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Practitioner Question of the Month – May 2017

Dr. Michael Ruscio’s Monthly – Future of Functional Medicine Review Clinical Newsletter

Practical Solutions for Practitioners

Practitioner Question of the Month - May 2017 - help circle

Practitioner Question of the Month

Jeff Finley says:

“It seems like a general practice you implement with anyone having dysbiosis is to supplement with enzymes and a probiotic. I know everyone is an individual case, but would you say that it is usually pretty safe to use enzymes with most dysbiotic people? Or are there more factors that these specific cases tend to have in common?”

Great question, Jeff. And yes, for most people, I start them off with an enzyme formula. The formula that I use contains a combination of hydrochloric acid, pancreatic enzymes, and bile. Now, there’s an important exception to this. If I suspect someone has ulcers, or if they have a history of ulcers, or I suspect they have a history of ulcers, or they have a history of gastritis, then I may not use an HCl-containing formula.

It depends on how severe these conditions may be and other details of the case. But as a general rule, the stronger the suspicion of an active ulcer or active gastritis, the less prone I am to use HCl. Or at least I’ll be much more conservative with HCl.

Now, there’s something else here I should mention, which is I suspect that, of all the frontline therapies that I use, using an enzyme-acid combination formula is probably the least effective compared to the other interventions.

But I still think it may have some impact nonetheless, especially when we consider that up to 50% of people with autoimmunity may also have autoimmunity against their parietal cells, which can diminish their ability to secrete hydrochloric acid.

And because I see a fair number of patients with thyroid autoimmunity or other autoimmune conditions looking to exploit the gut as a potential therapeutic avenue, I may be seeing a higher subset of the population of people with lower HCl.

Also, it’s important to mention that many symptoms of low enzymes or acid, or many test markers that may indicate low acid or low enzymes, may be false positives secondary to something like SIBO, dysbiosis, or gut inflammation.

So because of that, I don’t heavily rely on testing to guide this. But I also want to make sure that I’m giving some of these cheap and simple supports like bile, pancreatic enzymes, and hydrochloric acid, so that if this is something that’s important toward the resolution of a patient’s case, I don’t miss it and then go chasing down items that are more expensive to test and to treat.

All that being said, I use these in the active phase of treatment. Once a patient has reached adequate resolution of their complaints, we then have them work their way off of these and try to isolate to see if taking a digestive support like this has an appreciable impact on them or not. And if it doesn’t, then they don’t end up taking it.

It’s very important to mention that I frame that as such so as not to build an enzyme-acid formula in the patient’s mind as something that is essential for them to be healthy, because if you do, you have a very high likelihood that you will impart a bias on them that will placebo them into thinking that they do.

So I tell most of my patients, “I anticipate you will not need this in the long term. And once we get you feeling well and you’re stable in that improvement for a few months, we’ll then move to curtail you off this. And I anticipate that you’ll need little to none of this in the long term.”

So just something there that’s important in terms of how you communicate this to a patient so as not to, again, bias them into thinking that they’re going to need this in the long term.

So in short, I do use that on most patients, except for the couple exceptions that I mentioned. And once someone has been stable in their improvements for a few months, we then move to reduce or eliminate. And if people clearly notice that they need them, we’ll keep them on the minimum dose they notice they need in the long term. Thanks!

Practitioner Question of the Month - May 2017 - practice tip

Practice Tip

Having a well-trained office staff is absolutely essential, because they leverage your time in such a way that you almost have the chance to clone yourself or greatly multiply the amount of work that you can do with a good staff. But one of the challenges that comes with having a staff is occasionally needing to replace that staff. And that can feel debilitating.

So I thought we could briefly talk about or discuss what I have developed in terms of a hiring process that has made hiring so easy that I don’t even get upset when we have to replace someone anymore because that process is so streamlined and, more importantly, so effective.

We have a three-tiered approach to hiring. First, there’s an online form with an audio field. Second, there’s an in-person performance evaluation. And then third, there’s a two-hour one-on-one shadowing session with our medical assistant. So, let’s go through this briefly.

First, the online form allows me to weed out the—not to sound demeaning, but the bottom 70% that are just going to waste your time—the people who are incompetent, the people who are lazy, the people who are going to do nothing but waste your time that you don’t want to get burdened with.

So the online form, we typically post this onto Craigslist. And as you see with this online form, there are some unusual questions like, “What does SIBO stand for? What are the three main symptoms of SIBO? How does Graves’ differ from Hashimoto’s?” These are all questions to assess how lazy they are. If they’re not going to take a moment to answer these questions, then they’re probably too lazy.

And if they don’t know the answer, which I’m expecting a lot of them don’t, I want to see if they’ll take a minute, if they’re resourceful enough to and driven enough to take the 30 seconds to go on Google to search this and come up with an answer.

