The New Paradigm in Functional Medicine Part 2

Creating an effective treatment paradigm with Drs. Joe Mather & Robert Abbott.

Functional medicine needs a new treatment paradigm, one that doesn’t grasp at wild or unproven tests, supplements, or treatments. In this episode, Austin Center for Functional Medicine doctors Joe Mather, MD, Robert Abbott, MD, and I discuss how to harness the true power of functional medicine. It’s simplicity may surprise you.

In This Episode

Episode Intro … 00:00:44
Roundtable Background … 00:02:44
Path to AFM … 00:07:24
Facets of an Effective Functional Medicine Model … 00:14:19
The Business of Medicine … 00:20:45
We Get What We Train For … 00:22:56
Defining Best Practices … 00:28:22
More Doesn’t Equal Better … 00:35:32
Practical Solutions … 00:41:40
The Risk of “Safe” Therapies … 00:47:00
Access to Care … 00:55:00
The Patient Dashboard … 01:00:47
Clinical Studies … 01:05:47
Episode Wrap-Up … 01:08:43

The New Paradigm in Functional Medicine Part 2 - Podcast283b JoeMather RobertAbbott

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Hi everyone. Today is the roundtable I previously mentioned with Dr. Rob Abbott and Dr. Joe Mather, who are now both part of my clinic. The new clinic name is the Austin Center for Functional Medicine, and we’re following up on the podcast from last week. So make sure you listen to that one as a pre-emption to this one. There is a lot here that we discuss. We go in and out of all the aspects of what can make Functional Medicine successful versus unsuccessful. There’s really a lot here. I think this has something for everyone, for the person who is a practicing clinician there are a number of pearls. For an individual navigating the healthcare system and trying to use Functional Medicine, there are many pearls for someone who’s kind of going through the “do it yourself” sort of protocols.

Just very excited about the expanded clinic offering that we now have with a multi-doctor, multi-disciplinary clinic and the updated systems, and also the research that we’re going to be publishing. So I’m definitely proud to be offering what I feel to be the best offering that’s currently available in Functional Medicine. I don’t say that lightly, but I haven’t been impressed with what I’ve seen elsewhere. Again I do not think it the doctor’s fault. I just think the educational model is in need of some repair, and I’m very proud to be doing what we’re doing, helping people and doing so while also making them feel empowered and educated, not dependent upon supplements, not afraid of food and all the while doing it more inexpensively than seems to be the norm. So with that, we will go to the round table discussion with the two new doctors in my clinic. All right, here we go.

➕ Full Podcast Transcript

Intro:

Welcome to Dr. Ruscio Radio discussing the cutting edge in health, nutrition, and functional medicine. To make sure you’re up to date on this and other important topics, visit drruscio.com and sign up to receive weekly updates. That’s 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:

Hi everyone. Today is the roundtable I previously mentioned with Dr. Rob Abbott and Dr. Joe Mather, who are now both part of my clinic. The new clinic name is the Austin Center for Functional Medicine, and we’re following up on the podcast from last week. So make sure you listen to that one as a pre-emption to this one. There is a lot here that we discuss. We go in and out of all the aspects of what can make Functional Medicine successful versus unsuccessful. There’s really a lot here. I think this has something for everyone, for the person who is a practicing clinician there are a number of pearls. For an individual navigating the healthcare system and trying to use Functional Medicine, there are many pearls for someone who’s kind of going through the “do it yourself” sort of protocols.

DrMR:

Just very excited about the expanded clinic offering that we now have with a multi-doctor, multi-disciplinary clinic and the updated systems, and also the research that we’re going to be publishing. So I’m definitely proud to be offering what I feel to be the best offering that’s currently available in Functional Medicine. I don’t say that lightly, but I haven’t been impressed with what I’ve seen elsewhere. Again I do not think it the doctor’s fault. I just think the educational model is in need of some repair, and I’m very proud to be doing what we’re doing, helping people and doing so while also making them feel empowered and educated, not dependent upon supplements, not afraid of food and all the while doing it more inexpensively than seems to be the norm. So with that, we will go to the round table discussion with the two new doctors in my clinic. All right, here we go.

