How to Get Better Results With Functional Healthcare

Episode Intro:

Welcome to Dr. Ruscio Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player for weekly updates. Visit drruscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now, let’s head to the show.

DrMichaelRuscio:

Hey, everyone. Today I had a discussion with a few clinicians who have been following our work and specifically, The Future of Functional Medicine Review. We discussed ways in which this newsletter and database has helped clinicians with their patients. We also cover some foundational and extremely important facets for how clinicians should be thinking and applying the information. I should clarify that we have one level of data – clinical trials, meta-analyses – and it is extremely important to be looking at this level of evidence. However, that evidence needs to have a method of application. This is one of the key things that we were discussing in the podcast today – Why does it appear that much of integrative and alternative medicine does not have a structure system in place? That causes so much waste and unneeded suffering on behalf of patients. What can we do to provide structures of application of clinical science?

DrMR:

One of the most important things to understand if you are looking to improve your health would be this. This organizes everything – the low FODMAP, immunoglobulins, elemental dieting, limbic retraining, the post-concussion therapy, sleep disordered breathing. All these things are just in a blender of confusion until we start having a process through which to apply them. That was one of the main themes that we really hit in this podcast today. We also gave a little prelude into a recent review we performed on food allergy testing. If you are thinking about doing food allergy testing, I would definitely give this a listen. We review a few case studies and then have a solid discussion on how to think through and apply information in functional integrative and natural medicine.

DrMR:

With that, we will now go to a round table with a few clinicians who have read the FFMR and found it to be helpful. Also, remember that if you sign up any time in October, you will get 30 days of all access for only $1. I’m really passionate about this project. I hope you will join up and start reading through the information contained in the FFMR. It’s crucial for healthcare providers to offer people better care in this realm. I’m very excited and very passionate about it. I hope you will take advantage of this promotion that we do. I hope it’ll allow you to give this a read and a look to see if it’s something that you feel will help you. Now, we will go to the discussion.

Clinician Introductions

DrMR:

Hey, everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio today with two special guests, Gavin Guard and Scott Spiridigliozzi. It’s a great Italian last name. I was hoping I wasn’t going to screw that up too much here. I shouldn’t because I am Italian. However, there are many syllables in that strong Italian last name there. Both of these gentlemen have been readers of the book, followers of the podcast, and namely followers and readers of the Future of Functional Medicine Review newsletter and database. Today we’re going to have a clinician’s round table and discuss what they’ve learned from reading through the newsletter and how that’s helped them help their patients. That’s the high-level objective today – to share some of the good stuff that’s going on in that clinician’s newsletter/database. Scott – since you’re new to our audience, give us the short synopsis on your background and how you found your way into the FFMR.

DrScottSpiridigliozzi:

You said my last name just beautifully. I’m a naturopathic doctor and I went to medical school in Arizona. I graduated in 2018 and I stumbled upon your podcast about a year ago after I heard you on a podcast with the Carnivore MD. I was listening to him and then I heard you all your information. You were talking about gut health and this foundation up approach. From there, I jumped right to your podcast, dove in, and ended up at that next level of support. I then joined the FFMR and it’s been so helpful. I practice in Washington state and that’s pretty much the short summary there.

DrMR:

Nice, cool. Well, thank you. Gavin – I think people are accustomed to having heard your name. Gavin and I have been working diligently behind the scenes filtering the overwhelming stream of studies we get notified about through PubMed. As I’ve mentioned on the podcast in the past, anytime a published study is released on thyroid, levothyroxine, Hashimoto’s, subclinical hypothyroid, iodine and thyroid, probiotics, saccharomyces boulardii, soil-based probiotics, IBS, IBD, SIBO, Rifaximin, pro-kinetics, upper GI pro-kinetics, GERD, LPR – the list is long – we get an email notification. In my biased opinion, one awesome thing about the addition we now offer with the FFMR are these weekly research briefs of what’s been published in the past week or so. This used to take me at least seven hours of reading per week. Now I can read a brief or listen to the audio read of the brief in about 15 minutes. It’s been hugely helpful. Gavin and I have been working to hone and refine that process. Also, he will soon join up on our clinical team. I’m really excited for that transition to occur. Gavin – can you give your short synopsis in case people have not heard your name up until now?

GavinGuardPAC:

Sure. Folks might recognize my sultry voice from the FFMR Plus if that’s something that you are subscribed to. I have my own practice here up in the San Juan Islands in Washington state. I have been fortunate enough to help out with these research efforts that you, yourself, Michael, and the rest of the clinical team are putting forth. Just a side note – there’s a lot of folks out there that say evidence-based. Who doesn’t want to be evidence-based now? If you’re not, you’re kind of an outcast. However, you and the rest of the team are really putting your money where your mouth is – actually putting forth primary research and reviews. That’s really where the FFMR Plus comes into play. I hope that it’s been a valuable resource for clinicians. I’m sure it will be something that we talk more about.

Patient Personalization

DrMR:

100%. Thank you for the praise, but also raising the comment that everyone wants to present themselves as though they’re science-based or evidence-based, but not everyone does. This is one of my most annoying pet peeves. I hate it when people tailgate me too closely. I also absolutely hate it when people say “…the science says, the science is clear, we know from the evidence…” If you carefully listen to the person’s continued arguments after that, you will often see they do not have a command of a body of science. The Dunning-Kruger effect applies not only to politics, but also to healthcare – the less someone knows, the more confident they are. This will manifest as people making strong claims; making claims that are very unnuanced or broad.

DrMR:

That can only happen when you don’t understand the nuance. When you do understand the nuance, then your opinions are much more as “the totality evidence suggests this, although there are some data that have contradicted that…” or what have you. I think that’s actually a really insightful point, Gavin, and one that I just want to echo – everyone wants to put on a front of being scientific, but look for people who have strong opinions, who use strong language, and make broad claims. That’s usually a good indicator the person doesn’t know that much; they don’t understand the evidence for and contradicting a point so they can be really strong in their narrative on an issue. Phenomenal point.

