Practitioner Question of the Month – December 2017

Tamie Bilazzo asks

Dr. Ruscio, This is not related to this month’s case study but I am hoping you have a good suggestion for this lab test result. I have a 58 years old female came to see me for frequent wake-up at night, hair loss, brain fog and recurrent gastritis. Since she had H. pylori tested positive, she had a cleanse for 3 months got tested with BioHealth Lab, it came back Negative. I asked her to go to see her doctor get the blood test done includes Anti-Parietal Cell Test, Blood Sugar, Insulin, Thyroid Panel. Her Parietal Cell AB Screen => Positive (Negative) A, and Parietal Cell AB Titer => 1:20 (<1:20 titer) H, and the B12 level was 1,718 means she does not have Intrinsic Factor problem? (other markers: Glucose is 98 and Insulin is 4.4, Triglycerides is 49, Her Iron total is 105).

1. How can I understand this Anti-Parietal Cell Test result and how to treat this patient? Intake of HCl with each meal, ACV, Lemon or enzymatic therapy will be helpful?
2. Does her Anti-Parietal Cell marker become remission in the future if she gets tested again?
3. She does not complain about bloating, gas, acid reflux but not able to tolerate tomato sauce and peppers.
4. My other question is her Glucose is high end normal but Insulin is low. Is this patient belong to “pre-diabetes or insulin-resistance”? If not, why her glucose is high (for last few years straight)? From Stress? Her Thyroid (her doctor only tested TSH) was 3.97.

Hi Tamie,

Hard to say without seeing the labs. If she is normal for APCA and B12 levels, then she likely does not have an intrinsic factor problem. If B12 is high, then it’s likely something else entirely. Exactly what is very challenging to say, and I haven’t been able to find a good answer to this. For APCA, you need to know if the antibody titer is normal or above normal (i.e., positive).

If you look at the study we reviewed on this a few months ago, there are a few notes regarding interpretation. https://drruscio.com/practitioner-2017-mar-research/#1

• Look for accompanying oral symptoms that increase risk for APCA:
  • Burning sensation in the mouth, 98%
  • Dry mouth, 80%
  • Sore tongue, 60%
• This study found those with autoimmunity had APCA levels roughly between 123 and 178. After treatment, levels dropped significantly, but did not become ‘normal.’
  
• LabCorp lists positive being anything above 24.9.
  • https://www.labcorp.com/test-menu/20256/antiparietal-cell-antibody-apca

Answer to Question #1

• B12 injections are the only therapy I know to lower APCA, so for APCA that would be it.
• HCl and/or enzymes are a consideration, but this would be based on her symptoms, and then if the symptoms clearly improve from supplementation. My book will expand on this.

Question #2

• I addressed this above; in short, yes, the levels should greatly improve and be near normal if not in the normal range. Similar to TPO antibodies.

Question #3

• Since she is not expressing these key signs of gastric acid imbalance, it makes a problem here unlikely. This looks more like a nightshade sensitivity to me than a deficiency of HCl. Don’t overthink this. If she expresses the oral signs listed above, or typical low HCl symptoms, then perform a trial of HCl. If low HCl is the cause, she should respond. If these signs and symptoms aren’t present, then move on to other possibilities.

Question #4

• I think you’re reading too much into this. Her labs here look fine. Zoom way out, focus on simple fundamentals. Be careful not to create a problem where there is none.

These are my answers to the best of my ability without knowing the additional context of this patient, which is very important. I hope this helps.

Reprimand or helping hand – how to get the most out of your staff.

It can be frustrating when a staff member makes mistakes or oversights, or generally is not performing optimally. Firstly, it’s important to establish that if you are the one who owns or manages the operation, then it is your fault and responsibility – not theirs. Either train them better, improve your systems, or find a replacement for them. But, ultimately this comes down to the owner. This can be a tough pill to swallow at first, but ultimately this taking of responsibility can be a milestone in moving an operation forward.

But how to handle underperformance with your staff? I really like Mark Lemonis’ 3 component model for success: people, product, and process.  You need a good product, meaning you need to be a good clinician. You need a good process: office systems, billing software, office policies, etc.… Finally, you need good people. If someone is underperforming, I look at two things. Is the process broken, or is it not the right person? For example, is your billing system archaic, faulty, and difficult to use? If so, the billing problem might be due to the process and not the person. If the process is sound and errors are occurring, then it’s likely the person.

So this leads us to the original question of how to handle performance issues with a staff member. There are really two opposing views here. Reprimand them, or help them. It’s easy to fall into the trap of reprimanding, because it can be frustrating when people make mistakes. This can lead one to think, “How dare they keep making these careless mistakes? Don’t they appreciate how much I pay them? Don’t they realize they are costing the office money and tarnishing my reputation? I need to show them who’s boss.” But, take a deep breath, and get past the frustration of the situation. When I do this, I think for a moment and I realize one of two things is really happening:

1. The job I am asking them to do is very hard to do – meaning I am asking them to work a broken process.
2. They are not the right person for the job.

So I talk with the staff person and try to figure out how I can help them perform better. It’s simple. I ask questions like:

• What happened?
• Do you feel billing is difficult? Why?
• Do you feel you don’t have adequate time, support, or resources?
• What is difficult or broken with our process?

This is the helping hand. If you are diligent with this, you will quickly identify problems in and repair your process. Also, you will make your staff feel supported, valued, and heard. They will work much harder for you after this.  Once the process is fixed, if the problems keep happening, then you clearly know it’s the person. And instead of reprimanding them, you can let them know that you care about them and would like for them to be a part of your team, but unfortunately, their strengths are not in alignment with the office’s needs. Side note: you can now use the efficient hiring process we discussed a few months ago.

So what happened? You supported your staff and used their feedback to make your office a better place. You likely ended up with a better process and a better staff person. However, if the staff person did not work out, you are left with an improved process and a person who felt like you, as their boss, gave them every chance to do well. This is a night and day difference compared to reprimanding people without listening to them. This perpetuates broken systems and cultivates resentment in your staff. Take care of your staff; you can’t do your job without them.

If you have found this information helpful, please share with a friend using this link: https://drruscio.com/review/.

I’d like to hear your thoughts or questions regarding any of the above information. Please leave comments or questions below – it might become our next Practitioner Question of the Month.