Roundtable Background

DrMR:

Hi everyone. And now to the round table with Dr. Robert Abbott and Dr. Joe Mather the two gentlemen who are now part of Austin Center for Functional Medicine. There is a lot here to unpack and a lot to go into. Let me just start with a few remarks before we go into the round table. The few points I want to make sure that we try to impart on our audience is that this model or what we’re advocating for is model-centric, it’s not clinician centric. Some of the components of this model are being cost-effective, efficacious and improving patient psychological wellbeing. There’s more than just that, but those are a few of the high points I want to kind of impress upon people. Along those same lines, it is important for me to impress upon the audience again, that this is not something that’s dependent upon working with me or working with Joe or working with Rob.

DrMR:

This is really model dependent, and we’re all now working together in lockstep to continue to refine, update and improve this model. It is something I’m very proud of at the clinic and what I’m trying to preempt is people thinking that they heard a particular doctor on the podcast, but it’s a little bit of a wait to see them, and they don’t want to see the new doctor at the audience because that isn’t who they heard on the podcast. This is understandable, but no provider would be in the clinic unless they are fully up to speed on the model and trained in the model. Everything that we’re doing is to allow this to be something that is not dependent upon one person or persons, but rather it’s the model. That is where the real value is.

DrMR:

In case someone is asking “how could a new doctor be as skilled at this as someone who’s been doing this for 10 years”, the answer is that the model is a by-product of years of questioning the norms, cross-referencing science, doing things differently with patients and evaluating and learning from that response. That becomes kind of an answer or an algorithm, and that can be taught to someone. So all of those years of effort and learning culminate in “here you go, this is the model, execute this, implement this”. This is how we can get someone to a level of proficiency much more quickly. So I do feel much more comfortable with someone from our audience working with a clinician at the Austin Center for Functional Medicine, at my office, than with someone who may have laudable academic credentials.

DrMR:

Actually, just a quick side note on this, I was thinking the other day that in conventional medicine, you could argue, you can be much more trusting of the model that you’re learning, because there’s a well-established standard of care. That may actually deserve a conventional doctor when going into alternative medicine and Functional Medicine, because they have an undue level of trust in the education. They’re not realizing that in Functional Medicine, it’s kind of like the wild West and you have to be very circumspect with what you’re being taught. So the point I’m driving at here is someone could have gone to an Ivy league medical institution, and then they go and do the best “training” in Functional Medicine and you end up getting a lot of these things that we’re criticizing.

DrMR:

So again, I really feel it’s not credential dependent or person dependent. It’s model-dependent. I’m also not professing that we have all the answers, but I can’t ignore the fact that on a daily basis, and I know Joe and Rob, you’re seeing the same thing. You just want to bang your head against the wall with how frustrating it is to hear what patients are saying when they walk in the door. We experience a lot of that based on the fact that the model is, while perhaps well-intentioned, significantly off the mark. With that long prelude Joe and Rob, welcome to the show.

DrJoeMather:

Thank you.

DrRobAbbot:

Thanks for having another round table

DrMR:

You guys have both been on the podcast previously. So Rob, I want to let you kick things off because we had a chance to meet in person many years ago when you were coming out to shadow me at the office in California. So I figured we could kind of start there with our bromance backstory and then let you kind of share some of your thoughts. We’ll kick it over to Joe after that. Then we can kind of go into a round table.

Path to the Austin Center for Functional Medicine

DrRA:

Yeah. You know, we were talking just before we started to record, we’re recording this in November, 2020, and it was exactly four years ago when we met. I was doing a little vacation/tour/conference, just travel through much of California, looking at various residencies and enjoying myself and trying to meet some of the clinicians in Functional Medicine. I was a fourth year medical student at the time and had been doing my own personal study of Functional Medicine from essentially the first year of medical training. So I had been well-versed and had met a few folks at various conferences while I was in training, but was finding it very difficult to infiltrate those practicing because I think a lot of clinicians who enter Functional Medicine or they’re doing it on their own accord, which makes it very different than the academic structure where you have teaching built-in.

