Dr. Cady returns this year to repeat and update one of the most talked about presentations of the 2015 IMMH conference. In this presentation, Dr. Cady deconstructs the pressures and challenges facing patients, physicians, and all health care practitioners in today's practice environment. The role of integrated practice and functional medicine as a "differentiating factor" in one's practice is reviewed. The need for patients to adapt a healthy life style and take responsibility for their health for their own economic self-preservation is also touched on.

1. Medicine: A State of Crisis,
A State of Change
Louis Cady, MD
Presented at the 2016 Integrated Medicine for
Mental Health Conference
Reston, VA (USA) – September 30th
, 2016

2. Continuing Medical Education Commercial
Disclosure RequirementI, Louis B. Cady, MD, have the following commercial relationships to
disclose:
•Speaker honoraria received from:
• Immunolaboratories, Great Plains Diagnostic Labs, LABRIX
•Speaker’s bureaus (active) for:
• Arbor, Allergan (Aventis), Lundbeck, NEOS, Shire,
Takeda, Vaya Pharma
•Historical data – speaker’s bureau for Arbor, Bristol-Myers Squibb,
Celltech, Cephalon, Eli Lilly, Glaxo-Smith Kline, Janssen, McNeil,
Pfizer-Roerig, Sanofi~aventis, Searle, Sepracor, Shionogi,
Sunovion, Wyeth-Ayerst
•Distributor – Pharmanex supplements & Biophotonic scanner

4. Orientation to this lecture
The goal is not to get you depressed, but to open
up the possibilities of exciting change and
breakthroughs in your practice (which the rest of
this conference will cover).

5. Who this lecture is for
• All docs, all disciplines, all credentials
• All nurses and NP’s
• All nutritionists
• All psychotherapists
• Every one here who is or will be a medical
patient at some time.

6. Attention class!!
www.slideshare.net/lcadym
d
Cady Wellness Institute app –
Apple “app”store or Google
Android store
Where (else!) to get “the slides”

7. Everett Napier, an unemployed miner, said he pawned various items while he has
been looking for work, including rifles, tools, jewelry and two guitars he used to play
at church. 'I just swallowed my pride and quit playing. That's all you can do.' David
Stephenson for The Wall Street Journal. November 26, 2013

8. Chronic Disease Overview• In 2012, half of all adult – 117 million have chronic
health conditions.
• COSTS (per year):
– Heart dz/stroke $315.4 billion
– Smoking $289 billion
– Excess alcohol $223.5 billion
– Cancer care $157 billion
– Diabetes total csot $245 billion
– Arthritis $128 billion
– Obesity medical costs $147 billion
Total annual cost (est.) $1,504.9 billion, or….
www.cdc.gov/chronicdisease/overview/ - accessed 8/6/2015
$1,504,900,000,000/year

9. “F as in Fat – How Obesity Threatens America’s Future 2012”
Wood Johnson foundation
Current and
future IN
obesity rates:
2011 – 25
%
2030 –
49.5%
(if BMI reduced
5%)
2030 –
56%
http://healthyamericans.org/report/100/

11. (c) 2013 Louis B. Cady, M.D. - all
rights reserved
“Excess body weight is correlated with excess morbidity and
mortality. In particular, Grade 2 or higher obesity (BMI>35)
significantly increases the risk of death.”
(www.cdc.gov/nchs/data/hus/hus11_InBrief.pdf)

12. But what
about the
PATIENTS?!

15. http://money.cnn.com/2015/09/22/news/economy/health-insurance/ - accessed 8 15 2016

16. • Deductibles have increased 67% since 2010
• Average deductible for “bronze plan” through
the ACA = > $5700.00
• Deductibles have increased 67% since 2010
• Average deductible for “bronze plan” through
the ACA = > $5700.00
http://www.cbsnews.com/news/the-painful-rise-of-high-deductible-health-
insurance/ accessed 08/15/2016

