of its EFA grind it up.  Intake of whole unground Fax or Borage seeds is a great source of fiber bulk, but smaller quantities of the oils will be made available for absorption.

Bottom line... the best vegetable source for EFAs is Chia seed & extract.  The best animal source for EFA is Krill.  Better yet is to take a mix of both.  Variety always trumps picking only one source of any nutrient.  Hope this helps.

JP/

JP Saleeby, MD
www.saleeby.net
www.CarolinaMobileMD.com



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References:

Fatty acids and lignans in unground whole flaxseed and sesame seed are bioavailable but have minimal antioxidant and lipid-lowering effects in postmenopausal women

Karen D. Coulman 1, Zhen Liu 1, John Michaelides 2, Winston Quan Hum 2, Lilian U. Thompson 1 *

1Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada 2Robin Hood Multifoods Inc., Toronto, ON, Canada

^*Correspondence to Lilian U. Thompson, Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, 150 College Street, Toronto, ON, M5S 3E2 Canada Fax: +1-416-978-5882
Funded by:
 Natural Sciences and Engineering Research Council of Canada
 Robin Hood Multifoods Inc.

Antioxidants • Blood lipids • Flaxseed • Sesame seed • Tocopherols

Fatty acids and lignans in ground flaxseed and sesame seed are absorbed, metabolized, and exert some health benefits in vivo. However, it is unclear if they are absorbed, metabolized, and exert health benefits when consumed as ungroundg unground flaxseed, sesame seed, or their combination (12.5 g each) (flaxseed+sesame seed bar, FSB) for 4 wk each, separated by 4 wk washout periods. Total serum n-3 fatty acids increased with flaxseed (p<0.05) and FSB (p=0.064) while serum n-6 fatty acids increased with sesame seed (p<0.05). Urinary lignans increased similarly with all treatments (p<0.05). Plasma lipids and several antioxidant markers were unaffected by all treatments, except serum -tocopherol (GT), which increased with both sesame seed (p<0.0001) and FSB (p<0.01). In conclusion, fatty acids and lignans from unground seed in food bars are absorbed and metabolized; however, except for serum GT, the 25 g unground seed is inadequate to induce changes in plasma lipids and several biomarkers of oxidative stress. whole seed; therefore, it was investigated in this study. In a randomized crossover study, 16 postmenopausal women supplemented their diets with food bars containing either 25

---

Received: 20 January 2009; Revised: 26 March 2009; Accepted: 4 April 2009

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http://www.the-fertility-acupuncturist.com/omega-3-fatty-acid.html

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http://www.britannica.com/bps/additionalcontent/18/27261743/Omega3-DHA-and-EPA-for-Cognition-Behavior-and-Mood-Clinical-Findings-and-StructuralFunctional-Synergies-with-Cell-Membrane-Phospholipids

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Frankincense and medicinal application

As the Epiphany draws closer on Jan 6th and the story of the three Magi bearing gifts of Gold, Frankincense (Boswellia sp.) and Myrrh (Commiphora myrrha) comes to mind, we need to recall a study published in early 2009 in a bio-medical journal.  Frankincense a natural substance held in high regard for medicinal and spiritual healing in the middle east and Asia was shown to attack cancer cells of the bladder.  Not only did researchers find it attacked bladder cancer cells, it recognized normal health cells and did not destroy them.  The study used an extract of the oil of the Somalian Frankincense herb, Boswellia carteri.  There are other Boswellia species used such as B. serrata (Indian Frankincense) in Ayurvadic medicine and typically used to treat arthritis for centuries.

Source:

BMC Complement Altern Med. 2009 Mar 18;9:6.

Frankincense oil derived from Boswellia carteri induces tumor cell specific cytotoxicity.

Frank MB, Yang Q, Osban J, Azzarello JT, Saban MR, Saban R, Ashley RA, Welter JC, Fung KM, Lin HK.

Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA. frank@omrf.org

BACKGROUND: Originating from Africa, India, and the Middle East, frankincense oil has been important both socially and economically as an ingredient in incense and perfumes for thousands of years. Frankincense oil is prepared from aromatic hardened gum resins obtained by tapping Boswellia trees. One of the main components of frankincense oil is boswellic acid, a component known to have anti-neoplastic properties. The goal of this study was to evaluate frankincense oil for its anti-tumor activity and signaling pathways in bladder cancer cells. METHODS: Frankincense oil-induced cell viability was investigated in human bladder cancer J82 cells and immortalized normal bladder urothelial UROtsa cells. Temporal regulation of frankincense oil-activated gene expression in bladder cancer cells was identified by microarray and bioinformatics analysis. RESULTS: Within a range of concentration, frankincense oil suppressed cell viability in bladder transitional carcinoma J82 cells but not in UROtsa cells. Comprehensive gene expression analysis confirmed that frankincense oil activates genes that are responsible for cell cycle arrest, cell growth suppression, and apoptosis in J82 cells. However, frankincense oil-induced cell death in J82 cells did not result in DNA fragmentation, a hallmark of apoptosis. CONCLUSION: Frankincense oil appears to distinguish cancerous from normal bladder cells and suppress cancer cell viability. Microarray and bioinformatics analysis proposed multiple pathways that can be activated by frankincense oil to induce bladder cancer cell death. Frankincense oil might represent an alternative intravesical agent for bladder cancer treatment.

Real Radiation Exposure Risk in Americans

Radiation

by JP Saleeby, MD

As a prologue to my larger article on EMF I will discuss some risks inherent to ionizing radiation exposures during daily life activities and during radiological examinations in medicine. There are many sources of radiation and unavoidably we are exposed daily. Some sources are natural such as cosmic radiation from the sun and other distant stars, there is radiation that is under our feet as the earth contains radioactive material in our soil from sources such as uranium and thorium. There is probably not a thing we do today that will not expose us to radiation from the food we eat, cigarettes we smoke and television we watch. The man-made radiation is one we may exert some control over. We will cover the sources and come up with an estimated annual radiation dose that would be considered safe, tolerated and not to be exceed.