DrRA:

I was just wanting to see, firsthand, the clinical side and get out of some of the academic learning. I mean, I was doing some of the formal training with the Institute for Functional Medicine at the time and the Kresser Institute and that training is all great. But until you see what’s happening on Monday, what’s happening in the actual office with those who have adopted a value-based clinical model, it’s hard to see how this works. You were very gracious to reach out when I was constructing my trip and was able to see your clinical model. For those interested, I even went back and listened a little bit to our podcasts, kind of reflecting on my views and perceptions of your model at that time as a student. Some things stood out tremendously and have been the hallmarks of this clinical model that we’re gonna talk more about today.

DrRA:

It was at the time, even without the nitty-gritty deep details, and really only seeing a couple of days in the clinic, it was very obvious to me that some of the ways you utilize a therapeutic hierarchy, how you were using some of your clinical tools to seek quality of life improvements, psychological improvements. How you were incorporating the foundational aspects of lifestyle. It just made so much sense. It really sparked a growing personal and professional relationship for us. I felt so happy, fairly early on, to build a relationship with you as a clinician who was really on the ground and not stuck to a dogma and was wanting to continually learn from patients. Now fast forward four years, we’ve maintained this relationship and I’ve essentially been implementing those principles that I saw in your clinic four years ago in residency training and in my own clinical practice.

DrRA:

It’s just been wonderful. I can obviously get more into things today, but it was just a sort of serendipitous, romantic meeting of these two spirits who were seeing some of the potential downsides of where Functional Medicine was four years ago. And, uh, I think it’s just, I’ve really enjoyed this, uh, our, our relationship and, and the growth with Joe through the clinician training as well. I just feel really honored to have met you and for you to have invited me in to grow something that at the time we didn’t quite have a handle on where it was going to go, until now.

DrMR:

Yeah, it is exciting of course, to have you on board. To be able to leverage the impact that we’re having in the world. I also have to say, you really took to the concepts well. Yours was the first guest case study that we published in our clinicians newsletter. That was really validating for me. To see that, okay, this isn’t something that just I see, and I’m able to fix. This has demonstrated external validity in the sense that you were finding some of the same things that I was reporting in the newsletter in your clinic, applying some of the solutions I was finding were helpful and seeing similar results. So that, for me, really started to potentiate how excited I was getting about this and how much I wanted to try to forge forward into a multi-doctor clinic. So we could really improve and enhance our offering. That’s maybe a good segue to get some of your thoughts, Joe. We didn’t have the chance to meet early on like Rob and I did, but we’ve had a similar connection in terms of having some of the same goals and wanting to try to help steer a field in a corrective direction.

DrJoeMather:

It’s funny. I’ve told a couple people that, Oh yeah, you know, I’m now working at a clinic in Austin. They are always like, wait – did you move? I’m like no, it’s 2020, we just started a clinic, virtually, across the country. It’s not a big deal. This is what we do in 2020 and everything is possible with Zoom. So although we haven’t met in person, it’s amazing to me, I feel so close to you guys because I know we all share the same goal of getting patients better in a practical, effective way. I think that’s the glue that makes this clinic work. I’m just so happy and proud to be part of the team to make this type of medicine more effective for patients. It’s more patient focused. So I’m happy to give you any more background, Michael, as you, as you want to lead this discussion.

DrMR:

Sure. You make a good point, which is, so much now has gone to telehealth. Most of my patients, even before the Coronavirus associated restrictions, were telehealth. These case studies that we are obtaining, in some cases, remarkable results, were completely telehealth visits. The training that, you know, we’ve all been able to kind of share with each other and the model, that is all digital. If you think about it, it’s not like there’s a file cabinet back in a room with a bunch of this stuff written down. It’s all in Dropbox, in Google docs inside of a HIPAA compliant platform of some sort like Practice Better. Even being in the same physical office, we’d be using digital tools that wouldn’t require us to be in the same location. You guys will be, to some extent, rotating through and doing some in-person at the Austin clinic, but that’s really not the point of the model. So much of this, even if you are in person with someone, is the same exact tools that can be implemented remotely.