GG:

To your point, it’s ok to be convicted about a general trend you have most patients go down. I’m coming across at least one study per week on probiotics for IBS and a low FODMAP diet for dyspepsia and functional GI disorders. When you dovetail every single patient into that bucket, even if they have tried and failed those therapies, I think you’re doing people a massive disservice. You talk a lot about this algorithm and this hierarchal approach to patient care. That’s very important because we have to personalize that algorithm to each person we see, but at the same time, use what’s been tried and true at the same time – using both the research and personalization for the patient.

DrMR:

Yes. 100%. It’s simple in its label, but actually visualizing or using an algorithm is a bit more complicated. A rough heuristic in terms of how to understand or envision an algorithm in your head is that we take all the available tests and therapeutics – we put them in an order of operations from most common and safest, least invasive, and cheapest. We start there and then work our way down to the diagnoses or the treatments that are less common or less likely to help people (or make more sense to be applied once you’ve gotten rid of confounding noise.) So, the basis of how you’re thinking about helping a patient is informed by this algorithm.

DrMR:

We know that IBS is more common than hypothyroid. If someone is coming in with symptoms that could be attributed to either, we’re going to start with IBS or with the gut. Within IBS, we know that a basic elimination diet is going to be easier and helpful for more people than a low FODMAP diet. We start with the basic elimination and then we go to low FODMAP second. We also know that there’s much better research on probiotics than there is immunoglobulin therapy. We’re going to use probiotics before we use immunoglobulin therapy. We also know that for Exocrine Pancreatic Insufficiency (EPI), the response to the treatment enzymes in some circles is considered diagnostic in and of itself. So, if the symptomatic improvement from the enzymes is crucially important in affirming a diagnosis, it would make sense to do that later in the treatment hierarchy. We want to make sure there aren’t other things like true IBS going up and down in the background and making it hard to read – Did this person see improvements in their bloating and diarrhea from the enzymes?

Testing vs. Algorithms

DrMR:

So all those things congeal together to give a clinician a framework. You can picture this array of cascading decision trees. You’re thinking about how to navigate someone through this and that structure gives you the general map. To your point, Gavin, we personalize it based upon their history, their symptoms, their sex, their age, their prior treatments, and their specific symptoms. This is incredibly powerful compared to a patient coming in with bloating, brain fog, and fatigue – so now we’re going to test adrenals for the fatigue, run a uBiome (which has been debunked in terms of its accuracy) for your bloating, and run a gene test for the brain fog. So, you treat these tests instead of going through that brilliant algorithm of cascading decision trees used in functional medicine.

DrMR:

These three tests are not validated and you start treating based on the tests. Yet, you throw out the algorithm, which is built upon hundreds of thousands of patients. This algorithm is from all of the studies – individual elimination diet studies, low FODMAP studies, probiotic studies, and immunoglobulin studies. You’re looking at hundreds of thousands of participants that have been poked, prodded, and studied in different settings and helped to construct this algorithm. You’re throwing all of that away because a lab told you that brain fog can come from adrenal fatigue. Yet, there has been – to my knowledge – only one study in existence in the entire world that has taken patients, done an adrenal test, and then treated the patients based upon the adrenal test. This is the study of The Kalish Method with Dan Kalish – who I know and respect – but, it was also a multi-modal intervention. There were multiple things that you’re getting at the same time.

DrMR:

Pardon me if that’s a bit of a monologue here, but this is actually crucially important to understand. What much of the field is doing is using a test. It looks scientific using a test, but it’s actually 100% non-scientific. It requires you to throw out this algorithm – or these thought algorithms – which are commonly used in medicine. You’re throwing that out and the thousands of research subjects that have been studied to comprise those for a new test. It’s just a powerful admonition of how influential lab companies have been in the education, in natural medicine, in integrative medicine, and in functional medicine. I just want to plant that flag pole here.

DrMR:

That’s a good transition to welcome Robert Abbott from the clinic onto the podcast. I know you were running a bit late because your internet was going in and out. I’m glad you were able to get on the line with us. Welcome onto the call.

DrRobertAbbott:

Yes. I really love everything you just shared. I would encourage folks to go back if they skipped over that monologue. Go back to the beginning and really listen to that. What you just shared, Michael, is extremely important. One of the things we’re seeing in functional medicine is the misuse of the scientific method and lab testing is one great example. I think you did a beautiful job laying out how we need to be appropriately using the research that has been conducted across multiple different domains for these treatments and how we’re applying it in the clinic. There’s no perfect method. There’s no perfect solution, but that whole sequence really summarizes what we’re trying to do and what this process has been like from the beginning. When I first met you, that was one of your goals and I think you articulated it very well.

Foundation Up Approach

DrMR:

Thank you. Scott – to pivot back over to you, you can speak to being a young doctor, having not too long ago completed your training. I know that students, and rightfully so, are heavily marketed to by supplement companies and lab companies because they want to make you aware of their products. That is okay. That’s actually not the problem. I think the problem is clinicians probably aren’t aware enough of the bias that’s carried into the educational materials. I think clinicians have been too trusting. I don’t want to put all the culpability at the labs and the supplement companies, but, if they’re not being properly filtered by a clinician, then that can be problematic. How does this all map onto your experience going from a student transitioning into clinical practice? Are you seeing these things? Are you maybe not seeing them that much? Feel free to agree or disagree. I’m just curious of your perspective on this.

DrSS:

In school, just being on shift, one of the biggest things I remember that stands out to me is looking at thyroid testing. As a student, you just absorbed the information. Like – “They know what they’re talking about, they’re the doctor, I’m just a student. So, I’m just going to listen to them.” I remember hearing you want the patient’s TSH below 1.5 and if it’s anything above that, then they’re sub-optimal in terms of their thyroid and they should be put on Armour or NP-Thyroid.

DrMR:

Wow. That goalpost is shifting.

DrSS:

Yeah. It was around 1.5 or 2, if I recall. In 2016, 2017, 2018, that thinking was ingrained in us on shifts. You just take it at face value. Now, I’m a lot more analytical about it – thanks to your podcast and hearing you speak about it and really thinking about it. Like you said, IBS is way more common than hypothyroidism. Most people don’t eat the right foods, they stress, and they don’t sleep well. All those things impact the gut. With fatigue for example, we probably need look at the gut first to address what’s going on and that’ll likely improve their energy so they don’t need to go on thyroid hormone for the rest of their life.

