An Inside Look Into a Day in My Functional Medicine Practice with Medical Student Robert Abbott

Topics:
Episode Intro … 0:42
Practicing Functional/Traditional Medicine … 00:01:43
The Patient Interview … 00:05:37
Functional Medicine as a Vertical Structure … 00:10:50
Asking Simple Questions … 00:15:50
Responsible Testing-Procedures … 00:18:30
Falling Into Wrongful Testing … 00:22:15
Avoiding Dogmatic Protocols … 00:27:54
Utilizing Therapeutic Trials … 00:31:25
Testing To Lead to Treatments … 00:35:00
Specialization in Functional Medicine… 00:45:41
Keep Patients Moving Forward … 00:50:20
Episode Wrap Up … 00:55:50

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Links:

1. Mindful Medical Student Blog
2. A Week of Compassion

Episode Intro

Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. Today, we’re going to be talking with Rob Abbott who just completed actually his fourth year of medical school and recently came by and spent a day at the office. And he made a number of comments to me about some of the stuff that he learned.

So I thought it would be interesting to have him on and discuss some of what he learned to give a unique perspective as a medical student about to go into medical residency and someone who is also studying functional medicine. So I thought it would be interesting to get some of his input and insight. So, Rob, welcome to the show.

Rob Abbott: Hey, thanks. It’s really actually pretty awesome to be on here, having followed you for quite a while. It’s certainly an honor to get a chance to not only work with you and to share some these ideas coming from I’d say a different perspective within the traditional medical paradigm but trying to blend in the functional with traditional medicine. So it’s good to be on here.

Practicing Functional/Traditional Medicine

DrMR: It’s great to have you. And just like you said, I like the perspective that you bring to the table because you’re just completing medical school, about to go into residency. And you’ve also been studying functional medicine. Sometimes, we have someone come to the office who is newer to functional medicine. And they’re just trying to get an idea as to what it looks like.

But you’re a bit more experienced with functional medicine. And so you’re in a nice position to be able to compare and contrast functional medicine education, traditional medical education, and compare and contrast that with what you’ve seen at the office.

And so yeah, why don’t we jump into the dialogue here, I guess, with some of the big picture things that struck you. And then we can go into some of the details.

Rob: Yeah. Well, first of all, I was really blown away with just the therapeutic environment of your office. I think we’ve all in the functional medicine sphere gotten a little overwhelmed and pushed towards the really small micro practice, super-efficient, maybe running my practice from home, renting a space and not necessarily putting that much effort into creating this really therapeutic environment.

And the first second I stepped in, just walking around, you knew you were in a medical environment, a medical clinic. But it was simply bathed in green plants, very calm. You have beautiful scenery out your windows and just a very therapeutic space. There were posters on the wall with some of the more traditional medical anatomy and physiology that you might see in a traditional clinic.

So that was just something that I really resonated with because I think there is something to be said about creating a truly therapeutic space and not just conducting medicine simply through a computer and through an interface that can be a little artificial.

DrMR: I agree. And I think it’s one of the things that I understand, trying to make things, of course, more cost effective and more efficient. And part of the way that we can do that is by cutting down on overhead. I get that. But if you’re never actually sitting across from a patient and all of your consults are being done remotely, I have a little bit of trepidation toward that.

And so, yes, for me it was always important to maintain a physical office. Many of our patients who are nearby, only, say, 20 minutes away, still prefer to do maybe even half of their follow ups remotely. But it’s always nice, at least in my opinion, to have a physical office where you can actually see people and keep that face-to-face connection going.

Rob: Yeah, I agree. And I think that ties into another point which I really liked. You gave the patient flexibility about what really worked best for them. So on one hand, yes, you said, “Look, for this initial consult when I’m coming to see you, I need you to be here at the office.” But for follow ups, for check-ins as we’re progressing through treatment, really giving the patient some flexibility. “Can I just do this over Skype? Can it be at home?”

Even for patients, like you said, who were 15, 20 minutes away who realistically could come to the office, at least give them that choice on this. Give a day. “If it’s really stressful, let’s do our follow up over the phone.” But set what your expectations are for the patient. And so they get a really good idea of that balance between personal contact and work with you through Skype or over the phone.

DrMR: Definitely. Definitely. Now, gosh, there are so many directions I want to go. And you sent over a list of different things that you wanted to talk about. I want to try to give us some structure because I know that we’ll gab like two schoolgirls for hours here without some structure.

Rob: Yeah, totally.

The Patient Interview: Focus & Effectiveness

DrMR: One of the notes that you sent over was the patient interview or the patient history process can be focused and still remain effective. And you sent over some notes that sometimes in functional medicine training we recommend 75 minutes to 90 minutes for an initial intake.

And mine was quite a bit shorter compared to that. But I think we still retain quite a high level of effectiveness. So tell me, or us, a little bit more about what you took away from that.

Rob: Yes, so realistically so far, I’ve been able to take part in some formal functional medicine training, IFMCP. And the really big message that they’re pushing there is, “Let’s engage in this therapeutic story telling. And let’s give a space, whether that be 90 minutes or even 2 hours, to let the patient really let themselves meet you where they’re at.”

And I think that’s wonderful. But in the realistic setting of the clinic, it can be really hard to tease out what are the most essential things to developing a treatment plan if you’re really just sitting back and trying to look at a global picture.

And so I think you have a very focused intake and have a very deliberate period of time prior to seeing the patient where you are really highlighting on the areas that you think are going to have the greatest utility in terms of your focus with questions.