Facets of an Effective Functional Medicine Model

DrMR:

So yeah, it’s a great point that you make just to kind of speak to the portability of the model. I know you guys both had some things you wanted to discuss. Let’s start with what you’ve noticed, at the risk of tooting my own horn here, but one of the things that I’m trying to help the audience see is that these things that have bothered me about Functional Medicine are not unique to my observation. In fact, I had a great call the other day with Dr. Jeff Moss and Dr. Nick Hedberg, who also share a lot of the sentiment of trying to reform and improve the direction of the field and being frustrated with some of what they see happening in the field. Just briefly, are there some things that you’ve noticed coming from your training elsewhere and then having a chance to integrate into the office, that you’ve found to be novel or insightful? Rob, you made the comment about the therapeutic hierarchy. Are there any other things that you think are important for people to be aware of in terms of facets of an effective Functional Medicine model?

DrRA:

Joe, do you want me to go first, or do you want to go first?

DrJM:

We all want to get patients better as quick as possible. I think to kind of take a big step back, the question has to be what went wrong with Functional Medicine? It seems like when you start asking the question, why is this patient sick? You would think that if someone was observing their patient closely, they would be able to suss out the reasons why they were sick and what treatments were helpful or not. I think the problem comes in the way Functional Medicine is taught to the vast majority of practitioners. Most practitioners who are coming into the field of Functional Medicine are extremely attentive, intelligent, passionate, caring people. I think that the unfortunate reality is they’re just being taught a model that’s not quite right. They’re being taught based on the assumption that if they just do some advanced testing that’s not available to a conventional doctor, and supplement all the holes they find, then from that advanced testing that a patient will get better.

Frequently what happens then is that a patient will go years where a doctor is just testing and trying to shore up problems on that test. The problem, and Michael you’ve said it again and again, is that a lot of this testing just isn’t as accurate as people have been led to believe. I think some of that comes from problems with how the labs are taking over some of the training and the conferences. I think other problems come from supplement industries having a strong incentive to sell supplements. But why I love working with you two, is that we have kind of come together and put our heads together to really refine a system that helps patients no matter where they are. Maybe the next point we can kind of get in is why we’re able to do that with this model.

DrJM:

But I think that the most important focus is number one, focusing on patient’s symptoms and treating the symptoms, following the symptoms and not necessarily labeling patients with things that may or may not have meaning like adrenal fatigue or MTHFR. Once you do that, the things that work become pretty clear. Again and again, I still am sometimes surprised at the power of simply emphasizing proper gut fundamentals, at how many extremely sick patients get so much better when the correct gut treatments are done in the correct order. I think that’s one of the keys that, although we all have our different opinions and perspectives and background, I think that’s really a unifying principle.

DrMR:

Yeah. 100% that is something that often is glossed over. Obviously preaching to the choir on that one. We’re all on the same page there. I just want to kind of acknowledge the profundity of what you said regarding treating symptoms, because sometimes that carries a negative connotation like, Oh, they’re just treating the symptoms. That is true if you are giving an Advil for joint pain or an antidepressant for depression, but it’s not true when you’re using the symptoms as a gauge of if you’re using the right therapeutics. So the symptoms, when read correctly, can lead to the cause. That’s the big translation that I think needs to be made. It’s often said, if you have these symptoms, if we could just run these tests, we’ll figure out the cause. Ironically, you end up with much more of a “pill for an ill” treatment when treating labs, than you do if you’re using the model we’re advocating for, which is using the symptoms to uncover what the underlying cause.

