Immunology and the Skin: A Clinical Conversation with Alan Dattner,MD,and Robert Rountree,MD

Dr. Alan Dattner studied medicine at the New York University School of Medicine, followed by an internship at the San Francisco General Hospital, in San Francisco, CA. During his studies, he gained experience in various laboratories focused on immunology. Dr. Dattner has been a cancer clinical fellow and has postdoctoral experience as a visiting scientist doing research in immune recognition at the Dermatology Branch of the National Cancer Institute. He completed residencies in General Practice at Contra Costa County Hospital and Dermatology at Albert Einstein COM, and is board certified by the American Academy of Dermatology. Dr. Dattner is presently a holistic dermatologist in private practice in New York, NY. He is the author of Radiant Skin from the Inside Out: The Holistic Dermatologist's Guide to Healing Your Skin Naturally.

Robert Rountree: What made you decide to go in the direction of medicine? Were there any experiences you had as a child that made you think you wanted to be a doctor?

Alan Dattner: My mother had been a science teacher and my father a dentist. My father did a few unusual things; for example, in the 1950s, he used hypnosis. I was always fascinated by the idea of extending one's work. I got a hold of my parents' books on psychosomatic medicine and developed an interest. Also, as a child, I had allergies and related ear infections. It was easy to see how my own illness was a contributor, with all the various kinds of stresses that I experienced as a child. When I was 12, I got a hold of my mother's chemistry set and my father's books on hypnosis. So I was interested in those different areas.

When I was in college, I was studying chemistry, and I had an opportunity in the summers to work in the Sloan Kettering laboratory nearby in Rye. I happened to be in the lab with Dr. Lloyd Old, MD, who is now often referred to as the father of tumor immunology. I started reading about lymphocytes and immunology. I began to think that maybe most of illness was from the mind affecting immunity.

Toward the end of the 1960s, I took an internship at the San Francisco General Hospital in California, and later explored research in psychosomatic effect on immunity with Dr. Al Levin, MD. As you can imagine, California at that time was a hotbed of alternative thinking. I started hearing about a relationship between diet and disease. However, I was not convinced. Certainly, the stories were impressive about people with autoimmune diseases and cancer getting better, but I did not have a scientific basis for my thoughts. In California, I attempted to do a study on psychoimmunological variables and lymphocyte reactivity. However, at that time, the techniques were not available to do the kinds of studies I wanted to do.

Eventually, a post doc who had helped me with some of my experiments early on started a dermatology department at Einstein. I thought working with Dr. Franklin Pass, MD, would be fun, so I went into dermatology. I had already done a general practice residency and I realized that was not what I wanted to do. I just saw too many things being done without adequate knowledge of the consequences.

Dr. Rountree: What was it about dermatology as a specialty that drew you?

Dr. Dattner: It involved both immunology and psychosomatics—two important factors. Immunology is important in dermatology because, as we know, it is inflammation that can be seen right on the skin. However, people also came to see me with heavy emotional components to their disease. My background had extended beyond to general practice and to some of the basic sciences, such as immunology. So I thought that would be very exciting.

Dr. Rountree: From reading your biography, it is clear that you did not just dabble in immunology. In fact, you were quite immersed in the world of immunology for many years, and you were right there in the beginning of how modern immunology developed.

Dr. Dattner: Yes. I was in six different laboratories. I was in and around key pieces in the development of immunology. For example, Dr. Lloyd Old, MD, was a key player in the discovery of tumor necrosis factor (TNF). ¹ I was immersed in the basics of understanding that lymphocytes were controlling things. I read all of the original literature with Drs. Karl Landsteiner and Merrill Chase from the early 1940s. Also, in the 1960s while I was in the laboratory, Dr. Felix Rapaport, MD, and his group were discovering the various antisera from grand multips that identified the different tissue types. Correlating his findings with that of other labs around the world led to the agreed terminology for the histocompatibility locus. ² With Dr. Mark Hardy, MD, I was doing some psychosomatic research exploring the relationship between stress and lymphocyte reactivity in breast-cancer patients. We published on a kidney transplant patient who developed Kaposi's sarcoma in 1976, one of the first papers on the AIDS-related epidemic. ³ With Dr. Arye Rubinstein, MD, I was synchronizing Raji cells, which were lymphoma cells with a receptor used to distinguish T and B cells. Before that, during my third year of medical school, I took nine months off and did research with Dr. Barry Bloom, PhD, at Albert Einstein College of Medicine. We were working on macrophage inhibitory factor (MIF) as one of three labs in the world that were working with the first informational molecule coming from lymphocytes and informing macrophages. I never published that work. Instead, it was published by Dr. John David, MD, at the Harvard School of Public Health. ⁴ Dr. Bloom went on to become the head of the Harvard School of Public Health for more than 10 years. I worked with many people who were assistant or associate professors who subsequently went on to become world-renowned in their field.