And most of that is built around a broad differential which we’ll probably get into a little bit. But you really go in with a broad idea but a clear idea of what you want to gain from this encounter.

But also at the same time, you really leave the space when you enter the room to allow the patient to tell their story. And we talk quite a bit about this. We have a deficiency in our society of the safe space to share what’s been happening in our lives. And sometimes when people finally find that, they just want deluge everything. And it can be a little overwhelming.

But I think you have found a really good balance of allowing people to have that therapeutic storytelling but not be completely removed from the context of what you’re hoping to gain in terms of developing a treatment plan going forward.

DrMR: Yeah, and I, of course, agree with that because I set my clinic up in that way. And one of the things that I’ve learned exactly as you said is people need to get some stuff out. They need to feel heard.

Rob: Exactly.

DrMR: And I totally get that. But let’s say there are ten different areas that we can delve into—their childhood, their stress levels, their exercise, their diet, their gastrointestinal symptoms, their neurological symptoms, any skin symptoms they have or hormone symptoms.

So if we go into a detailed narrative, “Tell me all of your story for every one of those areas,” we can be in the initial exam for an hour and 45 minutes. And that’s not great for the patient because what that will do is it will drive a longer visit but a high priced visit.

Rob: Right.

DrMR: And a lot of information, a lot of that detailed information isn’t really needed. So I review the paperwork before we go into the exam. And if you have well-designed paperwork, you can pretty easily see the key areas you need to hone in on.

And that’s where I focus. That’s where we get the expanded narrative. That’s where I ask clarifying questions. So we allow the patient to tell their story. But we guide them to the areas where we need the most storytelling. And we guide them away from the areas where the storytelling is the least relevant.

And that really does give you a shorter exam that allows you to get the information that you need more quickly but also gives the patient the ability to feel heard, yeah.

Rob: Yeah, it’s one area that functional medicine is certainly doing very well and giving credence to—that space to tell your story. But we have to be able to find that balance of really putting forth an effort to really hone in on the areas, like you just said. If you pick up something on the intake and you’re like, “Hey, I do want to know a little bit more about that,” you can at least guide your interview in that direction rather than just simply walking in and being like, “Tell me what happened when—let’s just start when you were 5.”

And you really don’t know what you’re necessarily going to get if you just kind of come in there with that really general mindset.

And it’s not about one way being right or wrong. It’s just how can we be a little bit more directed and truly helpful for the patient because in the end, they’re the one coming to seek our guidance, our resources. And we can only provide for them our resources if we target it into an area that’s more productive.

DrMR: And it’s like I’ve said many times before. More testing doesn’t equal better results. And I think this falls into that same sort of philosophical line of thinking which is more question asking doesn’t guarantee better results. But the right question asking is what’s going to get you better results.

Functional Medicine as a Vertical Structure

And this dovetails into another area that I think you said this really well actually. You commented something along the lines of much of what regular—I guess we could say, regular—functional medicine teaches is this horizontal model where you’re looking at all these different systems and trying to tackle everything horizontally right in front of you at the same time.

Rob: Yeah.

DrMR: And I try to organize things more vertically, meaning instead of trying to tackle all ten systems at once, let’s organize this into a vertical hierarchy and start with the top three. But tell us a little bit more about what you took away in that regard.

Rob: Yeah. Well, I can certainly tell you this past September being in Baltimore for that AFMCP there were some people there who were really just getting into functional medicine for the first time. And some of the looks and just the glazed over eyes, and people were like, “Where do I even begin?”

DrMR: Right.

Rob: And I think when you see things as equally important across the spectrum like treating chronic mold versus chronic viral infections or other heavy metal toxicity, and, oh, they have to fix their gut. And it becomes this, well, they must all be equally as important. I have to do something in each of these areas. And therefore, I’ve got to research and provide a protocol. And it can be extremely overwhelming. And so I think we do have to break down.

And it’s important to see the interconnectedness of all the systems. It’s beautiful to understand how energy is related to structural integrity and these things. But you have to give yourself a reasonable place to start in terms of a treatment plan.

And so the vertical structure is a way to at least prioritize things that from a clinical standpoint seem to be giving you the most utility with your patients.

And so for you, I think you’ve dug into the GI side of things and thyroid, really being areas where you’ve seen great clinical benefit in your patients. And I agree as well. We can put lifestyle medicine at the top. If someone comes to you and they’re sleeping five hours a night and their diet is just pretty much full of processed foods and they have some really damaging relationships and the lifestyle piece, if it’s really a mess, those are the things I would probably prioritize working on first.

And yes, they might have heavy metal toxicity that if you treated simultaneously it could get better. But we have to start from a better foundation lifestyle-wise.

And then digging in with the GI dysfunction, I think, is a very reasonable place to start. And let’s turn over as many stones with healing your gut, getting some proper digestion so you’re getting the nutrients that you’re actually eating and see how much benefit that gets.

That being said, we can’t expect everyone to get 100% better from the best GI protocol or really going through that process. But it’s a great way to start with many patients. And so that’s where the vertical structure can at least give you some breathing space to say, “Okay. I don’t need to address this right now. I can come back to it. It’s still there. I’m acknowledging it. But I have at least a priority of where I can start first.”

DrMR: Absolutely. And we talked about this in [previous] podcasts about finding a good functional medicine provider. And it comes down to that same concept of not doing everything at once, which really makes it more enjoyable, I think, both on the doctor and on the patient end of things, because as the doctor you’re not asking the patient to do as much testing or as much treatment, and as the patient, you’re not having to pay for as much testing and undergo as much treatment.