Cosmic radiation comes from our Sun and other stars in our galaxy. Fortunately for us, our Earth's atmosphere blocks much of these damaging rays. The closer we are to sea level the better protected we are. At sea level we received annually about 25 mrem. To clarify; a mrem is a measurement of radiation. Roentgen Equivalent in Man (REM) is a rather high dose of radiation exposure, so millirem (mrem) which is a thousandth the dose is used. Those living a mile above sea level will receive twice the dose. When we fly in an airplane the lack of atmosphere between the solar rays and our bodies will increase our exposure drastically, but typically flights are short and a the usual dose rate is 0.5 mrem per hour in flight.

On average we will be exposed to about 30 mrem a year from the soil around us that contains radioactive material. Some places are safer (such as coastal areas) while the state of Colorado can expose an individual to an annual dose that is twice the average (60 mrem). Radon gas (a radioactive gas) that is inhaled gives us an average of about 200 mrem per year per person. Again some areas of the world have higher Radon exposures. There are towns in India and Brazil with rates as high as 1,000 mrem per year. If you are in a high risk area it may be worth you while to have your home checked for this gas.

Even the food we eat has some naturally occurring radiation. Almost all the food we eat contains carbon. Carbon-14 is radioactive as is some small amounts of Potassium which are present in our diet. There are also some plant and animals that accumulate radioactive materials making our intake even higher. On average our dose is around 20 mrem per year. If we are introspective and look at ourselves, believe it or not, we are also radioactive beings. Because we contain within our bodies potassium and carbon-14 and other radionuclides we in turn produce 40 mrem a year, so if you are around other people you expose them as they expose you.

The simple act of watching TV gives you a 1 mrem per year dose. Porcelain teeth and crowns give a dose of about 0.1 mrem/yr. Counter intuitive would be the idea that one is exposed to more radiation living close to a nuclear power plant, but the fact is that this would only raise your risk by 0.01 mrem while those living near a coal fired power plant will receive 0.03 mrem per year on average. This fact is due to the release of uranium and other radionuclides when the coal is burned. For those who have a plutonium powered pacemaker you receive an annual dose of 100 mrem and if your spouse has one you will get a dose of 7.5 mrme from them per year from just being around him/her (don't be alarmed there are less than 100 people in the USA with this type of device).

Iatrogenic radiation (that generated by the medical field on their patients) is probably a major radiation exposure to those that require frequent radiological studies. For example, according to the American Nuclear Society some typical doses from studies are as follows: An x-ray of the arm or leg will yield 1 mrem. Dental x-rays will give you a 1 mrem dose. A Chest X-ray will expose you to 6 mrem. A skull x-ray results in 20 mrem. A CAT scan will dose you up with 110 mrem and a barium enema will give you a whopping 405 mrem.

On average you will probably receive around 300 mrem per year and perhaps more if you are a frequent flyer or unfortunate enough to require a lot of hospital visits and x-rays. Typically naturally occurring radiation gives us a larger dose than our man-made radiation sources in most cases. To put things in perspective, our chances of dying from cancer increases 10% if you accumulate 250,000 mrem over your lifetime. It is estimated that over 3,000 mrem per year over an 80 year period would be required to achieve the accumulated amount to cause this risk. That is a lot of radiation considering in the USA we on average get a dose of 360 mrem a year. So the typical annual dose is still pretty low for most Americans.


References:

http://www.chestx-ray.com/GenPublic/GenPubl.html
http://www.blackcatsystems.com/GM/safe_radiation.html
http://www.nci.nih.gov/cancertopics/causes/radiation-risks-pediatric-CT
http://www.orau.org/PTP/collection/Miscellaneous/pacemaker.htm

(c) 2009

Maine follows some European countries with Cell Phone warning

Maine to consider cell phone cancer warning



By GLENN ADAMS, Associated Press Writer Glenn Adams, Associated Press Writer


Sun Dec 20, 12:07 pm ET


AUGUSTA, Maine – A Maine legislator wants to make the state the first to require cell phones to carry warnings that they can cause brain cancer, although there is no consensus among scientists that they do and industry leaders dispute the claim.

 The now-ubiquitous devices carry such warnings in some countries, though no U.S. states require them, according to the National Conference of State Legislators. A similar effort is afoot in San Francisco, where Mayor Gavin Newsom wants his city to be the nation's first to require the warnings.


Maine Rep. Andrea Boland, D-Sanford, said numerous studies point to the cancer risk, and she has persuaded legislative leaders to allow her proposal to come up for discussion during the 2010 session that begins in January, a session usually reserved for emergency and governors' bills.


Boland herself uses a cell phone, but with a speaker to keep the phone away from her head. She also leaves the phone off unless she's expecting a call. At issue is radiation emitted by all cell phones.


Under Boland's bill, manufacturers would have to put labels on phones and packaging warning of the potential for brain cancer associated with electromagnetic radiation. The warnings would recommend that users, especially children and pregnant women, keep the devices away from their head and body.


The Federal Communications Commission, which maintains that all cell phones sold in the U.S. are safe, has set a standard for the "specific absorption rate" of radiofrequency energy, but it doesn't require handset makers to divulge radiation levels.


The San Francisco proposal would require the display of the absorption rate level next to each phone in print at least as big as the price. Boland's bill is not specific about absorption rate levels, but would require a permanent, nonremovable advisory of risk in black type, except for the word "warning," which would be large and in red letters. It would also include a color graphic of a child's brain next to the warning.


While there's little agreement about the health hazards, Boland said Maine's roughly 950,000 cell phone users among its 1.3 million residents "do not know what the risks are."


All told, more than 270 million people subscribed to cellular telephone service last year in the United States, an increase from 110 million in 2000, according to CTIA-The Wireless Association. The industry group contends the devices are safe.


"With respect to the matter of health effects associated with wireless base stations and the use of wireless devices, CTIA and the wireless industry have always been guided by science, and the views of impartial health organizations. The peer-reviewed scientific evidence has overwhelmingly indicated that wireless devices do not pose a public health risk," said CTIA's John Walls.