After my dermatology training, I went to join Dr. Bill Levis, MD, at the National Institutes of Health (NIH). Between us, Dr. Levis and I had some 26 years of cellular immunology experience. In fact, we believe we had more than any other dermatology group in the world at that time. We did a lot of work on lymphocyte stimulation with specific antigens in a two-culture lymphocyte priming system. We eventually discovered that there was a requirement for the histocompatibility of the presenter cell, as well as for the antigen, in order to get optimal stimulation in the secondary response. We were looking at the nature of cross-reactivity, and I think we were the first ones in the world to demonstrate that this requirement went across a variety of antigens. The work was seminal in that Dr. Baruj Benacerraf, MD, in 1980 and Drs. Peter Doherty, PhD, and Rolf Zinkernagel, MD, PhD, in 1996 got Nobel Prizes for work related to ours. So yes, this is more than dabbling.

Dr. Rountree: This really begs the question of how this extensive background you have in immunology has come to play in your understanding of skin disease.

Dr. Dattner: This is exactly what I want to share with you. As you know, we can look at antibodies directed against a bacteria or a tissue in the body, and say that there is some evidence of a disease with immune reactivity. However, it is a kind of one-dimensional piece. Antibodies often recognize an antigen on an invading organism with no requirement for context of the individual. With lymphocyte recognition, what is recognized is a combination between an element of self and the haptene or antigen. Both are being viewed by the reacting lymphocyte. The reacting lymphocyte then looks in the body, and if it sees something similar, it attacks. That nature of cross-reactivity lends an element of specificity that is beyond the language that we had used formally for describing what would incite a disease. This means that strep, for example, plus self might attack some element in the papillary dermis of some people with particular histocompatibility antigens who also had a predisposition to rapid turnover of their cells, but not in others. ⁵ These people would get psoriasis. When we look in the literature, we see conclusions tending to dismiss the idea that food has anything to do with skin disease. The thinking is that if a few people develop a rash to a certain food, but not everyone, then that food cannot cause the rash. However, when you understand the histocompatibility aspect, you understand that you cannot just look at one food and one disease, but rather an individual-specific reaction. Dermatologists are now seeing that, at least in some areas, food might have something to do with some skin conditions, for example high-glycemic foods, milk, and so on in acne. In the past, dermatologists did have to think about food. However, once tetracycline came in, then they did not have to think about taking away certain foods, and everybody was happy.

Dr. Rountree: So we have evolved professionally with this scenario looming in the background: the thinking that food has nothing to do with the etiology of these chronic dermatologic conditions. However, as a person with an extensive background in immunology, I can see that you believe that food does play a role here.

Dr. Dattner: Of course. As we know from functional medicine and the study of leaky gut, we are exposed to food allergens. When I began to think about what I was going to do in my training, I went to meet Dr. W. Allan Walker, MD, now at Harvard School of Public Health. He had written with Dr. Kurt Isselbacher, MD, first Director of the Massachusetts General Hospital Cancer Center, about macromolecules crossing the intestinal tract. ⁶ He is one of the foremost pediatric immunologists, and has been working since the 1960s. He showed that horseradish peroxidase, with a very large molecular weight, got across the intestinal tract. ⁷ I began to question whether cross-reactions could be very specific for specific individuals. In other words, you have an epitope or antigen that is being attacked, which could be a very specific part of the structure of a particular type of cell, with specificity according to the individual's histocompatibility antigens, the tissue type, and other molecular aspects. So you could have very, very specific relationships. This means that it could be something that looks similar in some way, like from another mammal, or it could be something that had similarity because of a particular set of traits, like a microbe, or it could be completely different. For example, psoriasis could be precipitated by eating ham in one person and a streptococcal infection in another.

Dr. Rountree: So you are saying that there are all kinds of possibilities for cross-reactivity?