DrSS:

So I do remember learning about that in school. Moving forward, I definitely felt a little lost in terms of what to focus on. With people that have fatigue, we look at adrenals, but nothing was ever taught in this hierarchal model. Well, it just makes so much more sense in terms of the patients. They benefit so much more and I have these two perfect examples in my mind. I had this one patient that I was seeing a few years ago. I definitely didn’t do the best I could have because I didn’t have this structure in my mind of starting with the basics and then working forward. I touched upon some liver issues around some glutathione and did a food sensitivity test. She had all these things pop up and I thought “ok, we need avoid these.” It didn’t go well.

DrSS:

Contrast that to another patient with digestive issues where I actually wrote the case review. I started with implementing the paleo nutrition plan and some probiotics. We started with the foundations – we did the nutrition, we did the probiotics, and we did some digestive enzymes. Comparing and contrasting those two different patients and how they did – the first patient didn’t get better and the second patient got completely better.

DrSS:

I did not learn about this foundation up approach and I saw how my patients just didn’t get better the way they needed to. However, using this hierarchal approach allowed me to see dramatic improvement in patient care. We didn’t do expensive testing and I do want to talk more about that actual case study at some point in this podcast. It just really illustrates how much I’ve learned from you and the FFMR. I want people to really understand how powerful this approach can be and contrast that to the conventional and expensive lab-centric type medicine. I don’t want patients to drain their funds when it’s not needed to get better.

DrMR:

I would definitely love to unpack that case study. There’s one thing I want to share that you spurred my mind to think about. Part of the problem that we’re in this overly reductionistic, mechanistic thinking is probably a natural outgrowth of the coursework in medical school, right? It’s very mechanistic – “Memorize the Krebs cycle… be able to draw it out… memorize these various liver pathways.” By extension in learning about the body and all its components, parts, and pathways, you tend to start thinking that’s how a clinician should think. As an example of this, we know that the liver detoxifies certain compounds – if this person is expressing fatigue and brain fog, maybe this is hepatic encephalopathic overload, which has been actually shown in some studies.

DrMR:

However, one needs to shift their thinking from textbook memorization and mechanisms to solving the rubik’s cube equation of getting the person healthier. This is definitely what we’re trying to do with the hierarchies that we provide people. It gives you a structure for thinking through the problems. So now you have a position in that cascading array of decision trees where you may revisit a mechanism of liver detoxification, but you need the larger structure to guide you. Without that larger structure, you’re flailing about because you don’t know when to use the specific knowledge. Specific knowledge in the absence of a larger guiding structure is more prone to leading people in the wrong direction and spinning their wheels.

DrSS:

100%. I’ve definitely seen that mechanistic thinking. Looking at allergies is one thing that comes to mind. I had somebody tell me – and this may or may not be true – that vitamin B5 reduces histamine. I go into PubMed and all I can find are mechanistic studies. I can’t find any outcome studies with actual people where giving them this certain vitamin improves their allergies. So, the mechanistic thinking is definitely drilled into our heads. I think it has its benefits to understanding the bigger picture, but if we just focus on that and not on actually seeing people get better than I think the mechanisms are not that helpful.

DrMR:

The way that you’re analyzing that is brilliant. I don’t want to be too self-congratulatory here, but the work in the FFMR got you thinking about a mechanism. Let me see if this mechanism has been studied in humans, because the effect size of a mechanism can vary wildly. So yes, if we draw a Krebs cycle, we know certain B vitamins impact metabolism and liver pathways, whether it be mitochondrial or hepatic. However, the question is – Does that B5 impact the mechanism enough to lead to a clinically observable improvement in the thing that you’re influencing? So that’s awesome. I’m really happy that part of our work spurred you to check that.

DrSS:

100%. One more quick one is probiotics and histamines. Mechanistically, I’ve heard people say that you shouldn’t do probiotics if you have a histamine issue. However, when you look at the data, there’s actually a net improvement for allergy sufferers when they take probiotics. So that’s another mechanism that doesn’t necessarily support what the outcome data is showing. So yes – 100%. You’ve influenced my thinking in that area. Thank you for that.

DrMR:

That’s awesome to hear. Thank you because it makes all the work that we’re doing really worth it when we’re seeing that it’s influencing people in a positive way. Let’s go into your case study. I do want to plant one seed for after your case study for food allergy testing. Robert and I just finished doing a fairly comprehensive review on food allergy testing and that is going to be in the FFMR. It is going to be a position statement piece on what our perspective is on food allergy testing. I’m actually really excited for Robert to share more about that. Scott – let’s go into that case study that you were just referring to.

Case Study Breakdown

DrSS:

Yes. It was a young female that was having diarrhea for four months or so. Her doctor – an MD doctor – put her on a proton pump inhibitor (PPI). She came to see me. She was having diarrhea multiple times a day, really bad abdominal pain, and she was really bloated. I did some very minimal lab work. She wanted to do food sensitivity tests and I told her my hesitancy over it. However, I obliged her requests. I put her on a paleo diet and probiotics. One thing I really wanted to point out – I later found out that when her symptoms began, she had water damage in her apartment and there was mold present.

DrSS:

Thinking about it, I could have gone down this rabbit hole. We could have done urine mycotoxin testing which could have been positive. We could have spent months trying to treat the lab and trying to get her mold remediated. Not to say that’s not important, but by following the hierarchy, working on the gut first, and removing food sensitivities, she started having regular bowel movements and her abdominal pain was gone after a month and a half. She also moved into her parent’s home. So, she got out of the environment. I just think about how much I saved her; how much just wasn’t necessary at the moment because we worked on the gut first and she got better.

DrSS:

She also avoided the environment. When talking about mold, avoidance is going to be that base of the pyramid. So again, instead of doing all that testing and then treating the tests, we didn’t do that. She got better and saved a ton of money and time by just not going down that rabbit hole. Not to say that some people don’t need that. If she didn’t get better, then we would need to address the mold with binders and all of that. We didn’t have to do any of that. It was really awesome to see that using that hierarchy saved a ton of time and money and she got a lot better.