17. • $90.12 / month * 12 months = $1,081.44 with
insurance contribution
• $327 / month * 12 month = $3,924 straight out of
pocket
• What about two people with asthma in family?
– $7,848 per year

18. Current statusThe good ole days:
•People had jobs
•People had
insurance
•Insurance
PAID.
•Society was
healthier.
•Doctors were
plentiful.
•Your healthcare
was essentially
“free,” no matter
how stupidly you
behaved.
Problems:
•2001/2008
recessions
•Outsourcing
•More medical
technology
•More activism from
groups such that
“everything must be
covered.”
•Disastrous public
health
•More government
& PBM’s
interference in free
market
The RESULTS:
•Medical insurance costs
more $$$.
•Deductible increasing.
•Fewer doctors available.
• Doctors are
quitting.
• Insurance
companies/
government =
defacto
RATIONING.
•Now, you “gonna have
to PAY” for poor health
habits, poor nutrition,
obesity, smoking, etc.

19. Likely developments in healthcare, from
Tyler Cowen, Average Is Over
• “Just as some poorer people will do
without fancy infrastructure, so will
others do without advanced health
care.”
• “Since we won't be willing to pay for
full-benefit Medicare and Medicaid for
everyone who will need it, some
people will see cut benefits or
rationed access to doctors. Our
political system will try to construct that
rationing so that voters blame the
doctors rather than the politicians, but
one way or another
rationing will increase.”

20. “ELIGIBILITY, without
AFFORDABILITY and
ACCESSIBILITY, is not
true health reform.”
- Louis B. Cady, MD

21. The health of society & the doctors/HCP’s
needed to treat it
• Doctors are going to get squeezed. More will quit.
(& more patients will be hunting for a doc.)
• Patients’ out of pocket costs are going up with BIG
DEDUCTIBLES.
• Americans will have less money to pay for bigger
health care costs (e.g. Autism, Alzheimer’s)
• Average people need to do something NOW to
maintain health and minimize costs & out of
pocket expenses.

22. GOVERNMENT, BOARD
MANDATES FOR MD’S/DO’S
• ICD-10
• Second stage of Meaningful Use incentive program (MU2) for Electronic
Health Records
• “Sunshine Act”
• Updated rules for the Health Insurance Portability and Accountability Act
• Document risk analysis
• Comprehensive rules for protected health information
• Physician Quality Reporting System (PQRS)
• If not done you will have a 1.5% penalty for all Medicare part B
services
• “Maintenance of Certification (MOC)”

26. Connecticut: United Health Group cuts
2,250 physicians (810 primary care,
1,440 specialists) from its “Medical
Advantage” network
Connecticut: United Health Group cuts
2,250 physicians (810 primary care,
1,440 specialists) from its “Medical
Advantage” network
One solution to higher costs for medical care if you’re
an insurer: fire your doctors so people can’t get to’em.
One solution to higher costs for medical care if you’re
an insurer: fire your doctors so people can’t get to’em.

27. Another solution to
financial outflows
from private
insurers and
Medicaid/Medicare:
close hospitals &
“reduce beds” so
you’re not losing
money.

29. Heck, let’s run out of saline while
we’re at it.

31. “MOC” – IT
RHYMES WITH
“CROCK.”
Like many other mandates for the medical profession, physicians also
expressed confusion and anxiety about continually changing requirements
within the MOC program and a lack of systems support. Low perceived value
of the MOC activities and the challenge of fitting them into their already busy
schedules results in most participants procrastinating completion as long as
possible.
Of all the sections [there are four], the only one that physician participants notes
as somewhat useful was phase three, despite the inconvenience of having to
complete the examination at a secure testing facility and a lack of feedback on
their responses.
Like many other mandates for the medical profession, physicians also
expressed confusion and anxiety about continually changing requirements
within the MOC program and a lack of systems support. Low perceived value
of the MOC activities and the challenge of fitting them into their already busy
schedules results in most participants procrastinating completion as long as
possible.
Of all the sections [there are four], the only one that physician participants notes
as somewhat useful was phase three, despite the inconvenience of having to
complete the examination at a secure testing facility and a lack of feedback on
their responses.
http://medicaleconomics.modernmedicine.com/medical-economics/news/moc-needs-
revision-physicians-will-recognize-value - accessed 11 17 2014

