CRITICAL THINKING SKILLS
Essential to Diagnosis in Complex Medical Patients
Ah, here’s an old fashioned phrase for you: Common Sense. It is a bit of an oxymoron that common sense is actually, not common at all, but rare. We can even bring that phrase into the 21st century by calling it Critical Thinking Skills, but that does not change its essence one bit.
With the growing popularity of functional medicine, the vast majority of the patients who seek consultations with me have had extensive testing. For those who have been ill for many years, most of them will have acquired a positive titer for EBV (Epstein-Barr Virus), HHV6 and other viruses, Mycoplasma pneumonia, Chlamydia pneumonia, and varying degrees of heavy metal toxicity (usually, and of most importance, mercury and lead). Almost all will be shown to have difficulty with methylation. Testing may suggest the presence of parasites, or the presence of dental cavitations or root canals. Testing for Lyme disease and co-infections will have differing degrees of positivity, and testing for mold toxicity using either Dr. Shoemaker’s approach (relying on TGF-beta-1, c4a, MMP9, VEGF and visual contrast testing) or measuring mycotoxins in the urine may have been done as well. The patient may even have evidence for a struggle with mast cell activation and/or porphyria.
Both the physician and patient are left with a dizzying array of possible diagnostic elements. Where do we start? What to treat first?
From my perspective, the single most important question we have to ask, and answer is: Does this diagnosis fit the patient’s symptoms?
Unfortunately, in many of the consultations I am providing, that question has not been addressed. Patients are often being treated for months or years, for viral infections and methylation dysfunction with no improvement, or worsening of their clinical condition.
Let’s look at a relatively typical patient who presents to me. They will usually describe a wide variety of symptoms, which almost always include significant fatigue and cognitive impairment (“brain fog”, word-finding problems, problems with focus, memory and/or concentration). While these symptoms are a major source of disability, they are not specific for any of the various diagnoses we might be considering. With enormous variations, other symptoms related by the patient at our first visit could include muscle or joint pain, muscle cramps or spasms, muscle weakness, anxiety, depression, obsessive-compulsive thoughts or behaviors, numbness and tingling in various parts of their body, vertigo, dizziness, disequilibrium, increasing sensitivity to light, sound, touch, chemicals, and electromagnetic waves. Gastrointestinal disturbances including nausea, vomiting, reflux, constipation, diarrhea, and abdominal pain are commonly described. Shortness of breath, a feeling that they can’t take a deep breath (which we call “air hunger”), chest pain, cough, sinus congestion or repeated sinus infections are also described quite often.
So now our task is to fit whichever constellation of symptoms our patient is describing, to a diagnosis that matches it. To do anything less is to do our patient a disservice.
Let me get a little more specific here. Methylation difficulties are an almost universal component of chronic illness. It can present with some degree of fatigue, cognitive impairment, pain, or insomnia, but it does not cause the entire constellation of symptoms with which my patients usually present. To make this more difficult, approximately half of my patients are so toxic and sensitive that they cannot take even minuscule amounts of the supplements we use to treat methylation without getting worse, and I have found that often we have to treat the underlying condition(s) first, before we can even begin to address methylation concerns. So methylation should not be the first order of business for a patient who has been quite ill for many years and presents with a wide array of symptoms.
The same is mostly true (there are exceptions) of the role that opportunistic infections play in causation. Usually viral, mycoplasmic, or chlamydial infections are secondary, not primary. They have, perhaps, lain dormant for many years while a functional immune system kept them under control. When that immune system gets compromised by an illness that specializes in weakening the immune system (like Lyme, coinfections, or mold toxicity) they can be reactivated. But, and this is key, they are not the cause of these symptoms, and they would not describe the full gamut of our patient’s symptoms.
The role of parasites as a possible cause of these conditions, or dental cavitations (osteonecrosis) is often postulated as central to patients who are not improving. While these can be important, in my experience they are not key, nor do the symptoms they produce fully fit the symptom complex we are looking at.
With patients who present to us with complex medical illnesses, with symptoms running the full range described in my hypothetical patient above (and many of my patients do have all of those symptoms), this means that our attention should be drawn to Lyme disease (with its coinfections) and mold toxicity as the conditions we should first be investigating and then treating, as central to the causation of our patient’s illness.
Here is where clinical experience really comes into play. Teasing apart Lyme disease and/or mold toxicity as the central cause of our patient’s illness is often tricky. The current accuracy of diagnosing these conditions is far less than we need to help us with this critical step in our decision making. While it has its limitations, the RealTime urine mycotoxin test is currently the most useful and accurate for clarifying the presence of mold toxicity and provides an excellent blueprint for how to treat it. Since it is an expensive test, using provocation with glutathione and/or sweating prior to obtaining the urine specimen is helpful. The Igenix Western Blot testing is considered by experts to be between 50-70% accurate and is far better than getting Western Blot testing from other sources. More accurate still is the Advanced Laboratory Lyme test, which actually cultures Borrelia from the blood.
Given that many of my patients have both mold and Lyme, which do we treat first? I almost always start with treating the mold toxicity for several reasons. First, clinical experience has shown that most of these patients make very little progress treating the Lyme component until the mold has been addressed. Second, often what looks like Lyme or Bartonella on original presentation disappears when the mold has been successfully treated, obviating the need for extensive antibiotic treatment. Third, treatment for mold is less invasive and less intrusive to the body; treating with antifungal materials does not alter the delicate intestinal biome that way antibiotics can, so that sensitive or toxic patients can begin their treatments in a way that they couldn’t if they had to take antibiotics.
At the risk of offending many health care practitioners who utilize alternative diagnostic approaches, including ART, kinesiology, and electrodermal technologies: while the information obtained in this way can be useful, I find that relying on these approaches as the sole method for determining what needs to be treated primarily does not always work well. I want to emphasize that we need to use our critical thinking skills to review the patient’s symptoms and ask, again, that all important question: Does this diagnosis fit the patient’s symptoms? Regardless of how one arrives at a starting point, that question must be paramount here. If a kinesiological approach suggests a primary viral etiology, does that explain all, or most of my patient’s symptoms? If not, please use your god given gifts of listening and perception to put things together in a way that makes (common) sense.
To this end, I am delighted to announce the formation of ISEAI (please see below). I am honored to have been invited to join the Board of this new organization, which is striving to do exactly what I am describing in my discussion, above: teaching health care providers to apply the latest research, best accepted thinking and methods to help patients with complex medical problems.
ANNOUNCING THE FOUNDATION OF ISEAI
We are pleased to announce the foundation of the International Society of Environmentally Acquired Illness (ISEAI), a nonprofit professional medical society for clinical and environmental professionals, researchers and advocates in the field of environmentally acquired illnesses.
ISEAI was created as a collaborative organization to raise awareness of the underlying causes of environmentally acquired inflammatory illnesses, (e.g. CIRS), serve as an open and respectful forum for the exchange of scientific and clinical information, and advance the knowledge of environmentally acquired inflammatory illness as a new discipline of medicine. Our goals include conferences that promote the cross-pollination of ideas among different disciplines, a certification program that will train providers to diagnose and treat environmental illnesses through the use of critical thinking, research initiatives that are free of bias or conflict of interest, and a peer-reviewed journal. To learn more about ISEAI or to join us, please find us on Facebook (search for ISEAI nonprofit page), or go to www.iseai.org after November 1st, 2017.
Sonia Rapaport, MD
Mary Ackerley, MD
Vice President, ISEAI
Keith Berndtson, MD