James Keller of Lewiston, whose cell phone serves as his only phone, seemed skeptical about warning labels. He said many things may cause cancer but lack scientific evidence to support that belief. Besides, he said, people can't live without cell phones.


"It seems a little silly to me, but it's not going to hurt anyone to have a warning on there. If they're really concerned about it, go ahead and put a warning on it," he said outside a sporting good store in Topsham. "It wouldn't deter me from buying a phone."


While there's been no long-term studies on cell phones and cancer, some scientists suggest erring on the side of caution.


Last year, Dr. Ronald B. Herberman, director emeritus of the University of Pittsburgh Cancer Institute, sent a memo to about 3,000 faculty and staff members warning of risks based on early, unpublished data. He said that children should use the phones only for emergencies because their brains were still developing and that adults should keep the phone away from the head and use a speakerphone or a wireless headset.


Herberman, who says scientific conclusions often take too long, is one of numerous doctors and researchers who have endorsed an August report by retired electronics engineer L. Lloyd Morgan. The report highlights a study that found significantly increased risk of brain tumors from 10 or more years of cell phone or cordless phone use.


Also, the BioInitiative Working Group, an international group of scientists, notes that many countries have issued warnings and that the European Parliament has passed a resolution calling for governmental action to address concerns over health risks from mobile phone use.


But the National Cancer Institute said studies thus far have turned up mixed and inconsistent results, noting that cell phones did not come into widespread use in the United States until the 1990s.


"Although research has not consistently demonstrated a link between cellular telephone use and cancer, scientists still caution that further surveillance is needed before conclusions can be drawn," according to the Cancer Institute's Web site.


Motorola Inc., one of the nation's major wireless phone makers, says on its Web site that all of its products comply with international safety guidelines for radiofrequency energy exposure.


A Motorola official referred questions to CTIA.


[More on this in an upcoming article by Dr. Saleeby on EMF Radiation]

No End in Sight for Doctor Shortage

AOL News

(Dec. 16) -- The nation is short of thousands of primary-care doctors. Medical schools plan to add 3,000 first-year students by 2018, but that won't be enough to meet the need, according to a report from Bloomberg.com.

Though schools plan to educate more doctors, the demand for physicians is expected to soar if Congress passes a health care reform plan aimed at getting insurance to 31 million more Americans. The bill is being debated at a time when government-funded training for doctors has been frozen for 12 years, Bloomberg reported.

Skip over this content

Joe Raedle, Getty Images

A doctor, center, speaks during a cardiology class at the University of Miami. Medical colleges have added 1,500 seats since 2005 and plan to add 3,000 more by 2018.

"Do the math," said Steven Safyer, president and chief executive officer at New York's Montefiore Medical Center. "You give millions more people insurance, and it adds up to a much worse shortage."

Ed Salsberg, an official with the American Association of Medical Colleges, told the news service that the nation may be short of 159,300 doctors across all practice areas by 2025.

How should the shortage be resolved? Medical school officials have differing opinions. Read about them at Bloomberg Report.

ORAC

goji berries

ORAC

by JP Saleeby, MD

ORAC or Oxygen Radical Absorbance Capacity is a unit of measurement that gives us a value or score on different foods and supplements as to the free-radical or oxidative load fighting capacity.  Those with higher ORAC units have a better antioxidant effect than those with lower scores.  The ORAC scale was developed by scientists at the national Institutes of Health, and while the exact relationship between a food's ORAC value and its health benefit has not yet been well established, it does imply that a higher score does more effectively reduce oxidative load.  Oxidative load or free-radicals are what is theorized in the free-radical theory of aging (as proposed by Dr. Denham Harman) as the causative agent for degenerative disease ranging from arthritis to coronary disease and cancers.  For a rather extensive list of ORAC values of foods and supplements visit www.oracvalues.com.

A few examples include:

Vitamin A  1.25 mmTE/g
Vitamin E  1.25 mmTE/g
Lycopene  58 mmTE/g
Astaxathin  51 mmTE/g
coQ10  11 mmTE/g
Chia  70 for white seed and 98 for dark seed mmTE/g
Krill  378 mmTE/g

More on ORACs to follow


source:  http://www.oracvalues.com/

Leptin: Good for the Brain & Midsection

Leptin

by JP Saleeby, MD

Leptin is a protein hormone seeing a lot of attention recently in the press.  The December 16th, 2009 issue of Journal of American Medical Association (JAMA) published an article relating Leptin levels and the incidence of Alzheimer's disease.  Leptin has in recent years been linked to obesity and fat metabolism.  The word leptin is derived from the Greek word leptos which means thin.  It is a 16 kilodalton protein derived from adipose tissue and associated with the Ob(Lep) gene on chromosome 7 in humans.  One of the main functions of Leptin is that it relays a message to the brain satiety centers when fat stores are low as seen during starvation.  Leptin levels respond quite rapidly going up when we over-feed and put on more adipose tissue and drop when we under-feed and loose adipose tissue.  The brain's response to this chemical messenger when we drop body fat and levels ofleptin are reduced is to shut down our satiety centers causing us to overeat.  This feed back system is what most researchers feel is responsible for theyoo-yoo dieting problems of "keeping the weight off" when we drop a lot of fat while dieting and exercising. 

In 2005 Dr. Rosenbaum and his team of researchers published research in the Journal of Clinical Investigation showing that injections of leptin in those fasting kept them from gaining back the unwanted fat after they had dieted.  Leptin's primary goal then is to defend and support body fat stores by increasing food seeking behavior when levels are too low.  The more fat cells you have the higher your leptin levels are.  It would be great to have a "leptin pill" that you could take to help thwart the rebound weight gain one often sees after dieting.  However, this is impractical for several reasons.  One, leptin in a pill form is useless as stomach acids will quickly destroy it before it gets absorbed.  Injecting leptin would be the alternative, but one would have to do it daily and for life to avoid weight gains and this would be cost prohibitive.  The way around this would be to "trick" the body into believing it was well fed by having "cheat days" or overfeeding days once or twice a week to produce enough leptin in the blood stream to prevent an over-eating frenzy.  According to the JAMA study with regards to serum leptin levels and Alzheimer's disease, it was shown that circulating leptin was associated with a reduced incidence of dementia and Alzheimer's disease in normal older adult test subjects.  Further research will be needed to determine how we can maintain health levels of leptin for our brains without having to become obese in the process.