33. Patient solutions for cheaper care:
don’t go see your doctor

37. SOURCES OF FRUSTRATION (leading docs to quit or burn out)*:
•The hours and demands of the work
•Requirement to interact regularly with insurance companies
•Increase in required “clerical duties”
•Inefficient electronic medical records
•Loss of sense of autonomy
•Difficulty maintaining a work/life balance
* sources: RAND Corp, AMA, Mayo Clinic, University of Rochester Medical Center, Stanford University School
of Medicine – reported in Chicago Tribune and referenced in Evansville Courier & Press, October 27, 2014 –
page 9B

38. 7,288 physician responses
45.8% of physicians had at least ONE symptom of
burnout
7,288 physician responses
45.8% of physicians had at least ONE symptom of
burnout
CONCLUSIONS: “Burnout is more common
among physicians than other US workers.”
CONCLUSIONS: “Burnout is more common
among physicians than other US workers.”

39. 40% OF DOCTORS ARE
BURNED OUT
• TOO MANY
BUREAUCRAT
IC TASKS
• TOO MUCH
PAPERWORK
• ¼ of time is
spent in non-
clinical
paperwork.
• Dealing with
“checkbox
medicine”
Source: Medscape’s 2013 Physician Lifestyle Report cited in
“Staying Sane as Medicine Goes Crazy” – July 25, 2014

40. “Sunshine” in
Colorado

48. Instant replay:
Running like a hamster on a wheel
• Working 50 – 60 hours per week
• Declining reimbursements; increasing overhead expenses
• Hassled by paperwork, Medicare reviewers, prior
authorizations, federal snooping & micro-examination,
constant threat of malpractice lawsuits, continued baseline
2% inflation per year and no way to make it up.
• Discriminated against as a profession with invasive
monitoring
• Never able to meet all the federal and insurance
requirements
WHAT WOULD YOU DO???

49. Doctors quitting medicine
• "Half of primary care physicians in survey would leave
medicine ... if they had an alternative." -- CNN, November
2008
• Suicide* (2004):
• 1.41 X for male physicians vs. general pop.
• Schernhammer ES, Coldit GZ. Am J Psychiatry. 2004
Dec; 161 (12):2295-302
• Current rate of suicide* – 400 dead docs* per
year (in US), 2015. * = specified on death certificate

50. “Why I Left Medicine: A Burnt-Out Doctor’s Decision to
Quit”*
• “It may be dramatic and
self-serving to frame my
career change as a way
to avoid suicide, but I
can attest that medicine
was not conducive to my
health.”
http://commonhealth.wbur.org/2013/10/why-i-left-medicine-a-burnt-out-doctors-decision-to-
quit 10/18/2013 – accessed 01/07/2014

52. Patient complaints = suicidal docs
• Increase of moderate – severe anxiety
– 15% if recent complaint vs. 7.3% without (RR 2.08)
• Increases moderate - severe depression
– 17% if recent complain vs. 9.5% (RR 1.77)
• Increase suicidal ideation (RR 2.08)
• The more severe the complaint, the worse the
mental health effects.
Bourne T, et al. BMJ Open. 2015;5(1):e00687
[7,926 doctors in the UK studied]

53. Physicians – more than 2 X as likely to kill themselves as
non physicians
Female physicians = 3x more likely to kill themselves than
male physicians.
Physicians – more than 2 X as likely to kill themselves as
non physicians
Female physicians = 3x more likely to kill themselves than
male physicians.