Dr. Dattner: Exactly. So, I realized that if I see somebody with inflammation, there exists a molecule that is entering this individual such that it could be cross-reactive with the exact site that is being attacked. With that perspective, I take a history. For example, when did it start and what were all the things that a person can think of that were going on before that. I get a history of antibiotics and steroids, and then I start thinking about leaky gut. Eventually, I begin to find suspects that I can remove, if it is removable, or I can take away all the other cross-reactive things that would be chemically similar to that, and I see what happens. At the same time, with functional medicine, I try and fix the leaky gut so that these things do not get into the body. I began to bring that perspective into my history taking decades ago, and that increased more and more as I learned about functional medicine, and as I learned about other forms of treatment. For example, I learned about other ways to deal with these issues, such as herbal methodology for cleansing lymphatics, helping the digestion to cleave molecules better, or helping the liver to process what could have been overflowing into the bloodstream for years. Over the years, I have met other people in the field. For example, Dr. Barbara Solomon, MD, in Baltimore had been doing food allergy work for years. Dr. Russ Jaffe, MD, at the NIH at the same time as me, now does work with lymphocyte reactions, and we were doing that at the time.

Dr. Rountree: So to be clear, no matter what chronic inflammatory skin disease somebody presents with, you would always consider some kind of food trigger. Is that correct?

Dr. Dattner: Not necessarily food. I would consider some kind of molecular trigger for any inflammatory condition. However, the trigger could be food, environmental, microbial, and so on. It could be that somebody is spraying their office with pesticides every day. However, I would like to extend this even beyond skin diseases. I think that anything that involves inflammation is likely the result of a cross-reactive response. The opportunity for the practitioner is to begin to understand and unwind the concert of events that have brought that about. If a biopsy shows a lymphocytic infiltrate in the area where the damage is, and a corticosteroid or a biologic type of drug that paralyzes some part of the cellular immune response improves this, the chances are that this is a delayed response lymphocytic attack to a trigger specific to that individual. So in one person with psoriasis, the trigger may be strep, and in another, it may be a ham sandwich. We do know that it is not likely to be as simple as one trigger. Something has to open the door—the leaky gut. There are a number of other factors. Some people have a predisposition to rapid turnover of the cells with inflammation, and they get psoriasis or seborrhea. Another person might have a pseudolymphoma or a different condition. The reaction patterns are different among individuals. The antigen does not always predict the response.

Dr. Rountree: My training in dermatology could seemingly be distilled into one central question: do you use a corticosteroid to treat this condition or not? If a skin condition responds to steroid creams, we don't need to worry about what triggered it. Your approach is much more comprehensive and is really looking at the cause as much as the manifestation.

Dr. Dattner: That is the whole point. However, if the inflammatory rash is self-limited, for example a reaction to something they were exposed to once that clears using topical steroids with no further exposure, that is fine. If someone has a contact allergy to something they are exposed to more often, such as in the workplace, and it is identified by patch testing, this is great. This is getting closer to what I do, which is trying to identify the cause. However, if it is something that is chronic and the trigger can't be identified, then it becomes less appropriate to keep using a treatment such as a steroid or a biologic. I have been very fortunate to have been able to help some people who were offered even more dangerous drugs. The biologics aim at different, very specific, steps in the cellular immune response. They all work to some extent, but that same response that you are inhibiting might be controlling a slow virus, tuberculosis, lymphoma, and so on. ⁸ This means that some people end up with these unfortunate consequences with more problems in the long run. I am advocating for a system that allows for and compensates for detective work to determine the triggers. I have been unable to work in the insurance realm because they would rather pay for a $20,000-a-year drug than pay for my time and/or the patient's supplements.

I do not think my treatment is for everyone because there are many people who are not willing to make an effort at changing their dietary input. However, just like we send people to various specialists for particular kinds of care, there should be room in the system to send people who are motivated and/or not succeeding with their current treatment for getting at the cause and finding it. A questionnaire can be a starting point for the query in order to come up with a possible disease initiating insult without taking too much time. With my background as a chemist, I have an advantage over my colleagues who are acupuncturists and naturopaths. I can expand my imagination as to the molecular structures that might have been similar to one of the possible insults. For example, if a sulfonamide is a possibility, I am thinking of sunscreens with PABA or all the things that look like that molecularly, and then I can ask about those, for example. We need to go beyond gluten and dairy.