It’s not that you wouldn’t potentially have to treat all the different systems that you’re thinking about. It’s just let’s try to organize this into a hierarchy so that, let’s say, when addressing problems in systems one through three, the other symptoms or dysfunctions that we thought were in systems four, five, and six actually go away. So now we’ve saved the need to go into all that.

Rob: Correct, yeah. And I think it’s another way as well to, rather than keep things completely horizontal, when you address things vertically, you have a history of what you’ve done. And like you just said, you can see something you initially thought was maybe in system four, five, or six was actually in system one, two, or three when you address those.

So those things that you thought may have been the highest yield, let’s target this, when you really get down to it and treat some of the lifestyle and maybe GI areas, it becomes, “Oh, actually, that was really related to this parasite or to some SIBO.”

And it’s a very good way to maintain a structure and then look back too to see what you’ve down with the patient as you progress with their treatment.

Asking Simple Questions

DrMR: And this leads into another comment that you had made, which is asking simple questions that mean a lot to the patient. And I guess in that same line is just listening for simple answers like, do we treat their SIBO and see response? And if we do, great. And if we don’t, I don’t necessarily make the SIBO treatment much more complicated. But I start thinking that there’s something else besides SIBO that we might want to tackle.

But coming back to simple questions that mean a lot to the patient, were there some specifics that kind of struck you in that area?

Rob: Yeah, so I really loved—I think it was probably at the top of your intake—but the idea of asking the patient, how aggressive or conservative do you want to be with treatment? And that really can give you as a clinician a great idea of what it is that you might engage with in this patient.

In a lot of cases, we’ve seen people who have been kind of harmed by alternative care or functional medicine providers. And they come in. And they can be a little desperate and want to be really aggressive. You might have to balance that. But you can get a really good idea about how intensive your testing is going to be, how comprehensive a treatment protocol might be.

If they come in and say, “Yeah, I’m gung-ho. I’m ready to be aggressive. I’m on board. I have my resources ready to go.” Or if someone comes in and says, “I just kind of want to focus on one thing right now. I’ve got a lot on my plate. Let’s be a little more conservative. What’s your highest yield treatment idea for this case for me?”

And I think it takes a lot of onus off the clinician to simply think every time they see a SIBO patient, “I have to do this protocol, or I’m not actually giving my due diligence to this individual. And it just speaks to the personalization of treatment and meeting people where they are as they come.

Another analogy I really liked from one my colleagues that was related to weight loss was everyone seems to come into your clinic, “Yeah, I just want to lose that next 5, 10, or 20 pounds.” And you dig into their history. And you realize their body is in this stress overload state. And it’s basically sending signals saying, “Right now is not the time to lose weight.” And so we need to be a little more conservative. Let’s build you back up before we go on a more aggressive treatment.

And so I think it’s important to keep that in mind when you’re doing an intake with a patient. What are their symptoms telling you? How many areas of dysfunction do there appear to be? And actually, is being more aggressive when their body is sending a lot of negative signals or signs of dysfunction—we might need to balance how much we throw back into that mix. But that was one of the huge areas that I just really resonated with.

Responsible Testing-Procedures / Not Overwhelming Patients

DrMR: Yeah, it’s very important to meet the person where they’re at because if you give them more than they can handle, they’re not going to do it. And these are the patients that sometimes you never see or hear from again because they go home. They try to get started. And they feel so overwhelmed that they just can’t even start. And they say, “Screw it.” And they don’t do anything.

And that really does the patient a great disservice because instead of getting 30% of the help that they could get—100% would be the most robust program you could give them. But they can’t do that. So you give them a curtailed program at 30%. So instead of getting the 30% with giving them a curtailed program, you give them the 100% program. And they do 0% of that potential 100. And they’re not going anywhere.

So definitely, listening to someone, getting a sense for where they are with some simple questions like, “Do you want to be aggressive or conservative with your treatment?” can really help.

By the other side of the coin, though, if someone says, “I want to be aggressive,” I’m still a bit bridled in my enthusiasm. It doesn’t mean that, “Hey, here’s my chance to order any test I’m academically considering just because this person is giving me the green light.” You still have to, I think, be responsible with how you allocate testing and use funds and use treatments even if someone is aggressive.

And I think it’s unfortunate that, I think more often than not, some of the patients that are really desperate get taken advantage of. And we also talked about this in that last podcast about finding a good functional medicine doctor where people say, “I’m ready to do anything. I’m ready to do as much testing to get better” as if more testing would mean they would get better more quickly.

And it’s important as a clinician not to fall into that and to be responsible and focused with your testing, even if it’s more on the robust side, not to go over that edge into being excessive or wasteful.

Rob: Exactly. And I was just having this kind of discussion as well with testing. And in the traditional system, patients come in. And there’s a lot of misinformation about what is the true role of testing. And what is diagnostic testing even telling us. And I think a lot of patients assume that all the tests that we’re doing—and this is a broad generalization—but they immediately come back with an answer that is either sick or not sick.

And the unfortunate thing is these tests are not saying “sick” and “not sick.” A lot of times, they could be, “What’s the level of this enzyme in the body?” And then we through the study of physiology and anatomy and the human body understand, “Well, maybe in a state where this enzyme is elevated, we interpret that to be a sign of dysfunction in this organ system.”

But it’s not like this test is saying, “Yes, something is wrong. Or something is okay.” It’s not that black and white.

So we have to do due diligence as clinicians to educate patients about what is this testing actually—what can it actually provide you in terms of information that can guide our treatment? It’s not going to say, “Red light—here’s a major issue. Green light.” It’s just not that clear cut.