DrMR:

Yeah. That’s fantastic. You’re dead on. With the mold piece, it can be an issue. I’ve experienced that personally. However, with urinary mycotoxin testing, I think we still have a decent amount to learn there in terms of how to most accurately interpret a finding. I have a suspicion that food and probiotic use can skew your results. I’ve shared this on the podcast before, but I was having a positive urinary mycotoxin test before I left California and moved to Austin. There was mold in my home in Austin so it was less surprising to see a positivity there, but in the dry, arid climate I was coming from, the probability that I was ever exposed to mold was extremely low. At that time point, I did have a positive test. Exactly like you’re saying, if I was being advised by a clinician, I could have gone on months of binders and all this other stuff, and really got worked into a tizzy for something that was an anomalous lab finding.

DrMR:

The hierarchy helps us rule things out and rule things in. I’m really happy to hear that you didn’t go chasing the mold. Maybe once she goes back to that environment and some symptoms recur, at least you have confidence in that assertion rather than just blasting everything that you could possibly think about addressing on day one.

DrSS:

Exactly. Again, I definitely attribute that to your work and thinking about that hierarchy. That’s the way I think about things now – this hierarchal model.

DrMR:

Fantastic.

Sponsored Resources:

Hey, everyone. I’d like to thank Athletic Greens for making this podcast possible. If you’re like me, you may sometimes struggle with getting in enough nutrient-dense foods. One thing that I’ve really appreciated about Athletic Greens – or AG1 – is not only are they the best tasting one that I’ve had to date, they also help ensure that I’m getting adequate nutrition and really hitting the mark regarding nutrient density. I’ve been using them every morning as part of my morning shake. Now, one scoop of AG1 contains 75 vitamins, minerals, and whole food sourced ingredients, including a multi-vitamin, multi-mineral, a probiotic, and a green superfood blend all in one serving. The other thing I really like about the company is Athletic Greens continues to improve this one holistic formula based upon the latest research. They’ve produced 53 improvements in their formula over the past decade, which is pretty remarkable – a hat tip to them for that commitment. So I highly recommend Athletic Greens as part of your daily routine. Right now, if you visit athleticgreens.com/ruscio, you can get a free one year supply of Vitamin D and 5 free Athletic Greens or AG1 travel packs. Visit athleticgreens.com/ruscio to really cover your bases for well-rounded immune support vis-a-vis AG1 and that one year supply of vitamin D.

Food Allergies & IgG Testing Issues

DrMR:

Speaking of food allergies again and where we put them in the model, they actually go in the trash can. They go in the trash can next to the model. I say that facetiously obviously, but, Robert and I recently went through that review. It was pretty insightful reading through the evidence on this. There are a couple of takeaways there. Robert – I’m not sure if you want to share, but there are a couple that are so compelling. It makes it even more difficult to get behind food allergy testing.

DrRA:

Yes. This is a huge domain. It’s been on our collective radar for some time, but it just got brought to the forefront. I saw a social media post on a survey from one of the lab companies that utilizes a marketplace for the lab tests. They talked about the five most common tests used in functional medicine practice or ordered from their company. On that were basic blood tests, stool tests, organic acids, adrenal things – things that you would expect to see that are pretty common. Included in that top five was food sensitivity testing. That shocked me a little bit because it’s been something our practice and myself have not ever utilized and we’re clearly helping patients. I looked at that and said, “Wow, that’s amazing that this is one of the most common tests being used.”

DrRA:

Obviously we have a bias for seeing our patient population doing well. We’re able to help a lot of our patients and are not requiring that testing to help them. I have a bias that this testing is likely not helpful nor clinically valid. So, I have that bias, but I’m always willing and ready to be proven wrong; to be shown a test, a treatment approach, or condition that I’m not currently aware of and to change clinical practice. I think the FFMR over its several years demonstrates that for our collective practice and across multiple clinicians who’ve provided guest case studies.

DrRA:

So, I’m ready to be proven wrong. I wanted to go look at the literature. I wanted to see and really focus on outcomes. Am I missing something here? Is this testing actually valid and something we should be using in some of our troubleshooting populations – people who aren’t getting better, subpopulations of GI patients, or people with headaches, etc. that this could actually be helpful for? So, I go into the literature and you see pretty quickly that most of the consensus statements from the major organizations are saying this testing is not clinically valid. I’ve put this into the newsletter. That’s important to recognize and we don’t want to just immediately appeal to authority. They can make mistakes there in judgment, but you should recognize that if several organizations are saying if you choose to do something different than that, that is steering away from what this consensus is and what that consensus is being derived from.

DrRA:

There should be at least something that you’re basing your approach off of that’s going against what the consensus is suggesting. A lot of the sub analysis of that consensus was suggesting that the IgG pathology or lack thereof – the IgG physiology, the IgG presence – you could not use the IgG antibodies to a food antigen as a reliable marker of disease. For anything in terms of a lab test to be helpful, it has to be able to separate out a disease population vs. a healthy population. If something is found fairly ubiquitously in both a healthy population and disease population, it is very hard to use that test in any clinically meaningful way. Essentially, that was their summary statement from clinical reviews and consensus statements. Noting these IgG antibodies to different foods seem to be present in a lot of settings and potentially as a mechanism of the body, trying to maintain tolerance or unacceptability of that food and not actually a sensitivity as its widely espoused in the functional medicine community.

DrRA:

That was something I was pretty aware of, but it was interesting to see that these multiple groups are sharing this. I take that data and say, “okay, this is supporting the idea that this is unlikely to be helpful, but can I actually go find some of the studies that lab companies or practitioners using this testing have cited in support of their tests?” From there, I found one of the most widely reported studies from the early 2000’s. On paper this was a very well designed intervention. It was a randomized study where essentially one group was given a dietary protocol personalized based off of their IgG food sensitivity results.

DrRA:

Another group got a sham diet. I couldn’t get this completely from the write-up – whether the individuals in the sham group knew during the consenting process that they could get a completely bogus diet or if they 100% believed the diet given to them was there based off of their tests. There were potentially some ethical dilemmas there, but needless to say, one group got a diet based off the IgG testing; another group got a sham diet that was essentially opposite of their testing. The researchers saw that on a whole, there actually really wasn’t much clinically significant difference. The only significant difference noted were the extremes of adherence. The strongly adherent individuals to the personalized IgG testing dietary approach versus the sham dieters, they seemed to be better off. They used that as evidence to say this IgG testing to inform a personalized diet was reasonable for these individuals with IBS type symptoms.