56. REASON: “EHR” requirements. “Would cost too much in his small
medical practice.”

57. Aetna is withdrawing from 11 of 15 states it has health plans in
with ACA. - August 16, 2016

58. December 17, 2013

61. Are the Best and Brightest
Staying in Medicine?
“60% of physicians
would not recommend
medicine as a career to
their children.”
•The Physicians’ Foundation
http://www.mayorswellnesscampaign.org/wp-
content/uploads/2009/05/merritt-hawkins-survey.pdf.
Accessed April 3, 2010. Slide and reference courtesy
of John Adams, CEO, Cenegenics

62. So, for self-preservation, just
don’t go into medicine.
Might there be some
consequences?

63. “The United States is expected to have a
shortfall of nearly 160,000 physicians by
2025 – even as allopathic medical schools
have increased their class sizes by 30
percent.”
“The United States is expected to have a
shortfall of nearly 160,000 physicians by
2025 – even as allopathic medical schools
have increased their class sizes by 30
percent.”

64. • Demand will exceed supply {2013-2025}
• Demand projected to grow 17%
• By 2025, demand will exceed supply by 46,000 –
90,000 doctors.
• Shortfalls:
– 12,500 – 31,000 primary care
– 28,200 – 63,700 specialists
• 5,100 – 12,300 medical subspecialties
• 23,100 – 31,600 surgical specialists
• 2,400 = 20,200 other specialists.
Physician Supply & Demand Through
2025: Key Findings
“The physician shortage will persist under every
likely scenario.”
“The physician shortage will persist under every
likely scenario.”
From HIS, Inc. study, The Complexities of Physician Supply and Demand: Projections from 2013 to 2025, prepared at request of
AAMC.https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf
Accessed 8/7/2015

65. Is Being a Physician (of ANY discipline) – or any
other type of health care or mental healthy
worker (clinical or peripheral) still SAFE as a
profession??

66. “But I’m not a [Medical] doctor;
I’m not going to have those Problems.”
• Doctors of Chiropractic, Dentistry, Optometry, Naturopathy
• mixed fee for service model (at present) and insurance.
• Higher insurance premiums, HIGHER DEDUCTIBLES, & cash-strapped
patients.
• Worsening reimbursements
• Collateral damage from hospital/clinics closures - service providers
connected with them will lose their jobs.
• Paraprofessionals and service support people:
• dieticians, massage/fascia therapists, cosmetologists, servers,
maid/janitorial service = declining business, declining tips, declining
customer base

67. http://www.forbes.com/sites/davidwhelan/2010/08/23/
whither-chiropractors-a-new-study-shows-many-
ditching-the-table/ accessed 9 9 2014
http://www.chiroeco.com/joomla/images/stories/S
E_Survey2012.pdf - accessed 9 9 2014
2012 status: “salaries are
thus down 28% from last
year’s average…and average
total compensation fell 13%...
From 2011.”
2012 status: “salaries are
thus down 28% from last
year’s average…and average
total compensation fell 13%...
From 2011.”

68. “…an estimated 17.5 percent of newly-licensed RNs
leave their first nursing job within the first year and one
in three (33.5%) leave within two years”.
http://preventdisease.com/news/14/091014_One-Third-Nurses-Leaving-Jobs-
Losing-Faith-in-Vaccines.shtml accessed 9 11 2014
“…an estimated 17.5 percent of newly-licensed RNs
leave their first nursing job within the first year and one
in three (33.5%) leave within two years”.
http://preventdisease.com/news/14/091014_One-Third-Nurses-Leaving-Jobs-
Losing-Faith-in-Vaccines.shtml accessed 9 11 2014

70. “80% or greater chance exists for people who make $20/hour or
less to be made redundant by smart machines in the foreseeable
future.”
-Council of Economic Advisers, February 2016
“80% or greater chance exists for people who make $20/hour or
less to be made redundant by smart machines in the foreseeable
future.”
-Council of Economic Advisers, February 2016

71. • The middle class is being inexorably
eroded
• “STEM” careers – or management
having to do with STEM, are the
only safe ones.
• If your job can be done by a
machine or a replacement, or
outsourced to a cheaper labor
market, you are dead.
• Medical care rationing is coming (or
is here!); government can’t possibly
keep its promises.