DrJM:

It’s so ironic because the old school conventional MDs, the really old guys that we kind of leaned on in medical school to understand where we were going. They started their medical career and there were not tons of antibiotics available, there wasn’t testing that was accurate or available. So those doctors, all they had were symptoms. I think as the technological savvy of conventional medicine has grown, that it’s been too easy to mistake moving numbers on a paper with getting someone better. It’s not. What we do is we go into medicine so we can help people feel better, to help them heal. The only thing that matters is our patients are feeling better. So I don’t want to beat a dead horse, but I just feel so strongly that this is the way forward. Sometimes the labels of functional, conventional or integrative don’t matter. As long as the clinician is really listening to their patients and focusing on their symptoms, they’ll get there in the end. I really am proud to be a part of this team because I think we have the opportunity to bring this cost-effective, practical care to a lot of patients.

The Business of Medicine

DrMR:

You know, something that I want to mention for the doctors and this gets a little bit into the business of medicine, but I think it’s worth discussing. I was talking with one of my colleagues and he asked do we want to make Functional Medicine more cost effective? Don’t we think Functional Medicine doctors should be paid well? Yes, fully. But really where the cost savings occurs is with the lab testing, which don’t really make money. Doctors will oftentimes add a slight fee onto the labs or a slight margin, which is totally within the bounds of normal practice. But if you’re talking about from a pure business perspective, you have to look at what is your highest margin item as a doctor. If you’re looking at your clinic like a store, it’s your consult, it’s your opinion.

DrMR:

So if you have more time vectoring your opinion, you’re going to make much more money and you’re going to make more money, but you’re going to be billing the patient less. This is actually something I saw happen as my practice evolved to do less testing. We actually saw a drop in our collections and it kind of concerned me a bit, but then our profit margin actually went up. So there’s really a beautiful alignment of incentives where the doctors will make more money and get the pay that they should, because guess what? They’ve got huge loans that they’re buried underneath and they spend a good part of their life just being totally decimated by the demands of an academic process. They couldn’t work, they couldn’t have fun and so four to eight years of your life where you could have been earning money and saving, are gone. Now you come out with 200, 300, 400, 500K in debt. So yes, the doctors should make money, that that is important. But they should be able to do it in such a way where they’re not burdening patients unnecessarily, financially. So I think this is really an answer. That again is a win-win-win. It’s better for the doctors and it’s better for the patients and it ironically saves the patient money, but also makes the doctor more money.

We Get What We Train For

DrRA:

I think that’s really well said, and it’s the by-product of a correct process for the patient and the provider. I wanted to step back to something Joe had said regarding the current teaching and the current training, which I think is incredibly important for both the wider audience and for physicians to understand. I’ve been thinking about this a lot as I’ve been reflecting on my own journey in a very unorthodox fashion, through traditional training and my own functional training. One of my good friends, Ryan Muncie, basically says, you are perfectly designed for the results you are currently getting. So when we look broadly at, starting first with what we’re calling traditional medicine, the way we’re training conventional doctors, we’re getting precisely the type of doctor and outcome that that training is designed to produce thinking.

DrRA:

You’re going to get somebody who is incredibly compassionate and views things from a very holistic perspective with integrative modalities, conventional modalities, and also even has the time to fully care for themselves and potentially a family. That’s just not rational. When you look at the way we’re currently training our specialists, which are really organ specialists. So we, we are producing physicians in the conventional model. That’s a direct result of the training. It’s one-to-one concordance. To produce someone like myself through an aspect traditional model is a bit of an aberrancy. The same thing is happening in Functional Medicine, because why would it be run by different rules? It’s not. So the same thing is happening in Functional Medicine. When you look at the numerous paths to receive trainings in Functional Medicine, there are a few that have stood out as some of the primary methods.

DrRA:

It becomes pretty obvious how some of these very intelligent, well-meaning clinicians, many of who have already been in traditional models and are pivoting to a Functional Model, start practicing in the way that they are. It’s again, to expect them to practice a model that we’re discussing and how we practice based on what the education that’s available, that would be crazy. You can only expect them to practice with the teaching and the training that that they’re provided with. Right now, it’s unfortunately not up to standard because there really is no internal gold standard or best practice for lack of a better term. Just being on some of the clinician forums, I had to get off some of them, because it was just maddening to see some of the discussions that were being had about various topics.