DrRA:

Of course, that study then gets cited as now we should be using this testing because it has merit. On the whole, there wasn’t much difference – although maybe in the strongly adherent group, there was more difference. Seemingly, that would say more evidence to the diet informed from the testing being worthwhile. However, let me actually go look at what they did. I will say the authors were very helpful in providing specifically the percentages of the foods included in each of the groups. What was fascinating to see is when you looked at the percentages of foods that were excluded in the IgG testing group vs. the percentage of foods excluded in the sham group, the IgG testing group really became a group of people doing a very normal empirically formulated elimination diet.

DrRA:

They removed all the common things you would remove. If you were seeking to eliminate the commonly allergenic things – dairy, gluten containing elements, eggs, certain nuts – their diet was essentially eliminating the things that are most likely to be problems from known allergic responses. The sham dieters removed things that were very unlikely to be an issue – things like potatoes, apples, rice, etc. These things were not showing up on testing and empirically, aren’t the things that people commonly have allergies to. So, it was fascinating for me to really see the testing and how they got there. The study was just assessing an empirically formulated elimination diet to a sham diet, where people remove things they probably didn’t need to remove.

DrRA:

Even still, the sham dieters got better at the end, by a clinically significant margin. This just shows you the tremendous power of placebo. They were still including gluten, dairy, and all these potentially problematic things. Yet, they still got better by the clinically significant margin set for this IBS score. While it wasn’t as much as the people doing the diet – that was essentially an empirically formulated elimination diet – it just really showed me this is what this study actually looked at. These people eating all these things with IBS still got better, but nobody who is sharing this research study in favor of the IgG testing probably looked to ultimately see what was being shown. My conclusion from that would be that it looks like a really good empirically formulated elimination diet. Guess where that is in the hierarchy? Phase 1 of the hierarchy – without testing, without scaring anybody, or without telling anybody they’re allergic to this or sensitive to that.

DrMR:

It was eye opening to see the evidence for something that was seemingly for IgG testing, but really wasn’t actually for it. What it was for was a reasonably formulated elimination diet. It’s an issue we’ve presented on the podcast before that I see a lot in functional medicine. When you start using these tests and then someone either gets better or gets worse, you misinterpret how you treated the person based off the test as what got you there. This is happening a lot and I think Michael and I talked about this happening with some genetic testing. I see this all the time. “Because you have this snip and this snip and this snip, I’m going to recommend XYZ.” And I say, “Well, I would have actually recommended XYZ, which were reasonable recommendations, anyway.” However, you now did this and assumed you needed to do the genetic testing to do that.

DrRA:

The details of this study are in the most recent FFMR, but it just really showed this is a very common practice that people are learning in school or in these trainings and implementing. People are probably getting better from some combination of placebo or removing things they should have eliminated to begin with and falsely attaching their success to the testing. This is a huge problem that we have to be aware of. I think one of the only answers is trying to do these newsletters; trying to change the education of how we’re teaching clinicians to be critical observers. Otherwise, things get taken in as gospel, applied, and then actually reinforced in a way that says, “This is what I should have been doing.” In actuality, that wasn’t what was really happening. Anyway, a long answer, but it’s a hugely important topic that IgG testing is a good illustrator of this larger issue.

DrMR:

Fantastic answer. If people want to read through that again, that’s in the FFMR for you to easily be able to navigate back to, pull the references, and look at our notes. To your second point there about falsely attributing the test to being one of the factors that helped you improve the patient’s case – it’s almost like clinicians need to have anti-virus software running in their minds. I would look at this as malware. For example – I gave them this test, I did all this stuff I probably would have done anyway, and now they’ve gotten better. It must be the test. That’s a mental virus or just a bias. If you take two clinicians and one of them has this anti-bias program running and the other doesn’t, where they will be in five years in my observation, is ridiculously different. One clinician will be getting so much better and the other will be further entrenched in whatever the current thinking is, whether or not it’s accurate. There’s no mechanism in place to correct beliefs that were not helpful.

Mechanistic Teaching in Functional Medicine

DrRA:

I think this is a good point. As I was thinking earlier with our education, how do we teach clinicians? There’s so much that can be taught. What I hear over and over again in functional medicine education is that it’s like medical school all over again – or a second medical school – because there’s so much seemingly foundational knowledge that is needing to be incorporated. I get that. There are certain foundational elements that need to be learned, acquired, and put into conceptual maps/frameworks of thinking. However, in putting too much emphasis on that foundational knowledge – and a lot of it is mechanism – you’re doing a disservice to the clinician in helping them adopt a hierarchal treatment model to actually help patients. You see this all the time.

DrRA:

The Institute for Functional Medicine (IFM) is great organization, but I remember in the hormone module, you get a diagram of all the steroid hormones. That’s awesome and I think it’s really cool. However, is that clinically meaningful to me? No. It’s not really changing how I’m going to treat somebody and you can do a disservice by having too much of the teaching be facts and mechanism and not enough case-based, therapeutic, hierarchial thinking. We have to find a balance there and a way to appropriately use research to inform practice. I think that’s one of the things in the way of teaching where it’s too much mechanism and foundational knowledge. The clinical case-based approach is getting lost. That’s an observation I’ve seen having seen a decent amount of that educational content and how it could actually lead folks astray and does.

DrMR:

Yes. Obviously that’s like the choir preaching back and forth to each other. I fully agree with you. The way we think and teach needs to change. To some extent, it does feel like there’s this antiquated educational model that was more helpful in the industrial age. Now that we’re in the information age, memorizing information – a tidbit, mechanism, factoid – that’s not really as valuable as thinking, systems, and application. I can find the Krebs cycle or all of the hepatic cytochrome pathways with the click of a couple buttons, but how do we now take that massive amount of information and put it into a system to apply it, organize it, and really think critically about it? That’s the evolution that we have to go through.