72. Feb 5, 2015

73. New anesthesiologist on the team…

75. But what about working
people?
(The people who will have to pay
the huge deductibles or do
without)

79. “The Millennials” – any better off?
http://www.nytimes.com/2015/08/02/opinion/sunday/were-making-life-
too-hard-for-millennials.html?smprod=nytcore-iphone&smid=nytcore-
iphone-share-accessed7/31/2015

81. Is there a way forward?
What can we do about the
situation?

82. A clinical case presentation

83. A typical Western medicine train wreck.
• 50 year old MWM seen 3/2/2015.
• Chief complaint: “It seems like I’m always
sick. […] suggested I give it a try.”
• “I go to a regular doctor and it doesn’t seem
to do anything except solve the problem for
a short time, and then I’m right back in there
again for something or another.”
• History of liver cancer in PGF

84. Goals for treatment
• “have the strength and energy to get out of
bed every morning with an enthusiasm for
life.”
• “not get sick so often.”
• “get off all of the medications and devices I
fell I need now to get by every day. (Blood
pressure, cholesterol, BiPap machine)”
• “strength and energy to play with my 9 year
old son.”

85. Baseline meds:
•Atenolol 25 mg in a.m. daily for HTN
•Pravastatin 20 mg “daily” during the day.
•Depot testosterone 200 mg every 4
weeks.
•BiPAP – for three years.
•S/P a little anxiety and was treated wth
alprazolam 0.25 mg three times daily.
“the business thing on Monday a.m.”
•ASA 81 mg per day per MD suggestion.
Labs at intake:
•TSH 3.20
•Fasting glucose 99
•BMI = 43.5 kg/m2
Other labs ordered
•CORUS, TFT’s (complete), LH, DHEA-S,
free and total testosterone, HgBA1C,
Glycomark ®, CEA, UA, candida
antibodies. Fasting insulin.
• INTERVENTIONS:
– Sent to Doctor of Chiropractic for M-
skeletal.
– Potent MVI/Multi-mineral, fish oil.
– Energy supplement (cordyceps,
pomegranate extract, and panax ginseng)
– Colostrum formulation
– Gingko
– Probiotics
– DHEA 25 mg timed release – one every
a.m. and
– Metformin – 500 mg up to twice daily
as tolerated.
– Liothyronine – 5 MICROgrams –
increase by one per week x 3
– Topical testosterone/stop “q 4 wks.”
injxns.
DIETARY – 40 grams of protein
three times daily.

86. April 16, 2015• Treatment goals:
– Energy and strength
improved
– “haven’t been feeling
bad at all.” “Not ill.”
– Strength & energy to
play with 9 year old
son – increasing.
• STATUS: lost 18 lbs in
6 weeks.
• RX – still on regimen
started at intake.
Baseline Labs 3/3/2015:
•Suboptimal DHEA-S
•Free T3 2.9 {2 – 4.4}
•Testosterone 188
•Fasting insulin 16.2
•25-OH Vit D 18.6 (L)
•CORUS testing – 20 (14% risk
CAD)
•CEA negative
•New interventions:
– Clomiphene 50 mg daily
– Vitamin D 10K IU per day x 6
weeks, then 7K IU
– Start BFL and dumbbells.
– Education on low glycemic
eating.