References: 

Wolfgang, L., et. al, Association of Plasma Leptin Levels with Incident Alzheimer Disease and MRI measures of Brain Age., JAMA 2009;302(23):2565-2572

Rosenbaum, M. et. al, Low-dose leptin reverses skeletal muscle, autonomic, and neuroendocrine adaptations to maintenance of reduced weight., J. Clinical Investigations 2005;115, 3579-86

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Addendum:

The herbal Garcinia cambogia was shown in a 2003 study by Dr. Hayamizu, et. al. studying the effects of G. cambogia extract on serum leptin and insulin in mice found that this extract has leptin like effects.  G. cambogia also known as Brindle Berry the rind of which is uses in India as a component in curry may be helpful as a leptin like modifier and weight loss supplement as one of its components is hydroxycitric acid (HCA) which in other studies has shown to reduce weight in subjects. Further trials will be necessary to prove effectiveness and safety since there are issues with HCA and hepatoxicity.  Although a study by Dr. Stohs, et. al as recently as the summer of 2009 showed no evidence of toxicity with HCA.

~JP 

Krill Oil Article

Krill Oil the New Omega-3FA Benchmark

By JP Saleeby, MD

Krill oil is an Omega-3 Fatty Acid (n-3FA) rich oil harvested from a very small marine crustacean.  Krill are small shrimp like animals ranging from about ½ to 2 inches in length and are one of the most abundant animals in the ocean.  Krill is at the bottom of the ocean’s food chain and are eaten by a host of other animals from fish to squid to seals and whales.  They in turn feed on phytoplankton which occupies the bottom rung of the food chain.  The commercial fishing of krill occurs primarily in the northern Pacific Ocean and southern oceans along the coasts of Canada and Japan.  In Japan, krill is fished directly for food and is considered by the Japanese a delicacy called okiami.  But other commercial uses include use in aquaculture, sport fishing bait and the production of very high quality n-3FA oils.

In addition to it useful source of a high quality, krill oil shows a lower contaminant level of heavy metals and toxins.   For this reason n-3FA is becoming popular as a supplement.  Another reason is because of a unique antioxidant that it contains.  Astaxanthin is a type of antioxidant that occurs in this marine animal that can protect the human body from the damages of free radicals and oxidative load.  The characteristic red-pink color attributed to krill and other crustaceans (like shrimp and lobster) comes from the red pigment in astaxanthin, and is due to the type of algae that the krill ingest.

As we know, antioxidants protect our body from harmful highly reactive substances called free-radicals that are implicated in human disease and degenerative disorders.  One unique property of astaxanthin not found in many of the other antioxidants is that it crosses the blood-brain barrier, thus protecting the brain, eyes and our central nervous system where other antioxidants cannot.

Krill oil may become a favorite for those supplementing with n-3FAs as it may be preferred over fish oil (derived from a higher food chain ocean animal) that can accumulate higher levels of mercury and other toxins because they live longer.  Another reason is because krill oil does not come with the fishy taste often associated with fish oil.  Flax oil is a vegetarian form of n-3FA but there are those people who do not possess a critical enzyme that converts the substrate fatty acid to the desired n-3FA.  Remember, krill oil also contains a higher amount of astaxanthin than does fish oil.  Flax seed oil contains no astaxanthin.

Krill oil in one scientific study of 120 people with elevated LDL-Cholesterol compared with placebo showed a reduction in LDL by 34% and an increase in HDL (good cholesterol) by 43.5%.  When fish oil was compared it had less of an effect on LDL and HDL.  Krill also was shown to lower Triglycerides.

Pro-inflammatory conditions such as the discomfort common in premenstrual syndrome and arthritis were relieved by krill oil.  Krill oil at a dose of 300mg daily was effective in reducing arthritic symptoms in a study published in the Journal of American College of Nutrition.

Those with allergies to seafood should use caution when taking krill oil as there may be reactions.  With the use of any n-3FA, one can realize an increase in bleeding time and thus those on blood thinners or those going in for elective surgery should refrain from use.  Additionally, people using blood thinners, anti-platelet medication or NSAIDs must use caution and only use high doses of krill oil under physician supervision.  Herbs such as garlic, ginkgo biloba and ginseng can also increase bleeding times.

_References:

_{Bunea R, El Farrah K, Deutsch L.Evaluation of the effects of Neptune Krill Oil on the clinical course of hyperlipidemia. Altern Med Rev. (2004) 9.4: 420-428.}

_{Deutsch L. Evaluation of the effect of Neptune Krill Oil on chronic inflammation and arthritic symptoms. J Am Coll Nutr. (2007) 26.1: 39-48.}

http://altmedicine.about.com/od/herbsupplementguide/a/krilloil.htm (last viewed 12/15/2009)

