Fire your stockbroker, fire your doctor

Is it yet time to fire your doctor?

I advocate a model of self-directed health, a style of healthcare in which individuals have the right to direct his or her own healthcare with only the occasional assistance of a physician or healthcare provider.

Healthcare would not be the first industry that converted to such a self-directed model. Remember travel agents? Only 15 years ago, making travel plans meant calling your travel agent to book your arrangements. This was a flawed system, because they worked on commission, thereby impairing incentive to search for the best prices. You were, in effect, at their mercy.

The investment industry is another such example, though on a larger scale.

Up until the 1980s, individual investment was managed by a stockbroker or other money manager. Stockbrokers, analysts, and investment houses commanded the flow of investment in stocks, options, futures, commodities, etc. Individuals lacked access to the methods and knowledge that allowed them to manage their own portfolios. Individuals had no choice but to engage the services of a professional investor. This was also a flawed system. Like travel agents, stockbrokers worked on commission. We've all heard horror stories in which stockbrokers churned accounts, making thousands of dollars in commissions while their clients' portfolios shrunk.

That has all changed.

Today, the process has largely converted to discount brokers and online services used by individuals trading and managing their own portfolios. Stockbrokers and investment houses continue, of course, but are competing for a shrinking piece of the individual investment market. Independent investors now have access to investment tools that didn’t even exist 20 years ago. Companies like E-Trade and Ameritrade now command annual revenues of approximately $2 billion each.

Travel agents, stockbrokers . . . is healthcare next? Can we convert from the paternalistic, “I’m-the-doctor, you’re the patient” relationship to what in which you self-direct your own healthcare and turn to the healthcare system only in unique situations?

I believe that the same revolution that shook the investment industry in the 1980s will seize healthcare in the future. In fact, the transition to self-directed health will dwarf its investing counterpart. It will ripple more broadly through the fabric of American life. Health is a more complicated “product,” with more complex modes of delivery, and more varied levels of need than the investment industry.

I predict that the emergence of health directed by the individual, just as the emergence of self-directed investment, will dominate in the coming years.

While I hope you've already fired your stockbroker, and I doubt that anyone on the internet still uses a travel agent, I wouldn't yet fire your doctor altogether. But I believe that we are approaching a time in which you should begin to take control over your own health and begin to reduce reliance on doctors, drugs, and hospitals.

Comments (10) -

  • Jenny

    4/11/2009 3:04:00 PM |

    The problem with the concept of "self-directed health" is how ignorant most people are about health in the general population. The online community is self-selected and we are extremely well read and aware.

    But I have friends and even family who have medical conditions but know nothing about physiology and  have no interest in learning about it.

    My belief is that most people don't develop an interest in self-directed medicine until, like myself, they or a family member have been seriously hurt by a doctor they trusted. Until that happens most people will trust their doctors.  Sadly, for many of them the "seriously hurt" translates into "Unnecessary first and fatal heart attack."

  • Anonymous

    4/11/2009 3:19:00 PM |

    I would love to utilize the "a la carte" menu of healthcare model... in fact in many ways I already do.

    Hopefully the next thing to go will be the horrified looks... as if I am endangering my health by directing my care, for asking for tests or services when they are needed, for refusing to be a drug company research subject or pawn, and for being as informed about my body and about medicine as I can be.

    Yes, it is definitely time... but this model only works for those who are informed, aware and proactive.  Those who are too timid, or intellectually challenged, or lazy to direct their own care, will prefer the status quo.

    madcook

  • Anonymous

    4/11/2009 3:26:00 PM |

    I agree with your assessment. Unfortunately, there are many who believe that a national health care bureaucracy is the "answer." If this comes to pass, we will all be paying twice for our care: once for the bloated and ineffective system (just look at our public schools) and once for our self-directed care.

    Thanks for spreading the news.

  • Brock Cusick

    4/11/2009 6:15:00 PM |

    Speaking as someone in the "Investment Adviser" business, I can say with great certainty that Ameritrade and Charles Schwab can give people the ability to make stock trades cheaply, but they cannot help them (much) make trades wisely.  Main Street Joe has gained incredible ability, but expertise lags considerably.