87. What happened to labs (5/21/2015)?• Thyroid functions (on 5 MICROgrams T3 twice daily)
– TSH 2.22 {0.34 – 5.61}
– Free T4 0.7 {0.56 – 1.6}
– Free T3 3.4  {2.0 – 4.4}
– Reverse T3 17.6  {9.2 - 24.1}
• Hormones (Rx Clomiphene 50 mg/d, DHEA 50 mg SR a.m.)
– Total testosterone 400 {348 – 1197}
– Free Testosterone 13.9  {7.2 - 24}
– DHEA-Sulfate 601.5* (H) {30.9 – 295.6”; OPTIMAL
RANGE – per Cenegenics is about 500}
• * dosing was promptly readjusted
– Estradiol 78 (H) {20 – 70} [ ½ mg Anastrozole
added every week)]
Anastrozole ½ mg every week added for just a “touch” of control

88. June 5, 2015 – 44 lbs lost in 3
months
• “Strength & energy getting
better all the time”
• “I have not been sick since I
started this.”
• Strength/energy to play with
9 yo. “We’re doing pretty
good. It’s gradually getting
better. The more weight I
lose, the better I feel.”
• Joined gym – going
2x/week and @ 30min on
elliptical
June 5, 2015
Per LMD: “You know, he’s
jacking with your hormones
and that’s dangerous.”

89. Brain –dead, non-evidenced based
“practice guidelines or creativity???
There is inadequate supporting evidence for hair
analysis, celiac antibodies, allergy testing (particularly
food allergies for gluten, casein, Candida, and other
molds), immunologic or neurochemical abnormalities,
micronutrients such as vitamin levels, intestinal
permeability studies, stool analysis, urinary peptides,
mitochondrial disorders (including lactate and
pyruvate), thyroid function tests, or erythrocyte
glutathione peroxidase studies.”
http://www.cdc.gov/ncbddd/autism/hcp-recommendations.html -
accessed 8/7/2015
There is inadequate supporting evidence for hair
analysis, celiac antibodies, allergy testing (particularly
food allergies for gluten, casein, Candida, and other
molds), immunologic or neurochemical abnormalities,
micronutrients such as vitamin levels, intestinal
permeability studies, stool analysis, urinary peptides,
mitochondrial disorders (including lactate and
pyruvate), thyroid function tests, or erythrocyte
glutathione peroxidase studies.”
http://www.cdc.gov/ncbddd/autism/hcp-recommendations.html -
accessed 8/7/2015

90. Try reading this with a “practice guideline.”

91. What can we (personally &
professionally) do?
• Live as an example and take care of ourselves,
so that we can take care of our patients.
• Rationally examine the cost/benefits of our
current practice.
• Decide if our conscience (& our own personal
health and psyches) will allow us to survive in
the current regimented, bureaucratized, non-
evidence based practice of medicine.
• How to learn: “As much as you can.” [Jim
Rohn]
• Decide to adopt an INTEGRATIVE approach.

93. The LAST Slide – “The Challenge” – by Jim Rohn“Let others lead small lives,
but not you.
Let others argue over small things,
but not you.
Let other cry over small hurts,
but not you.
Let others leave their future in someone else’s
hands,
but not you.”
- Jim Rohn

94. Contact information and slide resourLouis B. Cady, MD
Cady Wellness Institute
4727 Rosebud Lane –
Suite F
Newburgh, IN 47630
USA
Office (812) 429-0772
info@cadywellness.com
Available on Apple “app store” and
Google Android store.
www.slideshare.net/lcady
md

96. Appendix

97. A primary care doctor would have to work nearly 22 hours each day
to meet all of the guidelines for preventive care and
chronic disease management for a typical patient
panel of 2,500, according to an analysis published in 2009(!).
“People who already feel like they are doing a ton of
work, are going to say, 'I can’t do anything more.
There’s nothing more to squeeze out of me,” says Marc
Tunzi, MD, a family practitioner at Natividad Medical Center in Salinas,
California.
http://medicaleconomics.modernmedicine.com/medical-economics/news/4-ethical-
dilemmas-facing-physicians accessed 08 11 2014