Dr. Davis:

what relationships, if any, exist between the nutritional history you've depicted in your post and pancreatic cancer.

Is there any way to heal our pancreas? I have a friend with pancreatic cancer and it's incredibly painful. I would love some preventative care for myself if you have any tips.
Jana

Pretty good advice, doctor.

The Centers for Disease Control has predicted that one of every three Americans born in 2000 will eventually develop diabetes (mostly type 2).  Your dietary advice, along with regular exercise and avoidance of obesity, would prevent many cases.

-Steve

Great article! Yes, our pancreas is neglected badly. It is working hard, day in, day out and we don't even notice this hard labor.
One can measure if the pancreas is still working ok by measuring "C-Peptid". A sensitive marker of insulin production. Mine is 1.0 (a little low), so I want to support my pancreas.
Does anybody know how to increase or re-generate beta-cells?
There is a herb (among others), called GYMNEMA SYLVESTRE that has supposedly regenerative capabilites. Has anybody tried this?
Thanks.

Doctor Davis:
No rice or potatoes?  Are you advocating a zero carb (except carbs found in veggies and fruit)?  Many of us are allergic to nuts so foods like walnuts are out, but peanuts are ok since they are legumes, but many seem to say stay away from them.  Be helpful to get more detail on your daily diet suggestions.

Thanks!

Doesn't the pancreas work to produce insulin and glucogen even on low-carb meals?  I thought the problem with high-carb diets was the elevated level of insulin in the blood and the various metabolic syndrome problems that causes, not necessarily that it overworks the pancreas.

Agreed!  Please correct me if I'm wrong, but isn't there the a danger that as a person gains weight and the body is experiencing continuing high insulin levels, some tissues become insulin resistant, so the pancreas is forced to produce  even more insulin to keep the glucose levels in the blood under control.  That, I understand, becomes a  "slippery slope" and difficult to recover from.  I don't mean to be alarmist - but it is downright scary.

Dr. Jack Kruse: Via current clinical (testing) methods by the time someone is diagnosed with Type 2 #diabetes, 50% of their beta cells are already destroyed. http://goo.gl/MAhVU

It's mostly the overwork, here's a little known pancreas fact: "Only 1% of the beta cells in the pancreas are devoted to producing insulin for handling sugars, 99% of the pancreas is devoted to handling the digestion of fats and proteins."   http://goo.gl/WlLML  and  http://goo.gl/wUcEB  

From Wikipedia: "The islets of Langerhans constitute approximately 1 to 2% of the mass of the pancreas. There are about one million islets in a healthy adult human pancreas, which are distributed throughout the organ; their combined mass is 1 to 1.5 grams."   And in rats, only 65 to 80% of those cells are devoted to producing insulin & amylin.  http://goo.gl/3zrHa

So when you consider these facts along with what Dr Jack Kruse says: "Via current clinical (testing) methods by the time someone is diagnosed with Type 2 #diabetes, 50% of their beta cells are already destroyed.", then YES, BABY YOUR PANCREAS!!   http://goo.gl/MAhVU

FWIW: I was spiking to 185-210 at one hour post prandial on Dr Fuhrman's greens/beans etc diet.  I added Gymnema from Pure Encapsulations Gymnema sylvestre extract (leaf) (75%)250 mg, one capsule, 3X/day and after about 5 months my highest spikes have been in the low 120's after BIG meals, same diet, no grains but plenty of fruit and some root veg and lots of beans.  Even a good sized serving of oatmeal only get my sugar reading to the mid 120's. Seems to me, likely some beta cell rejuvenation has gone on.  How much the gymnema and how much the diet is anybody's guess.

Agreed! And it's why I eat only 1-2 meals most days. AND ... very low carb.

Usually sub 20g of carbs per day!

Baby that THANG!

Could a high SHBG level be caused by a worn out pancreas?

Oops, wrong quote.  here's the right one.    "In addition, glucose sticks to proteins in the blood (glycosylation). These glycosylated proteins are sticky and slow down the blood flow through the capillaries and veins, preventing oxygenation. It has been shown that people with diabetes have higher rates of cancer and mortality due to cancer as compared to those without diabetics. The strongest correlation was for pancreatic cancer. Notably, it has been found that the higher the fasting glucose one has, the higher the risk for cancer."  http://goo.gl/PnJoU

Also see the article Tom Naughton wrote on his Fat Head blog about ‘Super-Sticky’ Cholesterol and Diabetics here:  http://goo.gl/JTi75

There's no evidence that using your pancreas is what leads to reductions in beta cell mass and function.   Have you looked at any of the peer review research demonstrating that drugs like Byetta can actually increase beta cell mass and increase insulin sensitivity?