Sharon makes news in AARC.org

		Good Press: AARC Members in the News December 10, 2009 Check out our latest list of newsmakers— Deborah Pierce Dan Conyers Walt Wilson Janyth Bolden Joe Conley Robin Miller Lawrence Johnson Rick Carver click to link to Dr. Saleeby's web site Sharon Saleeby Walt Garant David Goswick Jody Adkins John Murray Joseph Sorbello Jim Perrine comments on a free COPD awareness event held at his hospital in this article in the Huntington, WV, Herald Dispatch. "A lot of people who have COPD aren't aware of their problems until they actually have a screening for it," he was quoted as saying. Ed Newton is noted for conducting pulmonary function tests during a health fair in this article in the Bainbridge, GA, Post-Searchlight. Deborah Pierce is cited as one of two keynote speakers for a program on COPD in this article in the Battle Creek, MI, Enquirer. Monica Moore comments on CPAP for the treatment of sleep apnea in this article on the WSBT-TV web site out of Mishawaka, IN. “Some people notice a change right away. They'll call the next day and say they haven't slept that well in a long time,” she was quoted as saying. Dan Conyers is noted for his appointment to the Respiratory Care Council in Kansas in this article on the WIBW web site out of Topeka, KS. Kate Collins is featured for being on hand at a local farmer’s market in this article in the Martha’s Vineyard Times out of Vineyard Haven, MA. Harlan Hanson comments on the benefits of quitting smoking in this article on the KPTH-TV web site in Dakota Dunes, SD. "The minute you quick smoking, the little cilia in your lungs come back to life and start cleaning your lungs back out," he was quoted as saying. Mark Lotz is noted for giving a talk on sleep to a heart disease support group in this article in the Hannibal, MO, Courier-Post. Walt Wilson writes about a partnership between his RT educational program and school nurses in this articlein the Natchez, MS, Democrat. Tammy Kurszewski, Ann Medford, and Jennifer Gresham talk about a “Bowling with Cold Turkeys” event they held to support the Great American Smokeout in this article and video on the KAUZ-TV web site out of Wichita Falls, TX. (Stay tuned to AARC Times for more on this unique event.) Janyth Bolden comments on the Great American Smokeout in this article in the Mount Shasta, CA, News. Joe Conley is recognized for receiving his alma mater’s Respiratory Therapist Outstanding Alumnus award in this article in the Wausau, WI, Daily Herald. Robin Miller tells what it’s like to go back to school while working full time in this article in Mississippi’s Clarion-Ledger. Justin Misuraca’s children’s book, Lizzy’s Big Trip, is featured in this article in the Charlotte Conservative News. Part of the proceeds from the sale of the book go to support the foundation at the Denver children’s hospital where Justin works as an RT. (We featured Justin and his book in AARC Times back in 2008.) Thomas R. Harvie is recognized for being named treasurer of the New York State Society for Respiratory Care in this article in the Albany, NY, Times Union. Kathy Calvo is noted for receiving the M. John and Drenda Heydel Respiratory Therapy Scholarship in this article in the Greenwood, SC, Today. John Seifert receives kudos for receiving the Charles W. Serby COPD Research Fellowship at the AARC International Respiratory Congress in this article in the Montana State University Mountains & Minds. Lawrence Johnson is featured in this article and Skype interview on the CBS affiliate out of Springfield, MA. His topic: breathing problems and how to cope with them. Jennifer Grimes’ recent experience as a contestant on Wheel of Fortune is outlined in this article in the Phoenix, AZ, East Valley Tribune. Lynette Boudreaux’s side business, called Momma’s Heart Rosaries, is the topic of this article and video on HoumaToday.com out of Louisiana. She and her daughter paint Catholic rosaries with themes ranging from butterflies to the New Orleans Saints and LSU Tigers. Donna Schmidt is noted for receiving a Spirit of Achievement Award from the Oklahoma Hospital Association in this article in the Edmond, OK, Sun. Rick Carver has been in two recent articles for two very different reasons: this one in the Maryville, TN, Blount Today notes the success of his latest Rhythm and Roll event to raise money for cystic fibrosis; this one in the Blount County Daily Times covers his candidacy for county commissioner. Sharon Saleeby is noted for helping her husband, a local emergency room physician, establish a mobile medical service for their community in this article  in the Charleston, SC, Post and Courier. Walt Garant is cited for his role in his hospital’s cardiopulmonary program in this article in the Cape May County Herald out of New Jersey. Frank R. Salvatore Jr. is noted for his election to the AARC Board of Directors in this article in the Hudson Valley Press out of New York. Brian Murphy, Jamie Ryan, Samantha Preihs, and Tammy Redasky share great information about the Sputum Bowl team from their school in this article in the Tucson, AZ, Daily Star. Another Sputum Bowl team receives coverage in this article in the Enid, OK, News & Eagle. Educators Deryl Gulliford and Jim Grantz couldn’t be prouder of team members Kaci Bliss, Abigail Padilla, Nick Almack, and Dante Clark, all of whom recently graduated from their RT program. David Goswick talks about his new respiratory therapy educational program in this article on KentNewsNet.com out of Kent State University in Ohio. "The Respiratory Therapy program covers so many aspects that you're pulling from all different types of academia. It is a demanding field, but it's also a very rewarding field because you get to save lives," he was quoted as saying. Jody Adkins explains how a workforce retraining program helped her become an RT after she was laid off from her job at a stamping plant in this article on the West Virginia Metronews Network web site. Jody graduated May 8 and started her new job as an RT on May 21. Lance Lothert talks about the World COPD Day @ the State Capitol event hosted by the Minnesota Society for Respiratory Care in this article in the Redwood Falls, MN, Gazette. The MSRC held the event in response to an AARC request to the state societies to take COPD screening and information to their state capitols and/or state department of health buildings on November 18. You can read more about this effort in an upcoming issue of AARC Times. Cindy Soares writes about the expense involved in using nicotine replacement products to quit smoking in this letter to the editor in the Rome, NY, Sentinel. Cindy suggests a couple of organizations in her community that provide free assistance to people who want to kick the habit. Walt Wilson writes about a partnership between his school program and local school nurses in this article in the Natchez, MS, Democrat. John Murray is noted for presenting an abstract at Sleep 2009 in this article on Seacoastonline.com out of Maine. Joseph Sorbello comments on a new RT educational program in this article in the Watertown, NY, Daily Times. And last but not least, AARC President Tim Myers this articlein HomeCare. comments on the Association’s support for legislation that would end DMEPOS competitive bidding in
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Integrative Medicine featured in Natural Awakenings Magazine

Keep you eyes out for the January issue of Natural Awakenings Magazine.  The issue is dedicated to "Integrative Medicine".