And we really need to be, like I said, diligent about how we allocate resources and what the expectations are from this testing. We could get into some of the statistics behind testing and positive predictive value and these things. But I think the bigger picture is just realizing the true utility of this test or different types of tests and making sure the patient understands what can actually be gained in terms of information from such tests.

Falling Into Wrongful Testing

DrMR: And I’ll give a little, I guess, teaser for a future podcast episode where a fairly commonly used functional medicine lab just pled guilty to fictitious lab ranges and erroneous claims behind their lab testing. And their partner supplement company that provided treatment recommendations for said lab ranges also pled guilty to essential fictitious treatment claims and other shady doings behind the scenes.

And so we’re going to do a review of that. That’s coming soon. And if you stick to some of these principles that Robert and I are discussing, you can really prevent yourself from falling into some of these things because you’re a little bit more practical and tempered in your approach. And you’re not looking at a test as this end-all, be-all, but rather a piece of information to help you with the overall treatment process.

And we’re going to come to a point later that I think reinforces this. But as long as you’re reflecting and thinking back on these things, eventually you’ll start noticing the tests that seem to have the least clinical impact and start weeding out those tests.

And it’s not unforeseen or unexpected that some of these tests are tests that I’ve never really endorsed and I’ve never really found utility in. And this is the third test, actually, over the past three years that has later reported some sort of error or had litigation brought against it. And it’s not that I have a crystal ball.

But it’s when you’re not looking at these tests swept up in the dogma and not thinking, when you’re looking at these tests more practically, you can see through some of the spin and some of the fanfare and some of the marketing and see through to what it actually offers. And it’s usually the tests that offer the least that end up being the ones that are disproven or shown to be erroneous or illegal, for that matter.

Rob: Yeah. And this is a little bit tangential. And we had talked about it when I was in your office. And I think it relates really well to this. It’s easy for people in functional medicine to want to disregard or speak negatively of traditional medicine. And I’ve come across a couple different conferences and settings with clinicians quoting some statistics from some of these major academic journals—New England Journal of Medicine and JAMA. And the percentage of published research which is later found, 10, 15 years, to be erroneous, to be false. And I’ve heard statistics from anywhere around 50% to even 60, 70% of that published research.

And like I was telling you, of the research that is being done within functional medicine but just more broadly in terms of our approach in functional medicine, who is to think that we aren’t going to fall into that same category? That maybe 10, 15 years from now, 50 to 70% of what we’ve done is going to be proven to be completely erroneous with no clinical utility.

So thinking that we are somehow isolated in a bubble from that effect in a field where rigorous research is being done to protect patients I think would be a little bit naïve. And this is a perfect example, I think, like you’re saying, of these tests and vetting out these companies who might have biases or involvement with some of the diagnostic testing. And I think we’ve just got to keep that in mind as clinicians, as healers.

So I’m actually really interested to hear about this in this podcast.

DrMR: Yeah, I figured you would be. Yeah, that’ll be out hopefully within the next few weeks. But absolutely. I think our field is just as amenable to that, maybe even more in some regards because—well, I won’t go into the reasons why. But I think we’re equally as amenable if not maybe even more amenable in some regards.

And so we have to be careful as a practitioner because it’s our job to be able to evaluate the information and as a healthcare consumer. And this is something that I lay some very simple rules for you to follow as a healthcare consumer, ways that you can evaluate the healthcare claims that you’re reading and try to simply figure out if these things are more likely to be helpful or more likely to be marketing spin made to look like science, because it is important that we’re able to do this and especially for the clinicians.

A lot of the science that is brought to us is oftentimes brought to us by the nutraceutical company rep or the lab company rep. And we have to be able to be discerning in looking at that data and telling, “Is this information truly information that can be clinically useful? Or does this look more like marketing spin?”

And we’ve done a few product reviews. And I’ve been thinking about doing product reviews. But one of the challenges is that a lot of the new products that we review are built upon such sparse science. And there’s so much spin where I don’t even know if I want to put that bulls-eye on my back in starting to irritate all these nutraceutical companies.

My grandmother used to say, “A word unsaid is a word you never have to take back.” So I’m wrestling with this right now. And either we’ll start doing it. Or you can just look at what I recommend. And anything that I don’t recommend you can assume is probably something that’s not that great.

Avoiding Dogmatic Protocols

So anyway, moving us along without getting too far into that quicksand—you had made another comment about avoiding dogmatic protocols. And I think most of the people listening have heard me speak about this in some regard. But what were the things that you took away in that context?

Rob: Yeah, so you have, like you said, spoken quite a bit about the difference between process and protocols. And I think, getting back to the way that you structured evaluating the patient and making a broad differential and different areas where you could—

DrMR: Interrupt. Let’s back up for one second just for the people who aren’t clinicians. A differential is just a list of things that you suspect to be wrong. So you see the doctor. You tell them a bunch of information. And in their head, they’re thinking this might be SIBO. It might be more traditional IBS. It might be hypothyroid. It might be heavy metal toxicity. So that’s a differential. It’s like a problem list.

Rob: Correct. Correct, yeah. Thanks for backing up and giving that wider view. And I guess that’s something too that even in functional medicine people are trying to do away with the differential. I honestly think it’s something that does have a really good utility, biased from my traditional medicine training.