DrRA:

It’s not to say there aren’t many roads up the mountain, there are many approaches to help people. But a lot of what we’re seeing is perpetuation of poor training and poor clinical approach tied to that training. Some of the challenges that come with the embedded supplement companies and lab companies, which are really similar to big pharma conventionally, these are very similar relationships, I’m not saying right or wrong, in Functional Medicine that can sway practice. So it’s really going to take some pretty significant shifts in this community, that it is very diverse and in some ways, very disparate, which makes it very hard to develop gold standards and to pass along clinical models that can then be given to clinicians to utilize. So one of the things we can get in perhaps today is, as a field, as healers, as clinicians in a profession such as this, we have a duty to improve our methods of helping our patients to help themselves.

DrRA:

We have that duty, that mission. I think that’s something that’s been a little bit lacking because our community is so disparate with so many different professional accolades or people with different medical backgrounds, nursing backgrounds, practicing. If we really want to start to move this needle, we have to form collaboratives, like we are, to bring more heads into the room, to adopt practices and see what is working, and what’s not working and start to share that and allow each other to see how we compare. Not better or worse, but in different modes of clinical practice. A lot of people in Functional Medicine came to this because they don’t want to be a part of hospital systems with all of these ridiculous metrics and a lot of them being silly and not applicable, but at some level, if we really want to start moving this, we are going to have to come together as a community to start to identify what are the measures of best practice from our perspective as clinicians, but also for the patients. How do we define these patient centered outcomes?

Defining Best Practices

DrRA:

I feel like what we’re doing here is going to be the beginning of that. I hope this can be adopted on a larger scale for the sake of helping people in a better and more comprehensive way.

DrMR:

Well said. Something that seems to function as the bridge, you both are trained in conventional medicine, I’m trained in alternative medicine, but there doesn’t seem to be that much of a disparity in the “language” that we speak because we speak the language of science and evidence. We have an appropriate understanding for how to look at the science or the evidence behind a test or a supplement. That supersedes your philosophical preference, your academic credentials, your background, your training, because it wouldn’t matter if someone went to Harvard and was the top of their class, if they made an argument and it had poor evidence behind it, and they were arguing a point against me with an inferior credential, my point would win because the language that we’re speaking is science. It’s the argument from authority is not the correct argument. It’s what the actual data behind someone’s position says. That’s why I think we have the ability in a cross disciplinary model to always be on the same page. We’re looking to the evidence first. That’s one of the main guiding posts we have to follow this year away from where we currently are to where we’re trying to go.

DrRA:

I think it’s a really, really great point. We’ve talked about it before in these discussions of we have to move away from guru medicine. It’s not saying the person’s academic accolades or whatever they’ve provided doesn’t matter. It matters. But it is not going to guarantee you anything as a patient in terms of outcome. For me, I enjoy being a part of something that gets rid of the guru idea and allows the collective process and the patient to be the director of this journey. I’m reading this book right now by Dr. Marty Makary, who is a cancer pancreatic surgeon. He is well-known and well-versed in a lot of the things that are broken in the conventional healthcare model. He told this beautiful story in his book about how the clinicians, these surgeons doing a specialized type of sort of skin cancer surgery, called MOHS surgery, identified some metrics that were valuable to them and because of a medicare database, which, back to what I said earlier, we don’t really have this kind of database and agreement in Functional Medicine, as a good metric. But they identified this metric, as physicians, what would someone who on average, on the whole, over a number of patients do in this case, value based care.

DrRA:

So they use this database and they send the doctors letters basically showing them on a bell curve where they landed in terms of the average number of stages of the surgery. More stages means they are probably over-billing or have improper technique and are financially benefiting from that perhaps more than just helping the patient. So they just went and looked at this data and sent these letters out. They didn’t say that people with more stages on average were worse clinicians. They just showed the clinician where they stood. Were you two standard above the mean? Were you below? Where you at an average? Amazingly the feedback was remarkably positive because people wanted to know how they stood up to other clinicians. Without getting a label of “you’re a bad clinician because you do this, you’re doing these extra stages on average”, they saw refinement and improvement in practice.