DrMR:

This is probably the growing pain that we’re really bumping up against here. At one point, just having the more mechanistic, textbook information – like the pregnenolone steal from the Bill Timmins/BioHealth naturopathy circles from a decade ago. Those pathways were devoid of the context for how or when to apply them. That’s the information age teaching that is really deficient in education across the board. I think is an understandable growing pain the field is going through.

DrMR:

One of the challenges is there isn’t a lot of great financial incentive for this information management thinking. It’s easier if you’re looking to sell a supplement or a lab because it pulls you back into this mechanism. For example, the lab is telling you about the metabolism of the steroid hormones. So they’re going to show you this diagram of what mechanisms, inputs, and outputs the lab is reporting on. As I’m thinking about this, it does seem like a lot of the market pressures – which can be used constructively – are pulling us back into this gravitational field of staying stuck in mechanism-ville.

DrMR:

We are not sponsoring weekend seminars, but I know companies that sell labs and supplements are. Part of this probably a congealing of a few forces. One is trying to see the educational system evolve and then the other is funding. I’m sure there are many things that I’m not thinking about, but those are a few that just pop right up. This is what we’re trying to provide an antidote for with the FFMR.

The Hierarchical Method Across Multiple Medical Disciplines

DrRA:

I’m laughing inside realizing this, but what we have here between Michael, myself, Scott and Gavin is that we have four practitioners of all different backgrounds. I’m a medical doctor, Michael’s formal background is in chiropractic and natural medicine, Scott is a naturopathic physician, and Gavin is a PA. We have people with all different technical medical backgrounds who are talking about a shared philosophy and shared language. I hope that can show you that many roads can lead to a shared philosophy and treatment approach.

DrRA:

Within here, I also see a couple different generations of this evolved clinician. I see we became friends and colleagues in 2015 when I was still in medical school and began applying your principles fairly early on. My residency overlapped with the early production of the FFMR. Being able to do some of the guest case studies to demonstrate how I was applying these principles. It wasn’t just Michael and his echo chamber. These principles could be applied in other settings. As things grew, I became colleagues and friends with Gavin, building up a mentorship and seeing him grow and apply these principles. More recently, I built a relationship with Scott. It’s so nourishing to see this evolution and to be reinforced with the process; how that can be applied across multiple disciplines, training backgrounds, and geographically unique places to still achieve results. I hope people recognize just how validating that is to the approach. This is not only medical, this is not only naturopathic. This can be applied by providers of many different backgrounds who are trying to share this one philosophy; who have evolved through the use of this unique clinician training tool and modality. I wanted to offer that as an observation.

DrMR:

I love that. I want to pivot to Gavin because I want to get some of his perspective. As someone being newer to practice, what’s your perspective going from education to practice? How did the FFMR help you? There does seem to be this force at play. I’ll quote Paul Chek because the way he said it was really poignant – “The closer that you get to the truth, the more commonalities you find.” I think that’s what we’re all after – we’re all pursuing the truth. Maybe not absolute truth, but we’re trying to progressively pursue the things that seem to be the most true and the least wrong. This scientific self-critical process is how we get there. That’s what I think really unifies us.

DrMR:

Gavin – what are some of your insights? I don’t know if you have a case study or a few things in particular that you’ve noted, but I’m always curious to get additional external validation of these concepts having merit.

GG:

I have another case study I’d be happy to share to reflect Scott’s experience, but more so about my evolution in practice. When I was in Physician Assistant (PA) school, I was also concomitantly doing some functional medicine training. Like you guys, I think that we’re reflecting a lot of the same things. However, I could also highlight the fact that a lot of that training was so steeped in mechanism that it became so overwhelming. I remember with my first few patients, I admittedly spent an hour obsessing over all the potential mechanisms and pathways that are off. It became unbearable to be able to do that with every other patient. Quite honestly, it didn’t lead to any better outcome. I think that’s what we want as both practitioners and as patients — we want clinical outcomes.

GG:

As a practitioner, I like to see the forest through the trees. A common trend in functional medicine is like we major in the minors too much. We spend so much attention on and splitting hairs on the minute details that we miss being clinically outcome focused. So, when I started reading the FFMR as a consumer – and not yet as someone contributing to it – I started putting this model into practice and started seeing better results. I was no longer obsessing over every single minute detail and started walking patients through that hierarchy. Now that I had a model to adopt, I wasn’t reinventing the wheel for every single patient. I was trusting that model. Part of this is personalizing it, but that’s where you as a clinician comes into play. You are personalizing that model to your patient.

GG:

Admittedly, when I first started listening to your podcast, I was thinking “There is no way that he’s helping people with insomnia, fatigue, and joint pain by this GI specific approach.” Honestly, I was very skeptical. It wasn’t until I put that GI specific approach into practice that I was seeing those same things. My patient volume isn’t as much as you or Robert’s, but I can attest to that efficacy of that GI specific approach. Within the last year, my practice has evolved tremendously. I think the biggest thing that I’ve come out with is a greater sense of confidence as a practitioner. Perhaps more importantly, I’m getting my patients better results faster, with more simple and practical recommendations.

GG:

For example, low FODMAP diet and triple probiotic therapy – that’s level one support; adding in a layer of elemental dieting is level two. That leads to better patient satisfaction and clinical outcomes as opposed to obsessing over something like the visceral hypersensitivity is causing the IBS… and the food sensitivities are causing immune system Th1 and Th2 imbalances… and they have the MTHFR genetic snip and they’re going to be at risk for X, Y, and Z. So again, there is confidence and better clinical outcomes. As an aside, what we’re doing here is standardizing functional medicine education so that we’re all on the same page. What I see is that there’s so much discrepancy and variability from practice to practice within functional medicine that it’s hard to know what you’re getting. I want this to be the standard because I believe in it so much. I really do hope that people would put this into practice and just see it for themselves.

DrMR:

Yes. All great points, Gavin. I am fully there with you in terms of being skeptical about the gut work being able to help so many things. It’s even something that I periodically have to remore myself to. What really helps me there is the fact that I had crippling insomnia, fatigue, and brain fog and no digestive symptoms. Every once in a while I have remind myself of that because I feel the pull, too. Reading all the IBS literature and reading really conventional literature – it pulls you into thinking in these narrowed boxes or confines. What you see in the clinic when you start using a gut-first model is quite reinforcing. You will see things like skin problems, joint pain, insomnia and, brain fog improve. We’re seeing the evidence base really catch up to that, which is great.