Dr. Rountree: When we read integrative medicine literature or functional medicine literature, there is a lot written about gut immunology, but not much about skin immunology. You are saying that we need to understand the role of immunology in the skin as well.

Dr. Dattner: Yes, we need to respect the skin and have a deeper, more robust understanding of the molecular structures and potential targets and triggers in the skin. Things are going into the body, and once you have sensitivities, those things can cause reactivity. We now know that not only do we have circulating lymphocytes that have particular recognition receptors, but we also have some of those that get localized to the skin. ⁹ The illustration that I share with a lot of my patients who have recurrent reactivity is the nickel-sensitive patient who was breaking out under her ring. She got a cheap necklace from somebody and broke out not around her neck but around her ring finger. She had developed resident lymphocytes in that specific area that were hyper-reactive or hypersensitive to nickel. Some of that is related to first exposure, persistent exposure, or persistent deposition of nickel-sensitive lymphocytes. We also have both a cross-reactive response, involving molecularly similar compounds, and a bystander response, involving a reaction to compounds present in the area of the inflammation. For example, when a person who is allergic to poison ivy puts on Caladryl^™ with calamine lotion in it, and some of those people become allergic to Benadryl^™, that is a bystander response. So when I am taking a history, I am thinking about all of this—what else was also happening or being used at the same time? By using these tools, I am able to find various things that perhaps some of my colleagues do not find because they are not looking for it, or my colleagues in naturopathy have not had the same dermatology experience. Also, these principles likely extend beyond to all kinds of inflammation, from endothelial inflammation in cardiovascular disease to arthritis.

So some of my patients coming in have other issues, such as chronic viruses like Epstein–Barr virus and cytomegalovirus. This is another condition I address, and I have been fortunate to have some remedies that are helpful for that. I worked with a young woman who had been a patient of another physician. They thought she had Wegener's granulomatosis and was biopsied for it, based on a very high antinuclear antibody reading, positive ANCA antibodies, and extreme tiredness. By the time I had been able to help her with her gut functional medicine issues as well as her Epstein–Barr virus and cytomegalovirus, she was working 12 hours a day and was trying to get into the Marines. It can really make a difference if you persist in the detective work and you treat what you find. The more you know, the better you can do.

Dr. Rountree: Are there any other specific food antigens that people often overlook that you would be able to relate to specific outcomes? Are there any that you would say would be a surprise to many practitioners to realize the relationship?

Dr. Dattner: Based on a conversation with Dr. Peter D'Adamo, ND, it appears that lectins certainly have a role. I think that being aware of this opens up a set of questions to ask. Most foods have lectins, although some foods such as beans are higher. So, if someone is a secreter, that is, has their blood-type sugars on all of their cells rather than just the red blood cell, they will be more likely to be reactive to those things. They may not cause an allergy as such, but they might turn on a switch, which either punches a hole through the cell or flips on a switch inside the cell. I am not saying that this is the answer, but it leads to a finite set of questions rather than an answer such as telling someone not to eat any beans. We need to remember that much of the early immunology work involved lymphocyte evaluation by stimulating them with phytohemagglutinin. ¹⁰ Phytohemagglutinin is jack bean extract and causes most lymphocytes to divide. So for some people, avoiding certain types of beans might help. However, this does not mean everybody should avoid beans. So this is an important question to ask for people, not because it is necessarily an allergen, but because it is a different kind of “switch flipper,” if I may.

Dr. Rountree: A number of years ago, I heard Dr. Loren Cordain, who was one of the first proponents of the Paleo Diet, had written a research article on acne. My understanding was that they had studied some children on a Pacific island, and found a lot more acne in the group eating a higher carbohydrate diet.

Dr. Dattner: That particular work ¹¹ has become substantiated. Melnik has tied together a series of observations to propose how milk and sugar contribute to acne. ¹² The high glucose intake appears to stimulate insulin. High insulin causes IGF-1 release. Then there is a whole series of molecular mechanisms that increase androgen receptor avidity and lipogenesis. mTORC1 gets released. It is thought that this leads to more acne. ¹³ Most teenagers have higher IGF-1 levels to start with, so that has been proposed as one of the reasons for high glycemic foods causing acne. I just wrote my own invited article, which is in press, about how milk is involved. My hypothesis is that there are specific antigens in milk, which are analogous to structures in the sebaceous follicular-eccrine apparatus. ¹⁴ The mammary gland is similar to the apocrine gland, which is similar to the sebaceous gland. In the article, I discuss how there could be analogous structures, which are homologous at every level, functional and molecular. This notion of molecular triggers is for any kind of inflammatory skin disease or inflammatory disease in general.