So it assesses their motivation, it assesses their competency, and it assesses their confidence. Can you take a term like SIBO, type it into Google, find the answer, and report that back? That’s the kind of skill you want in an office admin, not someone who every time they’re thrown something that they don’t understand comes back to you with a question.

So this weeds out people who are incompetent and lazy. Again, I don’t say that in an offensive way, but trying to evaluate someone objectively for employment, we want to make sure we weed these negative characteristics out. We also ask a few questions about what their desired compensation would be, because if they’re looking for $30 an hour and we’re offering $18, then of course that’s not going to be a fit.

And we also look for how many hours per week would be ideal for them, because we want to make sure that what we’re offering and what they’re looking for is in proximity, because if they’re not, they’re probably not going to be in your office for long.

So the final component of this is a voice application field, and we simply just ask them why they think they would be a good fit for our office. And I’m simply looking for, can you articulate a thought? Can you put together three to four sentences?

And you would be absolutely amazed—absolutely amazed!—at how hard it is for so many job applicants to actually speak. And in our profession, speaking and communication is kind of a big deal. In fact, it’s huge. So someone may have the best credentials in the world, but if they can’t talk, then they can’t be a part of our operation unfortunately.

So I quickly can look at these forms. And by looking at this form for about 10 seconds, I can tell if this person should be allowed through to the next level of our screening process or not—by looking at the form and by quickly assessing their audio field.

So this may take 50, 60, 70, 80, 100 applicants. And over the course of 30 minutes, I can chop that down to a solid 15 to 30. This has saved a tremendous amount of time. This really cuts out 70, 80% of applicants and allows you to really get to the people that are going to be a good fit for your office.

Now, the second component to this is people come into our office and they do an in-person performance evaluation. We follow up with the applicants after we screen them from the initial phase as we just went through.

We follow up and we send them a small snippet from our office manual that has about five pages of different policies and such contained in it. And we tell them that they will be run through a number of mock patient scenarios for which all they will need to know is contained in these five pages of the office manual excerpt that went send them.

And so when they come in, I don’t really care about chit chatting. That’s all fine and good, but I don’t care about asking them about how they got into the field or them ask me questions about how I got into the field and having this coffee shop conversation with them.

When they come in, we greet them. We’re very nice, but then we get right down to, “Okay, let’s go through a few mock scenarios.” And we’re going to ask them questions that are very proximal to what they will actually be asked when they start working in the operation.

And we’re looking for, quite simply, can they take the answer to the question, which is written in the manual for them, and articulate that in the appropriate context to the patient?

And you quickly find, people have either prepared, or they haven’t prepared. And people either have the aptitude to do this, or they don’t. So it’s a very quick way… Seven, eight minutes is the average interview. And we can very quickly assess if people are in the right place or not.

Now, that usually weeds us down to maybe three people. And what I finally learned was some people study really hard from that five pages that we send them and they actually don’t have the aptitude needed to work at our office. But they just studied really hard and they kind of fool you into thinking that they can.

So we then have them come back and do a kind of mock day, where he or she comes in and spends time shadowing our medical assistant. And the medical assistant shows them some things, has them do some things, and observes them. And this is where you can tease out the people who really overcompensated by studying extensively for the performance evaluation.

You can weed those people out, because once you get into the situation where you’re just assessing someone’s raw aptitude because they haven’t had a chance to prepare, you can see what people’s short-term memory is like, what their uptake is, what their comfort level with the technology that we use in the office is, and what their ability is in terms of their demeanor.

We’ve had some people come in who just have no polish at all and have been very rough around the edges, which is something that we don’t want, of course, in a patient-service oriented operation, which our practice is.

And then usually from those three to five final applicants, after going through that two-hour shadowing, my medical assistant has a very good idea that there are one or two people who are the top candidates. And we go from there.

So my time used in this whole process is minimal. I review the initial forms. And that maybe takes me about an hour. And then we block off maybe one to two hours for the in-person assessments. And that’s the extent of my time.

So I’m looking at two to three hours total time to bring on a new staff person which, if you really think about that, is actually exceptional because it used to be far, far, far in excess of that.

So these are just some tips that have been extremely helpful for me, making sure I protect my time when we have to re-staff a position. And it has also greatly enhanced the effectiveness of the hiring process where we’ve learned how to weed people out and how to ask the right questions and create the right scenarios to determine who’s in the best place and who’s not in the best place.

And it’s not about someone being good or bad, or smart or dumb, or competent or incompetent, or what have you. It’s just about finding the right fit for our office, which will be better for us and also will be better for the applicant, because they’re going to feel better about themselves if they find their way into a position that they’re best suited to succeed in.

So I can’t overemphasize how important a good screening and evaluation process is for hiring a new person at your office.

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