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September/October 2008

THE NEXUS INTERVIEW

David Silver, M.D.,
Medical Advocate

Hunting the Cure

Read article on Nexus' website

The Denver area is a great place to live if you are sick, or diagnosed with a deadly illness. It is truly a healing Mecca. We have superb hospitals and medical research centers, and lots of renowned complimentary and alternative medicine (CAM) specialists. It should be easy to find the right combination of experts and treatments to fix your ills. “Sure, easy,” you may say, “If you have a PhD in 40 different disciplines, from Acupuncture to Anesthesiology.”

You’d have a point. But, intimidating as this medical maze may seem, there IS a way through it to a good outcome, if not outright full health, at least for many people. To help you or your loved ones navigate the world of conflicting diagnoses, specialists, tests, healers and treatment plans, we spoke with David Silver, M.D., who practices the new specialty of Patient Advocacy, also called Medical Advocacy.

This new field is as yet unregulated. There is one graduate program in “health advocacy” in the country, at Sarah Lawrence College in Bronxville, NY, according to a June 2008 Consumer Reports article on the subject. But many kinds of healthcare professionals function as advocates, including physicians.

David Silver M.D. straddles both the worlds of allopathic and holistic medicine. He practiced emergency medicine for 25 years in Colorado, beginning at St. Anthony’s Hospital in Denver.

About the experience of being an ER doc, Dr. Silver says, “Just seeing the onslaught of injuries and illnesses that present to an emergency department was a tremendous experience. That was where you witnessed where society didn’t function. You got to see all the people with a variety of addictions bottoming out, overdosing on drugs, crashing their cars. You got to see domestic violence, child abuse, and sexual abuse. It was all there. That’s what got me thinking about moving more toward a preventive area in medicine.”

For eight years Dr. Silver also volunteered at the People’s Clinic in Boulder, a reduced fee or free clinic, where he found a more holistic way to promote patients’ health. He left St. Anthony’s to start, with a few colleagues, Wellspring Clinic, the state’s first holistic medicine center, which operated for two years in the 80s in Boulder and incorporated a variety of CAM practitioners.

Dr. Silver’s other explorations beyond the conventional medical world included studying and practicing in several Yoga and meditation communities, including the Community of Mindful Living with Tich Nhat Hanh in Boulder and France, Ananda Marga Yoga Society in New York, and Kripalu in Lennox, Massachusetts. He studied body-centered psychotherapy for a year through the Hakomi Training. And he studied a psychotherapy system called Process Therapy with Anne Shaef for two years.

Currently Dr. Silver, in addition to his Medical Advocacy practice, is an associate clinical professor in the Department of Preventive Medicine at the University of Colorado Medical School, Denver. And he teaches a class in sustainable community development at CU Boulder.

We spoke to him recently at our office about how you can get the most from your healing journey, whether you use conventional medicine, holistic complimentary systems, or both.

RD: What is your main goal with clients? What degree of healing are you hoping they will achieve?

DS: In my practice I work with clients with challenging diagnoses, some of them life-threatening. It provides me an opportunity to explore with people what healing means at its deepest level. I believe healing is always a possibility, even in the face of a terminal illness. The body may go. It will go, eventually. But the opportunity to find a sense of resolve, growth, inspiration and aliveness in the face of death, to find a deeper sense of peace in the midst of turmoil, even loss of function, increased disability and impairment, is extraordinary.

RD: Could you give me an example of what you do in medical advocacy?

DS: One client came to me with a chronic hip condition that was going to require a complicated and life-threatening surgery. He was seeing a reputable orthopedic surgeon in Denver, and he wanted to find out what his other options were – where could he find the best treatment, who had the most experience, who had the best outcomes. And what about this procedure? What are the evidence-based risks and benefits for it?

Many times, people feel compelled to do whatever their doctor tells them, to accept it on face value, and to trust them. Most of the time, this works out just fine. But many times, it doesn’t, because of our current situation in medical practice. There’s increasing pressure on doctors. And physicians just don’t have the time, the energy or the resources to spend with their patients. They can’t do the research that I would like to think they would prefer to do.

RD: What kind of research? Do you mean finding out more about the patient’s condition or looking up the condition in the literature? Or both?

DS: Both. For example, what are the best tests to determine a diagnosis? Even getting something like an MRI could differ among different centers: the different machinery they use, who’s reading it and how it’s being interpreted. Or what’s the best evidence-based literature for certain tests? I consider myself a medical detective; I try not to leave any stone unturned.