DrMR:

To your point about personalization, this is something we were just having one of out clinical round tables on. We have a periodic meeting with all the clinicians in the practice. One of the things that came up today was – should we have this patient do vagal exercises like gargling or gagging? There’s this pull to do the esoteric, new, and different. It was a good learning opportunity for us to cover that. That’s something that is more of an exceptional time and place frame where that fits in the hierarchy. I’m not a huge fan of the vagal exercises specifically, but I think something like neurological rehabilitation, if you suspect post-concussion syndrome, is probably the better way to examine and consider that.

DrMR:

To your point about Th1 and Th2 balance, I did this testing early in my practice. I felt so unsure about it. Perhaps being a little insecure is a real blessing for a clinician. I’m not sure how much this comes across in the podcast. I like to think I’m confident to a degree, but even things that I’ve quadruple checked, I’m always a bit insecure on either my understanding or my mastery of, and that keeps me open-minded. I remember feeling so unsure and insecure when ordering some of these Th1 and Th2 tests. I had a really hard time wrapping my mind around it.

DrMR:

As I’ve said on the podcast before, I thought I was an idiot. I was not seeing it – I had my seminar manual, I took notes, and I paid attention, but I was having a hard time mapping this really elaborate immune cascade onto this patient. When I started to use the conveniently named Th1 support pack – by the supplement company that funded the seminar that was teaching me – I really wasn’t able to tie that to clear responsiveness. As a quick aside to offer this to clinicians – if you’re ever feeling unsure and insecure, to some extent that’s actually a gift because it keeps you honest, it keeps you questioning, and it keeps you double-checking. That’s akin to that anti-virus software that I was mentioning earlier. For me, that’s how I found my way out of this – or many of these fallacious practices. It really makes me feel so honored and validated in us being able to offer up a resource to pull people through that more quickly. By that I mean, getting away from the supplement company funded seminar manual that’s full of stuff that just doesn’t seem to work or resonate and giving people another educational body to really tie into.

DrMR:

If I could help a clinician in three months go through the learning curve that took me four to five years – that’s really how the field moves forward and improves. So, I love what you said. It makes me feel good about the work that we’re doing.

Dr. Ruscio Resources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to drruscio.com/resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of the fact that we deliver cost-effective, simple, but highly efficacious functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who’ve been unable to improve their health, even after seeing numerous doctors, to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our probiotic line, and other gut supportive and health supportive supplements. Health coaching – we now offer health coaching. So if you’ve read the book, listen to a podcast like this one, or are reading about a product and you need some help with how or when to use it or how to integrate with diet, we now offer health coaching to help you along your way. Finally, if you’re a clinician, there is our clinician’s newsletter, The Future of Functional Medicine Review. I’m very proud to say we’ve now had doctors who’ve read that newsletter, find challenging cases in their practices, apply what we teach in the newsletter, and are able to help these patients who were otherwise considered challenging cases. Everything for these resources can be accessed through drruscio.com/resources. Alrighty, back to the show.

DrMR:

Is there anything else?

DrRA:

For folks who haven’t joined the community yet to get access to these newsletters, we are continually making an effort to provide tiers of engagement. For example, that most recent IgG food sensitivity clinical review, we lead off with the most essential key points and what you could be doing in your clinical practice right now, as well as what we’re doing. Boom. Right there in two minutes, you can get those details. If you want more nuance, more information, there’s more of the research below that and then there’s more references if you’re wanting to go look at the studies themselves. So, you really can get as much of the experience as you want. We want to honor your time to be able to extract the most relevant information as quickly as possible, but also allow for that greater expansion.

DrRA:

The case studies themselves are also really trying to illustrate to the detail necessary what is being implemented – and not being either too vague or esoteric in that and applying the clinical hierarchies as we use them. So, if anyone isn’t currently a subscriber, we’re continuing to make efforts to make this content as readily accessible as possible. It’s been demonstrated now – based on all three of us (Gavin, Scott and myself) – we take those case studies, take that information, and apply that literally the next week on a patient. You can start to see benefits. I don’t want to feel like I’m overselling or overstating. It’s just that’s what has happened here.

DrMR:

We’re passionate about giving people an alternative to potentially biased educational sources. I really do mean that. It took me years of being quite unsure about the adrenal tests and the food allergy tests. I remember this crappy internal feeling like “I want to help this person. My whole purpose for being here and going through the God-awful process of 8+ years of school is to help people. I’m here for the right reasons, but, what I’m doing doesn’t feel right to me.” It was such a conundrum. So, yes, I think we’re all really passionate about preventing doctors and clinicians from that same fate and giving them something that now has a degree of proven external validation by five to seven clinicians; something that can help people and that can stop them from floundering, get them well, and allow them to spend less money. I understand where you’re coming from, Robert. We don’t want to be overly self-promotional – we’re trying to balance that against the fact that we’re just so passionate about sharing. Admittedly, sometimes it is a challenging balance to strike.

DrSS:

I think there’s a difference between having a skillset and then just having knowledge. Going back to that mechanistic data, you can have all the knowledge in the world, but you have to be able to translate that into a usable skillset. That skillset is what allows you to help a patient get from where they are now to feeling a lot better. I think it’s reading these case studies and learning, listening to the podcast, and reading the book. I’m literally not trying to sell those things. Those are the things that have helped me tremendously. I’m just being genuine about that. Those things have been so helpful. That’s how you gain the skillset. You can go to all these webinars and courses and learn all this information, but if it doesn’t have clinical utility in terms of improving patient outcomes then it was just a lot of money spent for education. Education doesn’t necessarily mean you can translate that into getting somebody better. Gavin said this earlier – by being part of the newsletter, you get to literally see where the patient is, their symptoms, where they started, the interpretation of the doctor, what labs they did, and what the doctor did with that information. You see the actual end result. You can just feel confident in knowing that this model is going to work for most people. I’m part of the group that subscribed just for the confidence of knowing how to treat people and to do it in a cost-effective and quick fashion.