    Most importantly, expertise will ALWAYS be lacking because (if Joe is doing his job) he spends most of his learning time on his real job, whether that's carpentry, plumbing, doctoring, or whatever. The guy who looks at stocks professionally will always have a better feel for the market and what makes a good stock.

    The solution isn't to fire the investment adviser (aka, the expert), but to change the incentives. Get rid of the commission. Fee-based advisers (who take a fee determined by the total assets under management) have the same incentive as the investor - to grow the value of the portfolio.


    ----

    We can make an analogy to Doctors. If the General Practitioner acted more like a Health Adviser who got paid only when you get healthy (rather than get paid when they sell you a medication or procedure) I bet we'd see radical improvement in care. There would probably also have to be payments in the event that the patient refuses to comply with taking his vitamins or stop eating bad things.

  • Lena

    4/12/2009 1:20:00 AM |

    I'd love for this to hurry up and be the case. My current GP always seems "concerned" if I try to take a detailed interest in my own health, as if I am a hypochondriac. I'm quite good at reading body language and am not a paranoia-prone person, so I don't think I'm misreading the situation. She got upset when I brought in some information relevant to my case because it had come from the internet. It wasn't even anonymous, dubious information, it was a guideline authored by two eminent professors in the subject which was widely linked to by medical professionals. But because it came from the internet it was somehow invalid.

    There will be some doctors that will fight tooth and nail before they give up their paternalistic doctor-is-god ways.

  • Dr. William Davis

    4/12/2009 1:11:00 PM |

    Good thoughts, all.

    The fact that we are even having this conversation online is testimony to the fact that self-directed health is ALREADY happening. It is not some sci-fi figment of imagination. It is happening, it will happen, it will grow.

    Granted, "only" 5-10% of the population (15-30 million) will, in the next 30 years, participate. That should not stop one of the most exciting, revolutionary steps in healthcare to develop.

  • Trinkwasser

    4/12/2009 2:29:00 PM |

    Fully agreed! Yes there are a lot of cranks on the internet but equally there are a lot of people pointing and yelling "Crank!"

    This does NOT happen with your GP who might actually know very little about your specific condition, and that knowledge may be 50 years out of date. Sadly this is likely to be the case if he (or you) inform yourself from some of the woefully inadequate "professional" sites.

    Many doctors are first class, as are many other sources of health information. Increasingly we are seeing first class patients also! Teamwork is the best plan, my GP has pointed me to information I didn't otherwise know, and I've returned the compliment.

  • Kris

    4/12/2009 6:51:00 PM |

    it reminds me of speed limits on our Highways. where many people can safely drive at 100 miles an hour but not every one is capable of doing it. Therefore speed limits needed where majority is expected to drive safely. The concept of "self directed health" runs in to the same danger. even though i my self, treated my misery by self educating after years of appointments with doctors and not only suffering physically but also paying big price socially and economically. It is  important to change the selection process of these so called doctors before an individual is allowed in to a medical school. the selection should be based on not only academic achievements but a real personality for community service without ego should be a major criteria. A doctor's inability to treat patient accurately effects our social life and community at large. i still believe that more doctors are sick themselves and therefore are blinded by the false ego. Most don't have the stomach to Liston to their patients. general public shouldn't have to waist their time learning "self directed health treatments". we have a system in place and there are people being trained to take care of the society. it is the selection and training of these individuals which needs an over haul which will require some major alligators/licensing authorities  in the medical system to be shaken.
    However, since internet is a useful tool for learning and millions are already using it for self diagnoses, The medical language (studies and trials findings)posted on the internet should be in plain English so that misunderstanding can be reduced for general public.

  • Anonymous

    5/4/2009 3:53:00 AM |

    Emancipated Patients and a New Kind of Doctor

    http://www.metzelf.info/articles/emancipated.html

  • Jessica

    5/6/2009 9:27:00 PM |

    Our medical director (and Vitamin D proponent) calls this concept "Medical Self Reliance."

    Sounds...empowering!

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Small LDL: Simple vs. complex carbohydrates

Small LDL: Simple vs. complex carbohydrates

Joseph is a whip-smart corporate attorney, but one who accepts advice at his own pace. He likes to explore and consider each step of the advice I give him.