Physician Recruitment and Retention in Rural SC

Incentives for Recruitment of Physicians and Problems of Retention

In Rural South Carolina

Case in Point: Marlboro Park Hospital and Surrounding County, Bennettsville, SC

Sharon K. Saleeby, RRT
College of Health Professions
Medical University of South Carolina

Abstract

Recruitment of physicians to rural areas is a difficult task. The federal government recognizes that rural health care recipients need physicians to serve in medically underserved areas; therefore they have devised monetary incentives to help accomplish the task of physician placement. The state government is involved with recruitment initiatives in a similar capacity. Rural hospitals, such as Marlboro Park Hospital in Bennettsville, SC are constantly seeking new physicians to expand their services and to replace those that have left or retired. The high physician attrition rate in the county is due to multiple factors. The inability to keep physicians in the county has multiple effects from community perceptions on the availability of health services to the long term viability of the hospital.

---


A persistent and pervasive problem facing small town community based hospital systems is the recruitment and retention of physicians. With the current downturn in the economy, the already arduous task of recruiting physicians has become even more difficult. While there are federal, state, and local initiatives to bring physicians into the community, retention of those physicians remains a constant problem, particularly to small community hospitals, like Marlboro Park, in Bennettsville, SC. The inability to keep doctors in the community effects the community’s perception of the hospital, causes rising visits to the Emergency Department for primary care issues, and will often force those same citizens to seek care outside of the county. Recruitment can be accomplished, but there are no easy answers and no quick fixes on how to keep these physicians in the county. The information in this paper is based on conversations held with the Director of Human Resources at Marlboro Park Hospital, the Director of Recruitment at the South Carolina Office of Rural Health, and through journal articles dealing with recruitment and retention of physicians to rural areas, not just in South Carolina, but nationwide.

Marlboro Park Hospital (MPH) is a private for profit hospital located in the town of Bennettsville, South Carolina. MPH has 102 beds, 18 active physicians, 28 physicians with courtesy privileges, 183 employees and 35 contracted employees. Dietary, Rehabilitation Services, and Biomedical are all contracted services. Additionally, the physicians staffing the Emergency Department are contracted. There are 12 specialty services (Family Practice, general surgery, Ob-Gyn, urology, radiology, pediatrics, internal medicine, nephrology, orthopedics, pathology, urology, and pulmonary medicine) and 2 consulting specialties (cardiology and gastroenterology). Some of the services that the hospital provide are: telemetry, cardiopulmonary, 24-hour Emergency Room, ICU, Imaging, Labor and Delivery, Laboratory, Pharmacy, and Surgical Services. They also have Post Anesthesia Care, EEG, Occupational Therapy and Physical Therapy Rehabilitation Care. Owned by Community Health Systems (CHS), which is based in Franklin, Tennessee, the company’s focus is on small rural hospitals. CHS provides recruitment services to these hospitals and management guidance. CHS’s mission, through MPH, is to build a strong community-hospital relationship. They currently own five rural hospitals located in the upstate region of SC. (C. Meggs, personal communication, October 4, 2009)

The Human Resource Department of MPH, as with many small rural hospitals, is staffed by one person. While Christi Meggs is responsible for overseeing the hiring of new employees, benefit packages and orientation of new employees, her main objective is recruitment of physicians and marketing for MPH. She is credentialed as a Senior Professional in Human Resources. It is through interviews with Mrs. Meggs that I am able to put the pieces of recruitment and retention into proper perspective and appreciate the difficulty involved.

The town of Bennettsville is located in Marlboro County, just north of Darlington, SC. The population of the county, based on 2008 census reports, is 28,021, of which 52.3% is black, 42.5% is white, and 3.7% is Native American. Sixty percent of the population has a high school education; 8.3% has a Bachelor’s Degree, and 8.9% have professional degrees. The school system in the county is ranked as one of the lowest in the state, based on Palmetto Achievement Challenge Testing results compared with state averages. (Great Schools, 2008) The median household income is $29,229 vs. $43,508 for the state and $42,000 US median. The unemployment rate is one of the highest in the state at 21.7%. (U.S. Census, 2008)

Nineteen percent of the population has no health insurance. Seventeen percent qualify for Medicare and 32% are Medicaid enrollees. (South Carolina Department of Health and Human Services, SFY 2008) While these are simply numbers on a census table, the stark reality is that 27.5% live below the poverty level in Marlboro County and these facts have a tremendous impact on the success of the hospital. (U.S. Census, 2008) Not only must MPH survive amid this, but they are faced with five competing hospitals within a 45-mile radius, and all with similar issues and competing for the same revenue base.

Over the past three years, MPH has been unable to hire a psychiatrist and therefore have had to close their Adult Mental Health facility. They have lost a gastroenterologist and had to close their GI suite. Two family medicine physicians employed by the hospital have relocated, which resulted in the reconfiguring of the hospital based Rural Health Clinic. The hospital has had a turnover of five CEOS and three Directors of Nursing. Though these problems seem insurmountable, Christi Meggs, prods forward and is enthusiastic in her endeavors to restore a semblance of stability within the hospital. These issues are not unique to Marlboro County; they are pervasive throughout the country.

When we speak of “rural”, we are referring to counties in which there is no metropolitan area with more than 50,000 residents. Fifty-three percent of SC is considered rural and only 9% of physicians practice within this rural area. Here we find our most susceptible and underserved populations. (Hancock, 2009) Statistics reported by the Center for Disease Control (CDC), state that those living in rural areas have “higher death rates from unintentional injuries, higher incidences of chronic obstructive pulmonary disease, and higher rates of suicide.” (Escarce, 2009, p.625) Heart disease, obesity, tobacco, alcohol and drug abuse are also higher than non-rural areas. Unfortunately, this vulnerable population is least likely to seek care, thus contributing to the high mortality rate.