DrMR:

Great point, Scott. There’s another visual that paints into my mind that I just want to try to share with people – we need this common model to work patients through because it allows clinicians a number of benefits. One of those is to learn what normal response to treatment looks like. Consider, if you will, from the top down, there’s this common pathway. The further down you go – or the further you draw that line down – it starts to branch and cascade outward. That’s a way of visually representing the thought flow. We want to start people through this common initial pathway of diet, which always isn’t so easy, right? We say it quickly, but there’s a handful of diets you want to navigate through and get that dialed in. Lifestyle, including sleep, can be a big mess for some people.

DrMR:

The first few starting points of the gut algorithm are very similar for most people – probiotic triple therapy, namely. What ends up happening is a lot of symptoms drop off and there’s fewer symptoms left. That helps you determine with that broadening of the line and cascades. It helps you say, for example – now that we’ve gotten through the initial couple steps and we’re seeing this branching array of decision trees we can navigate left or right to, we’re just seeing GERD. So maybe that’s an HCL issue. Or now we’re just seeing worry about relapsing and an inability to move forward and enjoy themselves. Maybe now we’re thinking limbic retraining. Or maybe there’s some symptoms that have improved, but there’s still fatigue. There were a number of flags from the intake process that this person might have sleep disordered breathing. So, now we go there. That’s kind of what this looks like.

DrMR:

So it makes clinical practice actually simpler. This is so poetic, it’s almost hard to believe. Practice becomes simplified for the clinician and also more expeditious to improve for the patient. Wrap your head around that – it becomes easier for the clinician and faster to get the patient results. We’re juxtaposing that to “here’s a whole bunch of tests – figure it out, good luck.” Right? That’s the other model that both Scott and Gavin have been alluding to. There’s all this stuff, but no system of organization. So, I’ll just toss it out there. I hope I’m painting a visual in people’s minds that helps them wrap their mind around this. There’s my best attempt.

GG:

I’ll just say one quick thing. Conventional medicine has one thing really right. They have a model, right? You go onto uptodate.com – I think we’re all familiar with that – and it’s a way for studies to get filtered into a model. Clinicians can go and get a quick summary on a given topic. Conventional medicine has a model. One thing that I’ve been fortunate enough to contribute with the FFMR Plus, filtering out the most practical and relevant studies, is we’re holding this model, we’re convicted about this model, but we’re holding it loosely enough that it can alter and change according to the latest evidence. One thing that we’ve all been working on as part of the clinical team is utilizing the most up-to-date literature and then fine tuning this model so that it’s more simple and practical. We have this model, we hold it loosely enough to fine tune it according to the latest evidence, and I think that’s really going to set us apart in our practices and patient outcomes, as well.

Episode Wrap-Up

DrMR:

Well said. All these roads lead to the same place and a lot of these things hold hands with another. We care about being up to date on the science. We care about updating our clinical model. We care about listening to the patient and using their feedback to further refine the model. They really reinforce one another in a synergistic fashion, which is fantastic. I think we picked through this fairly well. Does anyone have any pressing closing thoughts they’d like to offer?

DrRA:

I want to be a source of encouragement for all the clinicians listening to show you that you can be very efficient and grow as a clinician by learning from your patients and by spending very dedicated time with the best material to help you evolve – like the FFMR. It’s easy to look at the latest new thing or training and with our novelty bias, be thinking I need to be doing all of these things. I don’t have enough time. How can I become a better clinician? When in reality, you can evolve your clinical practice by really, truly using your patients as your teachers and having a dedicated practice of reviewing other’s case studies through this treatment algorithm and the research studies that Gavin was discussing. You really can become a better clinician.

DrRA:

A sign to me of someone becoming a better clinician is actually going against what would be the natural progression with entropy in this space – more time means more exposure to more supplements, more labs, more everything. There are new things to be exposed to. With entropy, you could very easily feel you need to be doing more testing, more supplements, etc., but a sign of a good clinician and a learning clinician is someone who continues to get positive outcomes by using less. This is something we’ve observed and we practice collectively – getting people results more quickly, with less testing, and overall less supplementation. I’ve almost turned it into a competitive drive. I want to see how well I can get this patient with as little treatment and testing as possible.

DrRA:

It surprises me over and over again how much people can improve with fairly minimalistic treatments. I just want to be an encourager to the clinicians. There’s so much – In training, you need CME, I have to get all these hours, I need to see these number of patients to get this accreditation. All that is nonsense. If you really put your time into practice and explore resources like the FFMR, you can really evolve your practice. One way to gauge that is – can you get patients better with less testing and less supplementation in less time?

DrMR:

Well, I think that’s a good final word to let people sit with and ponder. I fully agree that if you’re getting better over time, you should be getting results with less labs, less supplement, and less dietary changes. You should feel that what you’re doing is resonating progressively with patients. I think that’s a good self audit for all of the healthcare providers to do – and for the patients or the public if you’re working with any healthcare provider to think about. Does that resonate with you in terms of how you feel you’re being treated? As a reminder for everyone, if it’s not super obvious yet, we’re putting a lot of work into the FFMR – not just as a newsletter, but as a progressively growing database, so that it’s easier for us to practice a more cost-effective, science-based, and patient centered model.

DrMR:

Robert – I’m super appreciative of all the work you and I have done together and the friendship that we’ve been working on since 2015; Gavin – for all the hard work you and I have done behind the scenes working on the FFMR Plus and making it much easier for people to stay current with the literature; Scott – for your patronage of the podcast, website, FFMR, and reading of the book.

DrMR:

This is all just so reassuring and validating for me. I just want to thank you guys and thank our audience for following the work. Hopefully we can all continue to work and grow together so that we can all be healthy, be happy, and have the lives we want to have. So, thank you guys again so much and to our audience – we will talk to you soon.

Outro:

Thank you for listening to Dr. Ruscio Radio today. Check us out on iTunes and leave a review. Visit drruscio.com to ask a question for an upcoming podcast, post comments for today’s show, and sign up to receive weekly updates.

• Athletic Greens
• Dr. Ruscio Resources
• Future of Functional Medicine Review