2,000 - 3,000 Beta cell work to coordinate insulin put out every +/- 4 minutes; post-prandial there is a 1st response insulin spike, then smaller steady secretion, and in time a lesser 2nd insulin spike.  Some Type 2 diabetics don't  put out the 1st insulin spike, their blood sugar stays high and then eventually they do put out that late 2nd insulin spike.

"Amylin"  or IAPP (islet amyloid poly-peptide) is co-secreted with all insulin;  if  "amylin" goes on oligomerize into a  tangle of fibrils around the individual Beta cells this messes with their signal synchronization.  As the "amylin" kinks up with other amylin the Beta cells are pushed apart and those Beta cells change size; without Beta cell group co-ordination the individual cells' mitochondrial house keeping repairs risks compounding recycling errors and that cell goes into programmed cell death (apoptosis).

Zinc is what binds to an individual "amylin" fibril  in a central position and keeps that fibril from oligomerizing with other fibrils; too little zinc in pancreas lets tangles occur. Yet too much zinc in pancreas also lets tangling get going; this is due to when a 2nd zinc clings elsewhere on  the same fibril the first zinc already is bound to.  See  recent "Journal Molecular Biology", vol 410, 2, 294-306

Do you have a reference for that? Not a mouse study. Thanks.

http://diabetes.webmd.com/news/20110624/very-low-calorie-diet-may-reverse-diabetes

Damned interesting study if it bears out. It seems that a couple months of hard starvation lowers fat levels in the pancreas and can actually reverse diabetes, at least in people who are not too far along in the disease process.

It does not take anything like the starvation in the above linked study to reverse insulin resistance and effectively eliminate T2 diabetes.  There are a number of doctors who have been having that result for many years w/ a lowish fat, plant based diet, eliminating REFINED carbs, animal fat, saturated fat, and manufactured junk food.  See Fuhrman, McDougall, Barnard, Esselstyn, Shitani, etc. They all have books out and a track record easy to find.

Now I have Weird Al Yankovic's song "Pancreas" going through my head...

No need to starve to "cure" type 2 diabetes.  Just cut the carbohydrates, particularly the starchy kinds from grains, legumes, and potatoes.  No need to eliminate animal fat/sat fat, either. Natural fats have no effect on blood glucose and do not stimulate insulin production.  If you eliminate all the things Fuhrman et al say to eliminate, there isn't much left to eat and you will end up on a starvation diet anyway!

Might some of Doc's diabetics be getting their relief from eliminating wheat be due to more zinc absorption (and thus less "amylin" tangles) ? In theory  phytates  have the potential to excessively bind up zinc; although I hesitate to say one scenario fits all situations.

Zinc deficiency in the pancreas is hard to assess, since we use zinc all over ; specific tissue levels are a guess,  because we are physiologically designed to keep a baseline amount of zinc in our blood. In other words,  zinc can actually be retrieved from body tissue and put back into circulation;  maybe  some individuals have a disposition to leach zinc out of their pancreas and then their "amylin"  tangling worsens.  Constant adult doses of over 100 mg per day really merits caution and, aside from other side effects, may tag "amylin" fibrils with 2nd zinc that provokes  "amylin" tangles; I am not suggesting any specific dosage for anyone here.  

Meanwhile,  other individuals possibly avoid Beta cell death due to genetic propensity to maintain enough zinc in their pancreas;   and,  also some may have gut bacteria strains that slowly pass the  intestine zinc the bacteria cleaved from phytates' hold.  Not every overweight person, nor  grain/legume/nut phytate  consumer goes on to develop diabetes; there may just be some age related Beta cell decline  that is normal and not pathological.

The whole notion of beta cell regeneration, while tantalizing, is uncharted territory. I propose carb-limitation not so much for its beta cell regenerating potential, but for its ability to simply not challenge a compromised pancreas.