In response to the need for rural health care access, the Federal Government has tried to set in place initiatives to aid in the recruitment of physicians to rural areas. In 1987, the Medicare Payment Incentive Program was initiated in the attempt to retain existing physicians in rural areas and to provide funding to offset the cost of relocation and costs associated with opening new practices. In that same year, the Omnibus Budget Reconciliation Act was passed. (U.S. Department of Health and Human Services,[DHHS] Office of Inspector General, 1994) This provided for bonus payments to physicians for a five percent increase (now a ten percent increase) to the amount paid by Medicare for their services. This bonus was allocated providing they worked in areas designated as medically underserved. To establish guidelines in defining what regions actually qualified for funding, the Department of Health and Human Resources Service Administration, under the Public Service Act 1976, ( Sec. 215 of the Public Health Service Act, 58 Stat. 690 (42 U.S.C. 216); sec. 332 of the Public Health Service Act, 90 Stat. 2270 - 2272 (42 U.S.C. 254e) categorized areas as Health Professional Shortage Areas (HPSA). There are three subcategories of HPSA. Geographic HPSA must have a physician patient ratio of greater that 3,000:1. Low income HPSA is an area living below the poverty level. Facilities HPSA are non-profit medical facilities such as Community Health Centers, Rural Health Centers, and correctional institutions. The designation of these areas is determined by the states.(South Carolina Department of Health and Environmental Control, [SCDHEC]) In SC, it is determined by the SC Department of Health and Environmental Control’s Office of Primary Care after a Health Care Access Analysis is done. To achieve a designation of a Medically Underserved Area (MUA) or Medically Underserved Population (MUP), the U.S. Department of Health and Human Services will analyze the ratio of primary care physicians per 1,000 populations, the infant mortality rates, percentage of those living under the poverty level, and percentage of those over the age of sixty five. (U.S. Health Resources and Services Administration, [HRSA]) These designations make it possible to establish federally qualified Health Care Centers, rural health care clinics, and HPSA Medicare programs (due to the complexity of Medicare and Medicaid reimbursements to physicians, I have opted to only make mention of their existence.)

Recruitment of physicians is directly affected by HPSA or MUA/P designations in that it will determine federal funding. Thirty state and federal programs use the HPSA/MUA designations to establish eligibility for loan repayment programs, scholarships programs for medical students, and J-1 visa programs for international students. (SCDHEC) There are three specific federal programs available whose focus is rural area recruitment. The Health Resources and Service Administration Loan Repayment Program is funded through the National Health Service Corp. The program is aimed at primary care physicians that are U.S. citizens or naturalized citizens and requires the recipient to work in HPSAs that accept Medicare and Medicaid. Usual sites for placement of recipients are rural health clinics, public health departments, hospital-affiliated primary care offices, managed care offices, and prisons. Compensation varies by state. Presently, the limit is set at $35,000 for a two year commitment, but can be extended beyond the two year period with added compensation. All funds are tax exempt and medical malpractice is covered. Applications go through the DHEC Office of Primary Care. (DHHS,National Health Service Corp, [NHSC])

The National Health Service Corp provides both a loan repayment program and a scholarship program. The loan program is available for physicians whose specialties are Family Practice, Internal Medicine, Ob-GYN, Pediatrics or General Practice. This program also requires that the recipient make a commitment of at least two years to practice in a HPSA. The amount of repayment is up to $25,000 and up to $35,000 for third and successive years. Furthermore, physicians are given additional income (39% of the amount) to offset the tax liabilities of the funding. (American Association of Medical Colleges, 2009) The scholarship program requires the recipient to be a U.S. citizen attending an accredited medical school in this country. A future residency in a primary care field is required and a one year commitment for every year of aid is expected.

For international medical graduates, recruitment to HPSA is achieved through J-1 Visa programs. The minimum commitment time is three-years. For these graduates, they must first apply through the U.S. Department of State, then through the DHEC Office of Primary Care. Here in Marlboro County, J-1 Visa applicants work either at a local rural health office, also known as CareSouth, Inc. or at Evans Correctional Center (state penitentiary) or the Federal Corrections Institute (federal penitentiary). These same graduates will qualify for permanent residency status with an additional two year commitment to continue their work in underserved areas. (Pennsylvania Department of Health, 2009)

State incentives for recruitment are accomplished through a state incentive grant. This grant is sponsored through the SC Area Health Education Consortium (AHEC) and is co-sponsored by the Medical University of SC, and is managed by the Rural Physician Incentive Board. The purpose of this grant is to provide assistance to new physicians setting up practices or joining existing rural practices in the hopes that they will maintain a viable practice and commit to the area. Depending on state budget allowances, a maximum of $40,000 is awarded over a four-year period. First priority candidates of grant distribution would be SC natives that have attended medical school in SC. Recipients must agree to accept Medicare patients, Medicaid patients, and any other patient regardless of their ability to pay for services. The SC Office of Rural Health tracks the number of patients seen by the practice to ensure compliance with grant requirements. If default of the grant occurs, all funds must be returned. Additionally, there is a State matching Incentive program that was developed to help physicians start up a primary care office in an area designated at medically underserved. (SC Area Health Education Consortium, Recruitment and Retention Programs) This is both a federal and state plan in that funds from the federal government are matched equally by state funding. (Texas Medical Association, 2008)

Marlboro Park Hospital has its own incentives for recruitment. If the recipients of any of the loan repayment programs or J-1 Visa programs wish to continue service in the county after their commitment is over, MPH will often help them establish a hospital affiliated practice. This sets up a win-win situation in that it takes care of the physician, yet provides a revenue source for referrals to the hospital. (Norbut, 2004) As an added incentive, these physicians are given positions on hospital committees, such as the Hospital Utilization Board, Medical Executive Committee, and the Credentialing Committee. Studies have shown that physicians look favorably on being given leadership positions or expanding their administrative or clinical positions. (Deprez, 2004) Physicians are also offered commitment bonuses, varying from 10 to 30K, funds for Continuing Medical Education Credits (CME), and relocation packages. If there is no available physician to fill an opening, MPH can obtain help from the Department of Rural Health through membership services. The cost of membership is $3,000 yearly and the hospital is able to have access to their physician databases and recruitment services. (Stacey Day, Director of Recruitment, Office of Rural Health, personal communication, Oct 20, 2009) The corporate office of CHS also deals with recruitment by attending national conferences, direct mailings to physicians, accessing national databases, visiting medical schools, and referrals from other physicians. (C, Meggs, personal communication, Oct 4, 2009) While all of these programs exist to bring doctors into this community, it is quite another issue having them stay.