I say we don’t need to have that be the huge focus and still keeping the interconnections of systems. But it is a great place to organize ideas and to see realistically where you can help a patient. And I really liked how, in terms of following a patient—so I got to see a couple follow ups and how you systematically were tracking certain interventions and treatment plans and seeing what utility you got from this area. “Let’s try something more in the HPA axis or target the adrenals.” Or maybe, “Hey, the thyroid we haven’t quite tweaked as well.”

But it just was so much broader than focusing on just setting someone up as soon as you’re pigeon holing or seeing a pattern of SIBO saying, “This is the protocol that I need to give this patient in order to get any results.”

And it’s something that, yes, pattern recognition is certainly a skill as you’re developing as a clinician that I see in my training. It is very well espoused. It’s something to utilize in being an efficient clinician. But you can’t let that, like I said, pigeon hole you to be stuck in one paradigm or one protocol.

And so I think if you come from a place of dedicating yourself to the process rather than be attached to a protocol, you can save yourself and can be free of getting stuck in some of those traps.

DrMR: And something else I think as you’re saying that, or why that can be important, is because if you’re thinking about the process and less about the protocol, it frees you from getting trapped into this pigeon hole thinking, like you said, where we found SIBO. And it must be SIBO.

And so we’re going to keep treating SIBO instead of thinking about this from the perspective of, “This SIBO test was positive. But we’ve treated SIBO. We’ve tried a different approach of treating SIBO. Now, perhaps, we need to start thinking differently and change our process. Rather than going after SIBO with protocol and protocol and protocol and protocol and being stuck in that tunnel, let’s try reconfiguring our process. And I think that really frees people and prevents them from getting stuck in one line of thinking.

Utilizing Therapeutic Trials

And this is kind of a nice transition to one of the other comments you had made to me which was learning a lot without testing and utilizing therapeutic trials which I have been coming to utilize more with every passing few months in the clinic, utilizing a trial of a treatment to reinforce its utility rather than needing a lot of lab testing to reinforce that. So what would you comment on that regard?

Rob: Yeah, I think, to be honest, from many of the clinicians I work with across traditional to functional spheres, your approach of, “Let me see how much information.” We go back to testing. Testing is just one piece of information or a few pieces of information. And these therapeutic trials can be actually oftentimes much more helpful information than some of the tests.

And so we saw an initial consult. And the way you structured some of the treatment was focusing on, “Hey, maybe we can do a modified fast.” So you had them do the two to three day period of some bone broths or a lemonade recipe. And you really focused and asked the patient, “Let me know how you felt during that period. And give me insight into, ‘Was it challenging for you?’ Was this something that improved your cognition?’” And really telling the patient, “Hey, this could give us some information” and then supporting them through that.

Also you really focus on using a specific dietary plan. Depending on what they came in doing, it may be that you would give them the recommendation for low FODMAP. Or let’s do something more just paleo-esque, maybe an autoimmune paleo if they have some autoimmune concerns. And do that for two to three weeks.

And then even on top of that, you even got me to try in the office one of the new elemental formulas. And I was like, “Are you serious, man?” From everything that I’ve heard you talk about on your podcasts and even from Dr. Siebecker, this stuff seems like it tastes like dirty, rotten socks.

So you had to give me some convincing that it was actually pretty tasty. So of course, I give it a shot. And I was actually very impressed. It was more than tolerable. I could certainly see myself drinking that and then recommending it to patients and so asking patients if they would be willing to do a period of an elemental diet. And all of this can be done structured in a four-to-six week period following that initial consult so that when you come back—and you have informed the patient, “These are the things I would like you to do,” you can really gather quite a lot of information about what was helpful. How were they on, say, the low FODMAP diet, their specific dietary plan? How did you do on the elemental? What about the modified fast?

And you’ve really dug into things in a lot of different areas that you can come back to depending on the patient’s results. And I just found that to be refreshing because none of it had to do with testing. It was really freedom. So you gave people the instructions. But it wasn’t so strict that it was like a military protocol, but just giving them the flexibility to try these things and cultivate an awareness for the patient themselves of what may have made them feel better. And I really resonated with that approach.

Testing To Lead to Treatments

DrMR: Yeah. Well, one of the things I think of there is if a test is meant to lead, in many cases, to a treatment, then why not just start with the treatment.

Rob: Yeah.

DrMR: And one of the reasons for this is a lot of the tests that we think lead to treatments haven’t actually even been shown with any clinical data to show that that treatment is justified. And I think one of the areas clinicians make the most oversights is looking at stool testing, looking at cultures of healthy commensals, and recommending probiotics based upon that.

I don’t think I’ve read one study—there might be one or two or three out there looking at stool tests’ ability to predict response to probiotics, meaning how much Lactobacillus acidophilus do you have on stool culture? And looking at that as a way of predicting your response to a Lactobacillus acidophilus probiotic. There might be one or two out there. I don’t think I’ve seen any of those guys.

So to think that because you come up low with Bifidobacterium infantis on a stool test that you’re going to respond to that hasn’t been shown.

Rob: Yeah.

DrMR: And so to waste money on testing to just go back and try the probiotic that you’re going to try anyway isn’t super helpful. And we can even make some of the same criticism for SIBO testing. Now that we’re just starting to look at SIBO testing and how that predicts responsiveness to antibiotic and anti-microbial treatment, the results haven’t been super definitive.

And they certainly have not been very detailed, meaning we don’t get this highly specific take away from a “what this means in terms of treatment perspective.” What we do see are some broad strokes that are probably pretty simple to gather on your own anyway which are the more severe the level of SIBO, potentially the more rounds of treatment someone is going to need. But there are not these highly specific takeaways that we can extract.