Might-o-chondrial's proposal that grain phytates block absorption of zinc is interesting. However, I don't know how much of a genuine role it plays in the entire picture. I can say that the end clinical effects include HbA1c's of 5.0 or less, fasting glucoses of 90 mg/dl or less.

"If you eliminate all the things Fuhrman et al say to eliminate, there isn’t much left to eat and you will end up on a starvation diet anyway!"

Lack of imagination/creativity is a terrible thing.  The only thing Fuhrman et al say to eliminate is manufactured, highly processed, refined, chemicalized, "food like substances" (that are not really food at all).  I eat basic Fuhrman diet and can easily adjust my calorie intake up or down by 1000 calories or more just by substituting higher or lower calorie density real foods.  It isn't difficult, and even at lower calorie intake, no sense of deprivation at all after the first bit of breaking addictions and retuning taste buds.

60 - 80% of new Type 1 diabetics show anti-bodies for Zinc Transporter 8; there are 10 different zinc transporters (ZnT) in mammals.  ZnT works with the movement of zinc from a cell's cytoplasm to sites of action inside that cell and also moves zinc outside that cell (bringing zinc into cell is not directly mediated by ZnT).

A genetic polymorphism of ZnT 8 (SLC 30A8  rs13266634) causes less pro-insulin made into insulin (crystalization of insulin for stockpiling  involves zinc)  and when high blood sugar malfunctions;  if less insulin
stash in insulin storage granules then it's secretion on instant demand (ex: 1st post-prandial insulin pulse)  is impaired.  Normally lots of ZnT 8 is active in pancreatic  Beta cells and actually prevents Beta cells from dying off due to zinc deficiency;  as well  as  lots of ZnT 8 activity expression inducing more  insulin put out in response to blood glucose loads.

High blood glucose down-regulates ZnT8 and , on the contrary, up-regulates ZnT 3;  Doc is right to be concerned with excessive post-prandial blood sugar because ZnT3 and ZnT8  have different dynamics.  ZnT3 is linked to amyloid tangling in the brain (hippocampus has lots of ZnT3) and recent research find it is active in the pancreatic islets; so I wonder if it's transporter genetics (gene SLC 30A3) is how  zinc becomes a problem outside the cell,  and integral to how "amylin" fibrils then can kink into tangled oligomers that push Beta cells too far apart.

Sshort-term supplementation with cholecalciferol improves β cell function
Effects of vitamin D and calcium supplementation on pancreatic {beta} cell function, insulin sensitivity, and glycemia in adults at high risk of diabetes
Perhaps if they'd used 5000iu/d the results would have been even better as Dr Cannell suggests here

Improving melatonin secretion (or using a time release supplement) may also be worthwhile to protect pancreatic function.

Did they need to be starved as well. Surely just reducing the carb would have sufficed?

Glad to see T. H.  back .... for Melatonin synthesis we use zinc and taking zinc raises one's melatonin output (2003  journal Acta Physiologica Hungarica, 90(4),335-339).  Pancreatic lipase enzymes that help cleave fat we've eaten also  uses zinc.

I have no zinc guide lines for anyone, and definitely  am not claiming zinc is the only relevant parameter in pancreatic dynamics.  For home evaluation  of zinc status please see Dr. Dereck Bryce-Smith's  "ZTT"  technique; it is a 10 second mouth swish of 2 teaspoons of zinc sulfate mono-hydrate and how one's response ranges in four gradients  going from tasteless to metallic.

Fuhrman? Have you seen how he handles commenters on his site that challenge anything he says. He responds like a childish buffoon. Besides he is very much anti animal fat and anti saturated fat. No thanks.

I am just about convinced that I have experienced some amount of beta cell duplication as a result of many months of low carb dieting, as noted in an earlier post by Might-o in March regarding the formation of new, larger beta cells in the absence of hyper-glycemia.  After trying many diets to address my type 2 diabetes, I settled on a low carb diet of 65% fat 25% protien and 10% carb after extensive research on the effects of the different micronutrients on blood sugar.  For almost a year, my A1C has been 5.4, and I lost 40 lbs in that time period.

However, after feeling that I had lost some strength in weightlifting, I did some additional research on maintaining strength while on a low-carb diet, and it was suggested that on weekends, to eat anywhere from 100-500 grams of carbs to restore my glycogen levels.  To make a long story short, I ate half of a large pizza, and tested my blood glucose before and one hour after.  Before, it was 82mg/dl.  After? 67 mg/dl.  I tested this again the next day with a few tacos, which would have normally shot my blood glucose numbers in the 100's and it produced the same effect.  