Dr. Rountree: Are there particular nutrients that you use in patients in combination with your investigation for the trigger?

Dr. Dattner: I use various supplements to support digestion-elimination. I also use essential fatty acids, but I do not start with them. When patients are in turmoil, they are creating a lot of free radicals. Therefore, I do not want to saturate their essential fatty acids inappropriately. So I do not start with those. I start by trying to fix the leaky gut. So if gluten seems to be a problem, I take that away. I look for obvious foods that the person might be reacting to. For example, if you hit your thumb with a hammer, do not do that anymore. I try to get yeast under control. I think that is a very big thing and one that seems to be left out of the thinking. In dermatology, they have begun to see how important probiotics can be, but they have left the rest of the equation out by not taking away things that would cause yeast to grow, such as by changing the diet. The idea is to avoid what you need to avoid first. In many cases, it is pretty simple—simple sugars, which push up glucose levels and don't offer other nutrients. I see this as a public-health issue, as well as an individual issue. This is going to break our economy from the health standpoint if we do not deal with it. We have recent evidence that sugar companies have been able to convince major researchers essentially to lie and support their thinking. ¹⁵ We are paying a huge price for this from a public-health standpoint. We should be taxing empty sugars like we do cigarettes, and actually pouring that money into the diabetic care and the publicity for getting people to understand the damage that they can do.

Dr. Rountree: You mentioned probiotics earlier. Are you saying that you have not found them that valuable?

Dr. Dattner: No, I think probiotics are valuable, but they are valuable in the context of treating the entire problem that they are addressing. In other words, if probiotics are helpful, they are probably helpful because they are causing a more normal microbiome in the gut. However, that microbiome requires a fiber structure. It requires less sugar. If the microbiome disturbance is an overgrowth of yeast, it requires suppressing that yeast. In other words, using only probiotics to treat yeast is, like, we brought the drums for the band, but we did not get the guitar player. So I use probiotics in combination with all of these other things. One final thing is the idea of shifting our awareness to appreciation. We have to get back to taking that break to eat mentally, emotionally, and physically, and to take the moment to really enjoy and appreciate our food. Taking this time allows us to get the digestive juice and enzyme output that we need.

Dr. Rountree: Are there any other general tips you would give people to help maintain healthy skin throughout life?

Dr. Dattner: When it comes to skin cancer, my preference is sun-protective clothing. Also, for people who are sensitive, a non-chemical or less chemical sunscreen, such as zinc oxide or titanium dioxide, is a useful thing to use. Some sun exposure is good, but not when it is for hours.

Dr. Rountree: If “leaky skin” is an issue, are there any particular topical agents that you recommend for maintenance of a good skin barrier? Should we be putting creams on our skin every day, or should we put nothing on our skin?

Dr. Dattner: I think it depends upon various factors, such as type of skin, environmental humidity, and bathing habits. If someone has dry skin, they apply oils, ointments, or creams. Creams contain many components, including preservatives and other ingredients. These ingredients are potential sensitizers. Some can get away with it for six months or more, and then find reactions starting. Personally, I like a pure oil or emollient on top of moist skin. However, some people get sensitive to the oils, for example olive oil, lanolin, or coconut oil. These can work for a while, but once sensitivities start, the person has to switch to something else. In the end, my preference is to stay with simple products. Some of the products available have active molecules that can help your skin in combination with ingredients that can sensitize. There is always a plus and a minus. There are the immediate and possible longer-term effects that are beneficial, and there is the possibility of being or becoming sensitive to some component. That is the paradox that is involved.

An example of this is products containing ceramides and parabens. A colleague of mine in San Francisco, Dr. Peter Elias, found that as squamous cells evolve to the surface, they produce at least three different types of ceramides that give a kind of protective coating. ¹⁶ These can be very beneficial. However, these same products that contain ceramides often also contain parabens—these are commonly allergenic. Older antibacterial soaps were often photosensitizers for some people. So we need to watch and see how we react to these things. As we react to them, the Langerhans cells, and the cells in the skin, are seeing the compound and presenting it to the immune system.