And something like the low FODMAP diet, which has been well studied, doesn’t really have a lab test finding, per se, that coincides with it but rather the symptoms of IBS that show it can be helpful.

But then there are also people with IBS who I see go on the low FODMAP who feel worse. And it’s actually autoimmune paleo that works better for them.

So I try to look at the testing in a context of, “If I really need this testing to steer treatment, it’s going to be necessary.” I think a great example of this is determining if someone is hypothyroid or not.

And I mean true hypothyroidism because, as we’ve reviewed in a prior podcast the data on treating subclinical hypothyroid, meaning you have high TSH but normal T4, doesn’t show a ton of benefit except for a few small exceptions. But when looking to see if someone is truly hypothyroid, that can be very helpful.

But looking at the meticulous ratios of metabolites of thyroid hormone, in my opinion, there’s very little treatment data for that. In fact, you’re probably better off if you’re on thyroid hormone and you’re not able to respond, if you’ve been trying a T4 formula, try a T4 with T3 combination.

And if you’ve done that, investigate sources of inflammation or stress in the body that could be throwing off your conversion. And if that doesn’t work, something else you could try is potential Tyrosine which is a liquid T3, comes in a gel capsule, which has been shown to help stabilize dosing in TSH levels in those who haven’t been able to achieve a solid dose or control of their TSH levels.

So some of the most impactful things from a thyroid perspective don’t require anything more than a basic thyroid evaluation.

Now, I can hear the patient at home listening to this saying, “But everything I’ve heard from all the thyroid gurus tells me that because I’m sick I need this really comprehensive thyroid panel.” And the truth is you really don’t.

What you need to do is figure out what it is that’s causing problems with your body’s ability to metabolize thyroid hormone or why your dose of thyroid hormone isn’t able to be stable. Looking at these meticulous ratios doesn’t tell you anything about how to treat the underlying cause of the problem.

So it’s tempting to fall into this “more testing will allow me better treatment” until you start thinking about, “Is this testing necessary to get me to said treatment?” And oftentimes when we think about it from that perspective, it’s not.

Rob: Yeah. Beautifully said. And I think that’s actually a really good point to point out with thyroid testing because in the traditional medicine sphere, that’s certainly an area that is very well accepted. “Hey, we can test thyroid hormones.” And even, people are becoming more amenable to some of the other metabolites, reverse T3, these kinds of things.

But the reality is some of that can just be information grabbing from the clinician’s standpoint. And realistically, you can do a lot more for someone, getting some of just the basic thyroid labs and giving a treatment protocol and focusing on how they feel.

I didn’t want to back up too much. But it totally was ringing in my head when you were talking about some of these stool testings and whether they correlate with treatment. And let’s be perfectly honest. If we look at all of the literature—and there’s extensive literature about probiotics, about people’s responses with low FODMAP diets—guess what? None of those people in the majority of those tests are having stool tests done. They are just receiving probiotics.

DrMR: Exactly.

Rob: And generally speaking, they’re receiving probiotics that from a functional medicine clinician would say, “That’s not necessarily the therapeutic, nutraceutical-grade probiotic that I would recommend. So how helpful is it really being?”

And so from my looking at the literature, we can see there are some really beneficial areas for these probiotics. And the idea that you would need to do a stool test to then order specialize and pick a perfect probiotic which could then help this individual, we aren’t there yet. And for myself, perhaps that’s a place we will get 10, 20, 30 years from now, that specific of testing.

But realistically, I think, focus more on just a general ecosystem. And what’s the environment like? Is it supportive of beneficial microbiota? Is it beneficial of that flora?

And so yeah, to think that any of this stool testing, yes, they have certain utility. But I come back to it in the literature. And it astonishes me that we can think that we can really hone in and find something that’s going to be really specific for some of these tests in terms of probiotic treatments. And that’s that.

DrMR: Yeah, and the same thing goes for some of the most common adrenal supports. There is some very nice literature showing that they can help with energy, vigor, mood, stamina, endurance.

But virtually none of these trials—there is maybe an exception or two. But when you’re looking at a body of literature of 40 randomized control trials and you have two that violate this, that’s virtually none. None of these studies looked at adrenal testing before and then gave an adrenal support based upon test values.

So I think it’s important that all of us in functional medicine be okay with the fact that, “Hey, we’re doing some stuff that is excessive and not efficient.” And we need to not be offended by this news but rather look at this as opportunities where we can all get better, make this care more efficient which will be better for us because it will allow us as clinicians to help more patients and better for the patients because they can get the help that they need.

Rob: Correct. And I think one area that’s, for me, I’m very optimistic is in functional medicine, we are generally using nutraceuticals, more natural methods of treatment. So I like to think of things on a spectrum as risk-benefit. So how potentially risky is a certain treatment, whether it’s a nutraceutical, drug, what-have-you in terms of its adverse effects on the patient? And counter that with what are the potential benefits?

And so we are fairly lucky that if we stick with some of the natural treatments, the potential for really bad adverse effects is fairly low when you compare them with some pharmaceuticals.

And so the idea of needing to test to guide certain treatments is more of—if you were going to be prescribing a very specific drug with some really potentially negative side effects, yes that would be a situation where I would probably want to have as much information as possible before I go down that path.

But when it comes to some of the approaches, like you were outlining, what could we do with prebiotics? What could we do with probiotics? What could we do with herbal anti-microbial? What about what their dietary approach is going to be like? And then maybe an antibiotic such as rifaximin.

And if you stick to those areas, we can realistically give someone some therapies without having to have all the corollary testing beforehand. I honestly haven’t been working long enough in the clinic field to have that experience, to sort of see.