One concern that I have is that my pancreas is producing excessive insulin, which is a problem for us diabetics who have been abusing our pancreas for so many years.   However, I believe that I have recovered some insulin sensitivity by giving my pancreas a rest and keeping my insulin levels low.  Does that mean that I'm cured and I should start gorgeing on pizza, cakes, sodas, french fries, mashed potatoes, pancakes and fried chicken like I used to? (I know, I brought diabetes on to myself)  The answer is no.  But it is a good idea to preserve our existing working beta cells by giving it a rest.

Some nutritionists & dietitians recommend no more than 10 or 12 teaspoons of  *added*  sugar a day, as in addition to your regular daily diet, others say 10 to 12 teaspoons total sugars per day, with no additional.

Since only 1 percent of your pancrease is used to produce insulin to process blood sugars, and since the average human body contains 5 liters of blood which is equal to around 1000 teaspoons, and a homeostatic fasted blood sugar level of 60 to 90 mg. per deciliter equates to a little less than 1 teaspoon, the theory is the less sugar consumed is the better option.  A handy formula to memorize is the 1-5-20 rule, which means 1 teaspoon of sugar equals 5 grams which equals 20 calories, then just do a little multiplication or division to convert the grams & calories of carbs on food labels into a teaspoon equivalent that's easier to wrap your brain around, and as a good visual aid to understand how much glucose you're dumping on your pancreas all at once.

I seriously doubt Dr. Davis advocates *NO* carbs, very few people that understand how to exploit the macronutrients do, especially doctors.  Most people have poor long term results & can't sustain a food denial strategy, so rather than think in terms of carb denial it's better to just have limited amounts of the carbs you like while keeping in mind the total glucose content, glycemic index and glycemic load of those foods and the stress placed on your pancreas by overindulging.

There's a great carb intake chart over on Mark Sisson's website that explains the optimum carb intake levels, to see it scroll down the page here:  http://goo.gl/CYD1n

Just remember that carbs have 4 calories per gram, so to get the total calories by carbs per day just multiply the grams by 4.

Good advice, as usual.

I was wondering if you could plan a future post around Microvascular Disease, particularly in women.  I understand the symptoms are different, and was hoping that you may be able to shed light on which lifestyle factors are most effective.  I'm seeing more and more thin, active women (many younger than 65) with "perfect" lipids in cardiac rehab.

I have been taking metformin for polycystic ovarian syndrome. I have been low-carb/primal for a year now. Blood work (sugar and trig/hdl) look great. Any idea what I am doing to my pancreas by continuing the metformin? I have already decreased the dose since my blood sugar was getting too low. How do I know if I don't need to take it anymore? I am not taking metformin to control blood sugar.

Thank you for the valuable  information Dr. Davis.  I am using much of it.

Another way to baby your pancreas is to avoid, where possible, dysglycemic drugs--two examples include: quinolines (antimalarials) and fluoroquinolones (FQs, e.g. ciprofloxacin, levofloxacin, moxifloxacin).  Bactericidal antibiotics produce more oxidative stress than do bacteriostatic antibiotics.  FQs produce a lot of oxidative stress, probably more than others and they are handed out like candy.  FQs also deplete and mutate mammalian mitochondria.  

Interestingly, B-cells in the  pancreas have very low levels of antioxidant enzymes (glutathione peroxidase and catalase both mop up reactive oxygen species)  comprising only 1% of the levels in the liver.   This favors H2O2 accumulation which can mess up H2O2 signal transduction.

I wonder why our pancreas B-cells  do not have more antioxidant protection than do cells in the liver?  Maybe the difference is the amount of zinc and iron between the pancreas and liver?  Zinc is a potent antioxidant by itself and a cofactor for the third major antioxidant enzyme of our bodes--super oxidase dismutase.  Iron is highly risky for oxidative stress particularly in combination with a hydroxyl radical--this is an explosive combination.

How much the rapid increase in diabetes is associated with  the overuse of prescription medications that are tough on the pancreas?

I have references for all of the above if anyone is interested.

Hi Redd,
You may be interested that it is MnSOD (manganese superoxide dismutase) which makes risky super-oxide molecules into molecules of H2O2 (hydrogen peroxide); the net effect of having more MnSOD activity is lower levels of super-oxide but more H2O2.