Starting (NMR) lipoprotein panel on no treatment or diet change:

LDL particle number 2620 nmol/L (which I would equate to 262 mg/dl LDL cholesterol)
Small LDL 2331 nmol/L--representing 89% of LDL particle number, a severe dominance of small LDL

I advised him to eliminate wheat, cornstarch, and sugars, while limiting other carbohydrate sources, as well. Joseph didn't like this idea very much, concerned that it would be impractical, given his busy schedule. He also did a lot of reading of the sort that suggested that replacing white flour with whole grains provided health advantages. So that's what he did: Replaced all sugar and refined flour products with whole grains, but did not restrict his intake of grains.

Next lipoprotein panel with whole grains replacing white refined flour:

LDL particle number 2451 nmol/L
Small LDL 1998 nmol/L--representing 81.5% of LDL particle number.

In other words, replacing white flour products with whole grain products reduced small LDL by 14%--a modest improvement, but hardly great.

I explained to Joseph that any grain, complex, refined, or simple--will, just like other sugars and carbohydrates, still provoke small LDL. Given the severity of his patterns, I suggested trying again, this time with full elimination of grains.

Next lipoprotein panel with elimination of whole grains:

LDL particle number 1320 nmol/L
Small LDL 646 nmol/L
--48.9% of total LDL particle number, but a much lower absolute number, a reduction of 67.6%.

This is typical of the LDL responses I see with elimination of wheat products on the background of an overall carbohydrate restriction: Big drops in precisely measured LDL as LDL particle number (i.e., an actual count of LDL particles, not LDL cholesterol) and big drops in the number of small LDL particles.

You might say that wheat elimination and limitation of carbohydrate intake can yield statin-like values . . . without the statin.

Comments (17) -

  • medeldist

    5/4/2010 8:26:52 AM |

    Interesting. I'm looking through my screening results (I'm in Europe) and there is no mention of LDL, but I have two other values, P-Apo A1 (1.77 g/L) and P-Apo B (1.09 g/L). Is there a relation between these and LDL/HDL?

  • tom

    5/4/2010 1:02:12 PM |

    It is good to have positive feedback via blood testing to show changes one is making to their body. I wonder what is a good interval between tests to show cholesterol changes?

    On a similar note, I have been eating low carb for 4 months using my blood meter to reduce both blood sugars and insulin resistance for pre-diabetes. I am still thinking about your slo-niacin suggestions and how the bad increase in blood sugar and insulin resistance vs the good cholesterol effects would affect me. I am waiting to get results from my first NMR lipoprofile to make a decision.

  • Ned Kock

    5/4/2010 3:49:58 PM |

    Indeed, restricting carbohydrates is more similar to taking statins than many people think. With the advantage that it does not have the side effects of statins, and is not costly at all.

    Many people do not know that carbohydrates stimulate the production of VLDL, suppressing the production of free fatty acids and ketones. Our liver then pumps out small VLDL particles at a high rate, and these end up as small-dense LDL particles. The potentially atherogenic type, in the presence of other factors (e.g., chronic inflammation).

    Low carbohydrate dieting stimulates the production and release of free fatty acids and ketones, suppressing the production of VLDL. Our liver then pumps fewer VLDL particles into the bloodstream (since FFAs and ketones are already doing a good job at feeding muscle and brain tissue), and when it does it lets out big VLDL particles, which end up as large-fluffy LDL particles prior to re-absorption by the liver.

    If anyone wants to see what these particles look like, the figure in the post below may be useful:

    http://healthcorrelator.blogspot.com/2010/02/large-ldl-and-small-hdl-particles-best.html

    Ketones are not shown because they are water soluble:

    http://healthcorrelator.blogspot.com/2010/04/ketones-and-ketosis-physiological-and.html

  • Anonymous

    5/4/2010 4:01:31 PM |

    Do you have any comments on oatmeal? I've noticed that for me personally, it doesn't significantly spike my blood sugar, and I've heard a lot about how oatmeal can improve cholesterol -- but of course this is often just focused on total cholesterol or general LDL amount.