But my general understanding about these nutraceuticals and this approach is we can be fairly certain that we’re not going to be doing significant harm to people. Where the harm really comes in is by, yes, the financial burden of some of these elaborate protocols.

So saying that you need to do this treatment with six, seven things, we have to understand there’s a huge burden to treatment, whether that’s cost, time, energy. And so that’s where we need to be cognizant of our treatment approaches.

But like I said, I think we’re pretty blessed to have that. And for me, when it comes to some of the drugs, I’m very unbiased. I want to use the things that have the greatest utility. But I’ve got to keep it in that perspective of risk-benefit to the patient.

DrMR: I think that’s well said. And I think that maybe just to reiterate that—we test oftentimes before using a pharmaceutical to minimize harm. But in functional medicine, many of the agents that we’re going to use have little to no risk of harm. And if the testing doesn’t show us how to maximize effect, then it’s not really needed. In fact, it may even be detrimental if that testing creates a financial burden for the patient.

Rob: Exactly.

DrMR: So I agree. And that’s well said, Robert.

Specialization in Functional Medicine

And one of the final points I want to get your take on was specialization within functional medicine. And I’d also like to invite the audience listening to or reading this to chime in with your comments.

Something I think would be helpful for the functional medicine model and somewhere where I think functional medicine needs to go is towards specialization.

And this is because to become efficient, it’s very hard to be treating thyroid patients and gut patients and heavy metal patients and mold patients and Lyme patients and female hormone patients. It’s hard to be highly proficient in all these different areas.

And there is always going to be an aspect of generalization in functional medicine which is fine. But I think it is a good practice for us to have our main areas of focus so that we can gain the experience so as to become more efficient and more precise in what we’re doing.

And so I’d be curious for the audience to leave your comments in the comments section and also, of course, Robert, what your takeaways are in terms of specialization within functional medicine.

Rob: Yeah, so loved having this conversation with you in the clinic. And it’s another area where I think in the functional medicine sphere we have sent some negative language towards “the specialists in medicine” and that dissection of organ systems.

And I like to step back and say, “For anyone who’s taking a more holistic approach, we are so lucky because, guess what? Your toolkit of lifestyle medicine, you have that regardless of what the patient comes to you with.”

So I see myself. I want to be a super generalist on one hand. I want to be able to say for any patient that comes to me, “I can at least direct you at some direction that’s going to help you.” And a lot of that is going to come from optimizing certain aspects of your lifestyle. That, I’m going to have with me in my toolkit regardless of what kind of patient comes in.

And I think we forget that sometimes when we get locked into these treatment plans and protocols and some of the “sexy science,” I like to call it in functional medicine. And so I really see that as a blessing. And I would want to be able to provide any patients that come into my family medicine clinic with something.

With that being said, I can’t provide them everything. And one of my teacher’s actually in a yoga teacher training had this wonderful quote. And hopefully, I don’t butcher it. But he basically said, “Something is right for everyone. But everything is not right for someone.” And I think I did butcher it.

DrMR: Yeah, I get what you’re saying. Sure.

Rob: But the idea is that everything is not going to be right for the individual. But something will be right for everyone. And it’s our job to be able to try to see and identify what that something might be.

And so, yes, I want to have that broad scope. But realistically, I can be an expert on chronic mold and thyroid and GI and this. And it harkens to what you and Dr. Siebecker talk about. If I really want to get to know the nitty gritty behind SIBO, I want to just have that be my life for three, four, five, six, seven years and really dig into that.

And to be honest, I think we’ll reach a point where we have certain specialists, maybe even contained within one practice. Say you have three providers. And one of you is really the GI/thyroid guy. And one of you is the detox guy. And one of you is more chronic Lyme. And you can have this relationship where patients can be seen by each other because it’s not such an isolated system. “Well, I’m doctor. And it sticks with me.”

So that was potentially a little bit of a ramble. But I think we have to realize that we can’t do everything. But we do have something. And then cultivating those relationships with other clinicians, other providers who could help someone once we have really done our thorough job in our area of expertise.

Keep Patients Moving Forward / Referring Patients

DrMR: Exactly. And that last point I strongly agree with. And it’s something I do in the clinic and something that it’s one of the main points I always cover with my staff is make sure we always keep a patient moving forward, meaning let’s not let there be a bottleneck with insurance billing, with shipping them something, with a question.

Or even if they hit a roadblock in our clinic, meaning I don’t think I can help them anymore, we always have someone we can refer them to for the next step in our differential diagnosis. And I’ll often tell patients, “I think now would be a good time for a Lyme evaluation.”

And I’ll be very honest with them where, “I have some preliminary training in Lyme. I can offer you some testing. I can offer you some treatment. But I really think you’d be best served by working with someone who’s a specialist in this so you can have the most efficient care and the most experienced eyes looking at this. And then we’ll get them the referral to that person.

And I think it’s good for both the clinician and the patient. For the clinician, it’s not a very good feeling to feel like you’ve done everything you can do for someone but you’re still trying to do stuff that you don’t know that much about.

Rob: Yeah.

DrMR: It’s not a good feeling. And for the patient, it’s not a good feeling if you tell them, “I think you need a specialist in this area. Good luck.”

Rob: Yeah.

DrMR: It’s nice if you can have someone that you can refer them to because they look to you for your opinion. And they have a lot of trust in you as a provider. So having someone you can make that referral to, I think, can be very helpful.