"I ate half of a large pizza, and tested my blood glucose before and one hour after. Before, it was 82mg/dl. After? 67 mg/dl. I tested this again the next day with a few tacos, which would have normally shot my blood glucose numbers in the 100′s and it produced the same effect."
Hope you have previously tested those same foods at 30 minute intervals because blood glucose peak timing can vary greatly depending on specific food/meal and individual physiology. Pizza is one of the worst for long delayed but very high peak

Wow!  This is an incredible conflict of interest!!  No wonder I have felt so much pressure to do this and that despite never being sick and having no symptoms.  

How did medicine get to this point?  The better question is 'How can doctors live with themselves?'  

We all know that everyone has to earn their living but but this milking of the system and of patients is truly horrible! It is especially insidious when you are dealing with someone you need to trust implicitly and who tells you that you need to do these things because he/she is worried about your health!

I thought you might be interested in this article on a physician in Arizona who is remodeling his practice to offer concierge health care.
http://www.azcentral.com/business/articles/2008/07/23/20080723biz-elitedocs0724-ON.html
As an advocate of free market solutions, I will be looking for a physician in my area with the same philosophy.  But I don't really expect to find one, as I am in an area dominated both by a State University Health System, and a Private University Health System. My own PCP is in the private University system.  We are asked to sign arbitration agreements with the University in case of  some untoward event (I refused, but I believe many patients believe they must either sign or go untreated, or else do not realize what they have signed.) Now the system has implemented a program that is ostensibly designed to help patients develop preventive health practices.  You are provided a liason person ( a nurse I assume) to check in with once/month by phone,and in that conversation you are asked about your goals and what you're doing to reach them, and given the usual status quo, conventional advice about concerns.  (This person will never even set eyes on you, after all.)   Still, it  doesn't sound bad, even sounds as if they are making genuine if nonsubstantive efforts toward helping people be proactive.  But I would not be surprised if the whole scheme were somehow rigged to the advantage of the University insurance plan, such as being enabling them to see if you are receiving more treatment (such as seeing an acupuncturist or chiropractor) than "they" think is appropriate or taking only the drugs "they" approve, and I also suspect that one day it will no longer be voluntary, and that you will be coerced toward only the practices they approve of.  Why are they offering payments for participation, is my question, and what do they do with the information you give them?  I will be opting out of that too.

As far as free market solutions and the concierge model go, many will argue that it is too expensive and will only provide care for an elite.  The Arizona physician will charge a flat fee of $1500/year, and that will entitle his patients to direct access to him by phone or email, and at least 30 minutes of his time per visit.  His practice will have to be smaller than in the past in order for him to give more to each patient, but he will be able to actually practice medicine rather than be a cog in a corporate machine. Surely there are free market models that can be devised for the average person as well.  To object that the cost of modern health care is prohibitive may be simplistic.  Why is it prohibitive?   Can it be because the market does not function freely under the triple chokehold of insurance, drug company and government collectivism?    If patients and physicians were able to devise alternatives to the present environment of health care and PARTICULARLY if true, effective preventive practices (and many are already available at nominal cost but not promoted) became the norm, costs could plummet.  Hail to the pioneers such as Dr. Davis and the TYP members, and to the Arizona Concierge physician, who are striking out for new territory.  We will all benefit tremendously.

Dr. Davis,

Your fellow cardiologist Rich Fogoros also addressed this breakdown of the role of doctor as advocate, but he argues just the opposite: that PCPs today are essentially employees of the health insurance companies, tasked with controlling costs by minimizing tests, procedures, specialist referrals, etc., like claims adjusters.  His version certainly seems to be more true where I live.  I can't speak to the extent to which my PCP is under pressure to stay within a quota (however informal) for monthly rheumatologist referrals, CT scans, etc., or the degree such pressure taints his patient interactions, but I do know that he works in a clinic owned by the same (insurance) company to whom my employer and I pay my premiums, and that the same company also owns the local hospitals.  Clearly the profit-maximizing thing in such case is to maximize (healthy) policyholders and minimize claims (treatment).  There's no profit in gratuitous caths and bypasses when the hospital is the insurance company.  Fogoros claims that this sort of vertical integration became the rule when the HMOs bought up all the community hospitals and clinics in the late '90s.  A friend of mine (under my same plan) suffered a nasty GI tract problem and had to beg and fight her PCP, over 2-3 months of almost constant vomiting and other fun, for a referral to a gastroenterologist, who did finally diagnose and cure her.  The PCP was clearly in over his head, yet kept futilely giving her the same garden-variety pills (antiemetics, PPIs, etc.) and at one point told her, "Look, I can't just send everybody to the GI to have him say, 'Take the Purple Pill!'"  So Fogoros' "covert rationing" seems to go on in my town.  Can you reconcile that with what you're saying?