RD: After you meet with clients, do you then refer them to another physician, or do you treat them?

DS: I’m not treating people as a physician; I’m counseling them as a medical resource. I review a client’s medical records, so I can see what has been done, while concurrently reviewing the medical literature to see what the best practices are, and to identify the leading researchers and leading centers for my client’s particular condition--not only in this country, but also internationally.

For example, back to the client with the hip problem, it turned out that his Denver orthopedist had only done three of those procedures in his entire career. That’s not to say he wasn’t competent to perform this procedure; but if it were you, wouldn’t you like to know which physicians have done dozens, if not hundreds, of these procedures? My job is to find those physicians. I set up consultative interviews with them. I usually talk with at least two or three, or sometimes more, of the leading specialists; that’s something patients rarely have the chance to do.

I was also able to review the risks and benefits of the hip surgery with my client. We discussed, for example, “What would life look like if the worse case scenario happened? Could you be happy? Could you accept your condition? And then what would life look like if you didn’t do the procedure, and continue to deteriorate? Could you find contentment there?”

I think the bottom line question is, are we able to find a level of peace and contentment in our lives, no matter what our physical condition, environmental condition, condition of our bodies or houses or bank accounts? That option is always available. Living in the moment, there really is no problem. Knowing that and embracing that gives more freedom to clients to choose things that they may otherwise be more afraid of. Or it gives them a greater sense of resolve when they make choices, and know that the outcomes might not be what they would like them to be. They may realize, when it comes down to it, they’re in a no-lose situation. They can be okay if they do nothing, and they can be okay if they choose an intervention that might not work out. I don’t think many physicians explore with patients at this level.

RD: Do you direct people toward alternative therapies when allopathy has run into a dead-end?

DS: I do, especially if that’s a key interest of my client. For many chronic diseases, there are no satisfactory or adequate treatments in Western medicine. Short of surgery, people are left to take whatever pain pills and anti-inflammatory meds they can to get some relief. The need for medical alternatives has driven research and acceptance of new complementary medicine methods that have proven to be effective. There are also growing databases for complementary and alternative medicine that contain solid evidence-based research as to their efficacy. I would want to make sure that a particular treatment is acceptable– not by virtue of testimonials, which we frequently see for a lot of alternative treatments, but by sound evidence-based knowledge.

RD: Like double-blind controlled studies?

DS: Exactly. It doesn’t matter to me so much if the reasons why something worked aren’t clearly established yet, but rather that there’s a measurable indication of improvement. Either it’s the subject’s white blood cell count or it’s their decrease in fatigue.

RD: Do you encounter physicians who dismiss alternative medicine out of hand?

DS: Yes. Doctors just coming out of the cocoon of Western medical training have gone through almost an initiation ceremony that has been dismissive and condescending to non-allopathic practices.

RD: Even nutrition?

DS: I think that’s true to a great extent.

RD: It strikes me as odd: to study cell biology, and ignore nutrition. It’s like studying the suspension on the car, but skipping the engine.

DS: That’s true. And we’re also learning about other effective means to improve people’s health, like behavior change communication, and incorporating that into medical and public health education.

RD: Is that about how you talk to patients?

DS: Yes, and it’s how you can work with patients to change their attitudes and reinforce healthy behaviors. For example, how many Americans don’t know that smoking is linked with cancer, emphysema and chronic bronchitis? But people still smoke! The knowledge is there, but the behavior is not. The focus should be on how do you promote healthy attitudes and behaviors that will support people to make and maintain healthy changes.

With behavior change communication, we would go a step beyond giving people the knowledge of adequate nutrition. We live in a very savvy marketing world, and we’ve seen the power of advertisers and marketing to changing behaviors. The medical and public health world is waking up to the options of incorporating those practices to market good health practices. It’s being done internationally with hand-washing campaigns, a very simple behavior that can profoundly improve the survival, and decrease the morbidity and mortality from infectious diseases, which are rampant in developing countries.

RD: What about people with serious illness, who have exhausted their options in allopathic medicine and are moving into the world of alternative medicine? That world has so many diverse systems of healing: ayurveda, homeopathy, acupuncture, Chinese herbs, energy medicine, herbology – I could go on and on. In allopathic medicine, you see a specialist and get a second or third opinion, and you feel as if you’ve covered all the bases. In alternative medicine, each system is an entire perspective, with interventions that sometimes take months to reveal to you whether they’re working or not.