Rob: Yeah, and I see this. It’s something that does kind of rear its ugly head in some of the academic structures of medicine. People get really stuck in some of the vertical hierarchy among these specialties. And you just establish these relationships specifically with certain individuals.

And I think we really have to honor and respect fellow clinicians training within a certain field. And I think if we start by being a human being first, being a friend first, cultivating the relationships, yes, being professional, but cultivating that relationship as a friend, you will quickly see the people who you want in your tribe, who you want in your community. And respect the work that they’ve done. And see their intentions to help others being in alignment with yours.

And I think a lot of times it can be inadvertent. But we can be quite disrespectful to specialists or others within our field and not acknowledge the effort and the work that they’ve put, for instance, in chronic Lyme and thinking that we have to do it all ourselves and find those answers.

And so that’s just something that I have really begun to notice. And I spend quite a bit of my time each day trying to meet people where they are, whether that’s fellow students, nurses, occupational therapists, physical therapists, other doctors. If I had it my way, there would just be this completely horizontal world. And we wouldn’t have this structure of I’m on top, I’m the top dog.

But I think if we really hone in on that respect and just really focus on the human being aspect before entering into a strictly professional relationship, we can really help each other and help our patients.

DrMR: And I think from the perspective of functional medicine to conventional medicine, if you come back to one of the things we talked in the past episode about finding a good functional medicine doctor and realizing that someone needs a good provider on each side of the fence, instead of making it an us-or-them sort of perspective, you can say, “This is an area where I think you should check in with your endocrinologist or with your gastroenterologist.”

And it’s actually a very freeing feeling because you’re not trying to take everything on yourself.

Rob: Yeah.

DrMR: Because you really shouldn’t. And it allows you to bring in people who have a better amount of training and a different sphere of focus than you do. And that’s ultimately best for the patient. But it takes some getting out of your own way, getting your ego out of the picture, or getting your philosophical allegiance to functional medicine being “better than conventional medicine” which I do not agree with. But some people get caught up in that.

And it’s about realizing that these different providers have different things that they can bring to the table. And no one is necessarily right or wrong. It’s about working together as best we can to get the best result for the patient.

Sometimes, you have to do that with a grain of salt because you send someone to their specialist. And their specialist gives them attitude about working with you. But to tell you the truth, if you’re open minded in your dialogue with a patient, they usually tend to respect for that. And they don’t have as much respect for their conventional doctor who is essentially going to name call you because that doesn’t look very respectful or very diplomatic.

But rather if you can just be that voice of reason and be positive and make that referral even if you know you’re going to get chastised in return from their provider, I think you’ll come out on top. And your patient won’t lose any respect for you.

Also, I think we’re starting to see with every passing few years, there are fewer and fewer of those dogmatic, conventional practitioners who scoff at alternative medicine. But also remember, if you’re an alternative medicine provider scoffing at the conventional doctor—

Rob: Exactly. Exactly.

DrMR: You are mirroring exactly what you don’t want. So it’s important that we all keep that in mind.

Episode Wrap Up

Robert, I don’t want to cut us off here. But I want to ask you one last question, because we are kind of getting toward our time, which is, “Do you have any big picture thoughts or ideas that you’d like to share with people as we bring things to a close?”

Rob: Yeah, I’d say the biggest picture thing that I bring into my own practice, my own lifestyle is being as open minded as possible. And I like my analogies. Sometimes, they’re a little crazy and tangential. But I try to see how many open windows I can keep in my life, knowing that as I progress as a clinician, windows will start to close as I get more focused.

And we often need to take back, to stop, and to take a pause. Be mindful of where we’re coming from, where we’re at in this moment, and see maybe I’ve close a couple windows. And I should open them back up. Really dig into some of our biases.

And I have found for myself doing a regular meditation practice, doing a regular yoga practice, surrounding myself with not necessarily just simple likeminded people because I’ll be the first to say there are not very many functional-minded people where I am at right now at school. But being surrounded with people with whom I can break spiritual bread, where I can truly connect, be heard, and listen to them.

And that has been so fundamental in maintaining my openness in my training and trying to stay away from the dogma.

And so I’ve focused in the healthcare field with this from my own personal experience. But we can do this. Any individual can do this wherever you are in your life. And so yeah, that’s a big picture thing that I’ve kept near and dear to my heart.

DrMR: And if people wanted to track you down, do you have a blog or website or anything like that where people could connect with you?

Rob: Yeah, so I joke at some of these conferences. People have asked for my card. And I tell them I’m not important enough yet to have a card. But I do have a blog that I haven’t been updating as much frequently that has some really interesting posts.

And I also have a regular newsletter that I send to members of my community called A Week of Compassion. It just contains some really fun, thoughtful articles and videos and music, trying to cultivate an aspect of gratitude and kindness in our lives. And so people can find me on Facebook and see that there and sign up. I call it my kindness propaganda.

But I’m hoping to try to continue as I move forward. I don’t know yet where I’ll be for a residency come next summer. But growing in connections with others in the functional medicine sphere. And I’ve been blessed with wonderful people like you. And I can only hope to provide and continue to stand on the shoulders of giants like you.

DrMR: Well, I think you will. And I think for everyone listening, give Robert a few years to button up his residency. And I expect big things from you, my friend. So I’ll be watching and waiting.

Rob: Good deal. Well, thank you again for having me on.

DrMR: Absolutely. It was my pleasure. And everyone listening, thank you for your attention. And leave some comments, especially on the specialization piece. I’m really curious to hear what people think about that in the community.

And until next time, thank you, Robert. And thanks, guys, for your time and attention.

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