The other issue is the potential for a secondary bacterial infection; this causes the immune cells to go into high gear. In this situation, there might be broken skin with a honey-colored or yellowish ooze. This then causes the eczema or psoriasis to get worse, and we have a vicious cycle going. In order to control the cycle, we need an antibiotic. Sometimes where I see cracked skin, I use goldenseal or one of the bitter, berberine-containing salves. Where I see intact skin, I like a mild anti-inflammatory such as chamomile or chickweed or calendula as a soothing ointment. Usually they are infused in olive oil. In the end though, if someone reacts to an ingredient that is in the prepared product, even olive oil, then they might have to make their own infusion. Remember, people can react to anything. I have patients that cannot even use monolaurin that comes from coconut. People can have logarithmic differences in their reactivity. So some people can have a little bit, and some people cannot have any at all. In any situation where there is inflammation, you have got to be able to suspect by your questioning not only what it could be, but also what level of concentration is possible to cause it.

In the case of poison ivy, secondary reactivity can happen at a much lower level. In this situation, somebody who breaks out while pulling weeds that were poison ivy becomes much more allergic avid, and might start breaking out in other places, even if they didn't go outside, because the dog, which went through the woods, sat in their chair. Or they then touch a tool or other object that has been in contact with the poison ivy and breakout now since they are 100 or 1,000 times more sensitive.

Dr. Rountree: We have not mentioned your book. Can you discuss your new book Radiant Skin from the Inside Out: The Holistic Dermatologist's Guide to Healing Your Skin Naturally ?

Dr. Dattner: My book is for people who want to understand what is going on with inflammation and their skin according to solid principles based on my years in the world of immunology, dermatology, and alternative medicine. ¹⁷ These people may have some information from the blogosphere and the Internet. Often the information from these places comes from people who may be saying the right thing but for the wrong reason. In other words, the information cannot be extended to other situations because they have a simplistic explanation. The book is based on solid immunology and dermatology, so that it gives the reader an understanding that can be extended to better answer all of the questions that they will face in the process of healing their skin or other inflammatory condition. I have already had reports of people healing their skin condition just by reading the book.

Dr. Rountree: Given your background in dermatology and integrative immunology, what do you recommend to a practitioner with a patient who has a chronic skin problem? What should they do? What would be their next step if there is nobody like you in their area?

Dr. Dattner: If the physician develops a good relationship with somebody who is doing integrative medicine or an alternative field where they have an additional perspective, for instance, an acupuncturist, a naturopath, or a functional medicine practitioner, and they are able to share differential diagnosis and their sets of thoughts, that could be helpful. Another possibility is to gain one of those perspectives by studying some other area that gives them this information. There might not always be someone like me in the area, given the difficulties of insurance coverage. When I wrote my book, I was aware of the difficulties of getting this information out to both physicians and patients. I really wanted to make sure that people would have this resource and be able to benefit from my decades of experience. I am also starting to get more information into the peer-reviewed literature. I do not know whether this is going to reach the insurance companies and other people who make decisions in order to make it viable. When it comes down to dealing with difficult problems that are not being solved, or the solutions are untenable, a skillful integrative approach is very important.

To Contact Dr. Alan Dattner

Alan Dattner, MD

Advanced Dermatology

211 Central Park West #1 D

New York, NY 20024

Phone: (212) 722-2441

E-mail: doctordattner@gmail.com

Website: http://holisticdermatology.com/

I have one other thing that I would like to add. I recently had a case that I dealt with in two or three phone sessions. I had a young boy with lymphomatoid papulosis. Given the 10% risk of lymphoma, he was about to go on methotrexate for two years. As I took a history, I found out about Epstein–Barr virus and treated him for that. I also found out that his condition got worse after the holidays. This led me to think about sugar, and we made some changes in that direction. Once this was in place, he was 99% better. He did not have to go on methotrexate. This can make a big difference in people's lives. Adequate insurance support for integrative medical care should be out there as much as a referral to a neuroendocrinologist or some other kind of specialist who has experience with various difficult issues. I think it is important that we still maintain the understanding that we have other kinds of tools besides new drugs, machines, and surgery. As highly educated integrative specialists, we can help many people who fall through the cracks of current medical care, and we should not get blocked from proper compensation because of thinking that just any physician or assistant can treat these conditions with available medicines.   ■