  • Anonymous

    5/4/2010 5:05:47 PM |

    Hi Dr. Davis
    I'm really hoping to hear your opinion on this study:
    http://www.pnas.org/content/early/2009/08/21/0907995106.abstract?sid=

  • Dr. William Davis

    5/5/2010 1:38:40 AM |

    Hear, hear, Ned!

    I agree: Carbohydrate restriction is the unsung hero of VLDL and LDL reduction, though actual measurements are required to appreciate this effect.

  • Dr. William Davis

    5/5/2010 1:40:35 AM |

    Oatmeal anonymous--

    It's all about individualizing your food choices.

    Checking postprandial blood sugars is an excellent way to know if these issues apply to you or not, or to what degree.

  • Jeff

    5/5/2010 11:56:35 AM |

    What are your thoughts on Amlamax for the reduction of LDL?

  • Lucy

    5/5/2010 3:41:11 PM |

    OK, so here's my question... I am young (late twenties), thin (BMI: <20.2), and active (run, bike).  However, I still have almost all small, dense LDL.   I'm an ApoE 3/4, which I understand means I need to limit the amount of fat in my diet.  However, if grains also contribute to small LDL, what am I supposed to eat?   I don't eat much wheat as it is (my husband is celiac), but I do enjoy oats, rice, and the occassional piece of bread when we eat out, etc.  Would cutting all grains from my diet and living on only vegetables, some fruits, and lean meats be acceptable? Sounds like a boring and sad diet...

  • pjnoir

    5/5/2010 9:58:04 PM |

    Oatmeal reducing Cholestral is a joke. If I eat Oatmeal for breakfast( even a 1/2 cup) my BG numbers stay HIGH all day. Oatmeal is not a food I have on my breakfast table ever.

  • Anonymous

    5/9/2010 3:08:36 PM |

    Over what time period were these
    panels taken or in other words, how many weeks or months in-between test?
    Love the blog!
    CB

  • Conrad

    5/11/2010 2:28:43 PM |

    Who knows where to get an (NMR) lipoprotein panel in Toronto/Mississauga?

  • holym

    5/12/2010 6:36:06 PM |

    You say, "LDL particle number 2620 nmol/L (which I would equate to 262 mg/dl LDL cholesterol)"

    Why would you equate 2620 nmol/L to 262 mg/dl? The conversion factor given at http://jama.ama-assn.org/content/vol295/issue1/images/data/103/DC6/JAMA_auinst_si.dtl is roughly 1mmol/l = 39mg/dl.

  • Dr. William Davis

    5/12/2010 10:21:43 PM |

    Holym--

    I believe you are confusing Friedewald calculated LDL in nmol/L and LDL particle number--two entirely different things.

    My simple conversion is meant to yield a "Friedewald-like" LDL cholesterol from LDL particle number.

  • Dolly.G

    5/14/2010 3:34:18 AM |

    I do agree!!

  • Anonymous

    5/22/2010 11:06:37 PM |

    Where can I find the peer reviewed research upon which you base your advice? Thanks

  • David M Gordon

    6/15/2010 1:18:55 AM |

    My lab results are in, and they are,  on balance, not much improved. I think.

    The changes I effected since my prior panel panel 3 months ago:
    1) Lost 20 lbs
    2) Ingest 6,000mg of fish oil for a total of 1200mg (total) of DHA and EPA/day
    3) Ingest 500mg of Slo-Niacin/day (with 125oz of water/day)
    4) Ingest 6,000mg of Vitamin D/day (Changed to the proper Vitamin D soy capsule from the powdered tablet)
    5) Eat a large handful of almonds/day
    6) Exercise hard (weight training and cardio intervals for a minimum of 90 minutes/day).

    The (worsened) numbers:
    1) Total Cholesterol: 269 (from 267)
    2) LDL Cholesterol: 186 (from 175)

    The (improved) numbers:
    3) Triglycerides: 201 (from 280)
    4) HDL Cholesterol: 43 (from 36)

    Unfair to ask you, I know, but I am frustrated. What do I do wrong? What can I do more? I am VERY reluctant to take a statin, as I have tried many, all with terrible side-effects. And, fwiw, I started today on my wheat-free diet.

    Thank you for your guidance,
    David

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