DS: That’s a great question. It’s important to start with the understanding that every practitioner you see is looking through the lens of his or her own specialty. Most Western docs will see through the lens of Western medicine. A homeopath looks through the lens of homeopathy. If we can take all those practices as a whole, we’d have a much better opportunity to find where our illness might lie and what the best treatment options are.

My advice is to educate yourself. In the best of all possible worlds your doctors or alternative practitioners would also be your advocates. And to some extent they are. But the reality is, the task of teasing out specific variables, all the evidence-based information, or finding leading practitioners or centers, is not something that most doctors or alternative practitioners are able to do in an office visit. It really is in a patient’s best interests to find their own personal medical advocate, whether it be a friend, relative or a professional medical advocate.

RD: Is the world of medical advocates and the world of alternative medicine viable only for those who have lots of money? Or do you think people who aren’t rich can manage to utilize it?

DS: Sadly I would have to go beyond your question into the state of medical care in this country in general. Adequate medical care is not available to a substantial percentage of the population because of financial barriers. There’s a sizeable group of welfare children who are receiving little or no primary healthcare in this country. That’s inexcusable.

And, sadly, insurance companies haven’t yet caught on to the financial, emotional and medical advantage for reimbursing advocates who can help direct insured patients to a less expensive, more favorable and more rapid outcome.

As far as cost, I’ll use myself as an example. I work on a sliding scale. I have three initial consultations with people to see if my services are a good match for my client’s interests and situation. I will then set up a menu for clients for what services they would like in terms reviewing their medical records, examining current literature, or developing a care map, at the rate of $150/hour.

RD: In a typical case, if there is such a thing, how many hours would that be?

DS: Typically within three hours I can review a fairly substantial medical record, condense it into a comprehensible form that I could use to discuss the case with other professionals, review current literature, and develop a list of key questions to guide a patient’s pursuit of care and treatment. So $450 is not inconsequential, but when you think of the amount of money people spend on their healthcare directly in terms of doctor fees, indirectly in terms of time and energy, worrying, researching, being sick, being unable to work at the level they would like to, in terms of seeking dozens of alternative healers that they really are uncertain about, I think it’s a good investment. And actually quite a bargain.

RD: Are there many people like you, or are you a unique specialty?

DS: Medical advocates are now on a new frontier that hasn’t been well-defined. There’s a whole range of people who call themselves advocates, from nutritionists, nurses, physical therapists, alternative practitioners or PhD’s, to medical specialists. Again: consumer, beware. If you’re facing a serious illnesses or complex diagnoses, I think it’s in your best interest to seek someone with more of a formal medical background to help navigate a complex sea of information.

RD: It’s a maze, of sorts. And it sounds to me that you might shorten the journey through the maze.

DS: That’s a good way to put it. The medical advocacy strategy can significantly reduce your time in the maze and the complexity of the maze by more clearly identifying and orienting your path at the start.

Once you are armed with a substantial amount of information you can say, “I know what I’m up against, and I’ll choose that aggressive allopathic chemotherapy because it’s got the best results. It’s a tough way to go. I’m not looking forward to the side effects, but with a 60 percent remission rate, that’s better than anything I’m aware of, and I’m willing to take the risks.” Or, you could say, “You know, with a 20 percent remission rate and my doctor saying that’s all they can offer, I’m not willing to go that route. I need to identify some other options. If the main route is improving my immune status, how can I best do that? What’s the best evidence out there for increasing my white blood cell count? For increasing my immune globulins? For increasing my hematocrit and hemoglobin?”

You want concrete answers – not some loose promise based on pseudo-scientific associations that something can lead to something else. Your life’s at stake; you want to know what’s out there; who’s done the research and how do you find it.

RD: The hyper drama approach of the media isn’t especially helpful either. In women’s magazines at the grocery check-out stand I am sure you’ll see “miracle fat burner” mentioned somewhere. There must be hundreds of miracle fat burners discovered every year!

DS: We all want to believe in the miracle. Paradoxically, the miracle that we think we’re looking for is, in most cases, unreachable. And the miracle that is deeply satisfying and healing is already there, just waiting to be discovered.

The opportunity to experience healing and awakening on a deep level is the miracle, and it’s always there. It’s always ready to be uncovered and seen for what it is. We tend to look in the wrong places too often, and make things more complex and unreachable, as if what’s here now isn’t just perfect, isn’t just the exact circumstance and opportunity in our lives to bring us into this next level of healing.

Copyright 2008 – Nexus: Colorado's Holistic Journal

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