Once physicians are recruited to rural areas, there are problems inherit is continuing to live in small communities. Chief complaints for doctors usually revolve around educational isolation and long hours and frequent on call schedules. (Deprez, 2004) For instance, in Marlboro County there were six physicians sharing call for medicine patients, which means that the call schedule was rotated every six days; not necessarily different from an urban area. However, there is only one surgeon, so he is on call every day. There are three Ob-Gyn physicians, which necessitates a rotation schedule every three days. All three Ob-Gyns service the neighboring county, which is likewise a rural agricultural area. Attaining continuing medical education credits (CMEs), as required by the State Board of Medical Examiners, is difficult here as well. The hospital will periodically sponsor in-services and will reimburse for travel to programs, however, most rely on on-line programs. The South Carolina Area Health Education Consortium will frequently offer classes to ensure the attainment of required CMEs.

There are issues with medical insurance reimbursements, keeping in mind, there are high levels of uninsured patients, and those on Medicare and Medicaid. While there are government programs in place that aid in Medicaid payments, such as the Physician Incentive Bonus Payments, reimbursements tend to be low (mentioned previously, gives a 10% bonus to those treating Medicaid patients.) (Phillips, 1998) Specialty physicians are often concerned about the number of patients to support their practices. Financial viability is an extremely important consideration. (Deprez, 2004)

Issues with spouses and children, seems to be the largest disincentive to stay in the county. (O’Shaughnessy, 1997) This is especially true in cases where the spouse has left behind a successful career, described in HR and management literature as the “Trailing Spouse Syndrome”. (Phillips, 1998) Spouses often leave behind careers and/or take substantial pay cuts, or else face extensive travel to other areas to retain their jobs. They often must take a back seat in their career plans. Regarding the family, the children are often placed in school systems that may be inadequate. Such is the case in Marlboro County schools where scores remain some of the lowest in the state based on Palmetto Achievement Tests. An alternative to the public school system is a private school; however, enrollment is currently very limited. Travel to the neighboring county of Chesterfield or Scotland County, North Carolina are other choices that some parents consider, due to higher ranking test scores. Ultimately, issues with the spouses and children significantly undermine the retention rate. Not everyone is cut out for the bucolic lifestyle, and many families of these physicians opt to live outside of the county. In fact, some of these families live as far away as Columbia, SC and their spouses commute over an hour and a half to get back into the county. (personal observation)

Of those physicians that opt to stay, studies have shown that many have backgrounds growing up in small town atmospheres. (Rabinowitz, 1999) They were looking for comfortable environments that offered a slower pace of life and the chance to get to know their patients. In short, they wanted to feel a community connection. Other factors that have a positive effect on their decision to stay, revolve around the types of rural care programs accessible in their medical school training. Some medical schools offer in their curriculum rotations through rural practices, rural health centers or health departments. (Hancock, 2009) Others believe that if medical schools encouraged students to follow in primary care studies, then more would be inclined to practice in rural areas. (Phillips, 1998) Their involvement with this type of curriculum tends to be a positive affirmation to pursue rural care. It has also been shown that when physicians buy practices they are more likely to be committed to their community and are more likely to stay. (Pathham, 2004)

A negative community perception of their hospital is directly affected by the inability to recruit and retain physicians. Citizens want to have a continuity of care and with a steady stream of changing physicians it is difficult to establish trust. This is especially true if the same physicians that work in the community do not live, nor do their children attend schools in the county. (O’Shaughnessy, 1997) The same citizens may feel that the rural hospital may not be as up to date as larger more urban hospitals and therefore will leave the county for their care. Interestingly, the Northeastern Rural Health Network keeps statistical information of those that use MPH emergency room and those that seek the same care outside of the county. Of the total number of cases seen by MPH and other ER facilities by the residents of Marlboro County, 57% of those cases remained in the county and sought care, while 43% went to other emergency rooms outside of the county. Of this 43%, most residents sought care in the neighboring county of Chesterfield, followed by Florence and Dillon counties. (South Carolina Budget and Control Board [SCBCB], 2009) These facts account for a tremendous amount of revenue lost by MPH. Studies have also shown that one-half of pregnant women in rural areas bypass their local practitioners and hospitals and opt for more urban centers. The same is true of those with private insurance, except the percentage is lower at 30%, and those seeking treatment for more complex illness. (Escarce, 2009) While hospitals may have these services, some people are just resistant to using these rural facilities. When informally questioning neighbors and asking them why they did not use the local hospital, the overwhelming response was that they felt services were lacking. The second most frequent response was that their primary care physician had moved and they were forced to see a physician in another county.

Lack of primary care physicians also account for frequent visits to the Emergency Department. Data attained from the Northeastern Rural Health Network show that MPH had 13,567 ER visits. They also listed the top fifty reasons for these visits. While they did not categorize these into what constituted simple primary care issues, we know that there is a 10% admission rate from the ER at MPH. (SCBCB, 2009) National averages of admission rates are 12.8%. MPH reports that ER visits have shown a yearly increase, while admissions have basically not changed. The same is reported by the Center for Disease Control (CDC) in their National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. From these reports, we can determine that most visits involved non-emergent issues, thus probably primary care issues. Under Emergency Medical Treatment and Active Labor Act, or EMTALA, these patients cannot be turned away, however, if they do not have a primary care practitioner, where are they to go? Those without resources or transportation are limited to their county emergency departments and unfortunately drive the cost of care up and play havoc with the revenue of the hospital. Again, the answer to this problem is the availability of primary care physicians and a community commitment to utilize what is available in the county.

The incentives given by federal, state, and the local hospital for physician recruitment are entirely monetary. The retention involves more than just a monetary fulfillment, but rather a family and personal commitment to a community. If that commitment cannot be attained, then the attrition rate will remain high for rural areas. Again, there is no simple solution to keeping physicians. The community must support their hospitals. MPH is convenient, there are services available, and there are doctors that are giving their time and dedication to serving the county. The more the community gives to the hospital, the more the hospital can give to the community. It falls on the lap of the human resource department at MPH to remain on the front line of physician recruitment and retention, not only relying on what the state and federal government provide, but becoming creative in developing solutions to overcome some of the counties short comings.


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