All my adult life I've been told by doctors I have "borderline hypertension" (about 140/90). None, however, ever even suggested that I take an anti-hypertensive. Now I have atherosclerosis and can but wonder what might have been. Let mine be a cautionary tale.

Not all insurance plans require a person to go through the PCP for referral to a specialist. I have seen patients who are seeing multiple specialists where it seems no one is in charge of the overall picture. These people may be given duplicate tests and incompatable medications. Doctors don't always communicate with each other. Shouldn't there be one chart that follows the patient from doctor to doctor?

When I was seeing a university PCP I found it difficult to get tests such as vitamin D, B12 and A1C.
Anne

Practicing primary care in the US in the current environment is incredibly challenging, but still very rewarding. As an employed family physician in Massachusetts, I am pulled in many competing directions: the hospital encourages referrals and admissions into the system the patient's insurance company discourages some referrals and limits access to certain medications and expensive tests.  There is more paperwork and bureacracy than ever.  Patients are more informed now, and often come in with information, some of which literally may be based on one person's opinion from a website or blog.  There are often many issues to try to sort through in one visit, a visit which is often limited by time pressure that exist as doctors try to see more and more patients.

Despite this, I still feel it is a privilege to be chosen as someone's family doctor.  I tell my patients that I will try to treat them like my family and give them the same advice I would give my mother or my daughter.  I see my role as their guide, and I try to lay out the different options, and then tell them which one I would personally choose, but that it is ultimately their body, and they get to make the decisions.

What it comes down to for me is that medicine is still about the interaction between the doctor and the patient, and if a patient is unhappy with that interaction, then they have the right to try to find a new doctor where they will feel cared for.

I had to also respond to Jenny's post about concierge medicine.  It is definitely an attractive option for some patients and physicians.  I once read it explained like this: "Imagine you're a plumber, and someone says I will pay you more money to do fewer plumbing jobs, so you can spend more time on each job, and really focus on doing the highest quality work you can, really get back to what it was that drew you to being a plumber."  Who wouldn't want that?  My problem is that it is not extrapolable.  If a primary care concierge physician only has 300 patients, there is going to be a huge shortage of primary care doctors in this country.  My training in both medical school and residency was oriented around taking care of all the patients that needed help, not just the few hundred that could afford an annual fee of several thousand dollars a year.

There is a group of doctors who have come together in Seattle to practice medicine in a very intriguing model.  It is called Qliance (www.qliance.com).  It has some similarities to a concierge practice, but is much more affordable.  They don't take insurance, there are direct monthly costs that are charged to the patient which covers unlimited visits.  Additional tests are paid for by the patient.  This model financially aligns the patient and physician, and the usually-hidden costs of medicine are out in the open.  One physician who works there described it as very refreshing to feel that you are really working for the patient.  It won't be the answer for everyone, but it may be the answer for many.

Anne posted that some patients are seeing multiple specialists without having a primary care doctor.  

That's my predicament, and I wish it weren't so.  As an 57 year old woman with multiple annoying health problems including diabetes, hypertension, and some difficult-to-treat chronic pain (chronic daily migraine, neck problems), I can't find a PCP who will stick with me: They are apparently so unnerved by the list of maladies that I must deal with that they decide I must be crazy, not ill, and stop working on my behalf.  

I just hate trying to be my own PCP!  I'm terrible at it!  The idea of having a PCP who would help me manage all this stuff is a dream!  And I haven't had a physical in over a decade because I can't keep a PCP.  And although my specialists kindly try to fill that gap in my treatment, I know that not having a PCP is dangerous.

However even with my excellent insurance and ability to pay and living in an area with an unusually high number of doctors/capita, apparently I fall into a category of patient that PCP's just can't deal with.