DrRA:

That’s some of the thinking and some of the ways that we have to start seeing in this Functional Medicine community, how can we start to help each other as clinicians not feel like we’re bad clinicians or right or wrong, or that we’re messing up, but just seeing how do we compare to others. Finding some metrics that we agree upon that are related to clinical practice so that we can start to refine internally in a way that’s not alienating or making someone feel like they’re a bad clinician. You get rid of that dialogue. You just show them where they stand. I feel like that’s such a huge thing that we’re doing and have been doing with the clinician newsletter. The number of case studies that are included with this model, we’re constantly refining and using each other as those internal barometers of like, how are you doing this? And seeing, Oh, maybe I could do this a little bit differently and achieve better outcomes. That’s what we have to do internally, because the by-product of that is going to be better patient care, better patient outcomes and what we all want to be happening collectively.

DrMR:

Yeah, very well said.

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More Doesn’t Equal Better

DrMR:

Joe, maybe you can speak to one of the ways that we can kind of do this comparison that you’re alluding to Rob. Great example. Would be this thinking that I think we’ve all been trying to kind of pioneer, which is more, doesn’t equal, better, more testing doesn’t equal, better results, more supplementation doesn’t equal, faster response. Are there any thoughts there that you think would be salient to share?

DrJM:

Yeah, I mean the more does not mean better just comes up clinically again and again, when you’re listening to patients. I agree with every single example you just gave. I was reflecting Rob on that story and the feeling that kept coming up was just how much fun this is. When you’re using patient symptoms as a guidepost, you don’t have to have all the answers because you can simply say to a patient, based on my experience, I think this has the best chance of getting you better and it will either work, or it won’t. If it doesn’t, that’s okay, it’s not about my ego, it’s about your results and we’ll try something different. It’s very liberating to be able to do that because we don’t have to be right every single time.

DrJM:

The truth of medicine is that we’re not magicians. We can’t see through people and have a magic wand to find the root cause. It takes some experimentation and tweaking, and the longer we all do this, the better we become at problem solving and matching. I really think that the true beauty is just focusing again and again on the symptoms which lets us hone in closer and closer and closer to get patients better quicker. Collaboration just helps pour gas on that. It’s why it’s so much fun to work with you two, you know, behind the scenes we’ve been going back and forth on fluconazole and itraconazole and when to use. I think that despite all of us coming from slightly different backgrounds and perspectives, we’re able to find a really close place where all of us agree on how to proceed. It’s so much fun to be able to continually refine and get better and better. So, Michael, did I answer your question or did I meander?

DrMR:

No, you answered the question, which is essentially just trying to help people understand. I think we’re all on the same page here. It’s disheartening how many patients come in having been through the wringer? Like every test I have heard about these patients have done and then some I never even heard about. Yet, they’re not feeling any better. They’ll even sometimes go as far as to say, you know, I’ll do anything to get better. Like “doc, I know you’re light on testing, but if there’s anything you think I need, just let me know”. Slow down. Testing does not tell me how to fix you with no exception. You know, it’s really inverting, whole thinking, which is testing is kind of the cherry on top.

DrMR:

It’s a secondary, or I I’d argue as almost a tertiary importance. Now some things are more clear cut than others. Hypothyroidism is clear cut, even though, unfortunately, that’s something that the functional community seems to have really screwed up in my opinion. Um, yeah. And, and we have published many a case study where someone was just being beat over the head with a diagnosis. Was it you Rob that was saying before the recording that you had a case of someone who was diagnosed as hypothyroid in the supplement aisle at Whole Foods.

DrRA:

Something to that level. I mean, I’ve also overheard well meaning people talking at Whole Foods about like “maybe you have a parasite”. I’m just like, man, I’m a doctor, but I would not be saying that. It’s just, yeah. The thyroid stuff is maddening and there are tons of case. I mean, we’re not making this up. These are real people’s lives that we’re seeing and that are documented in these case studies. It’s multiple clinicians and not just us.

DrJM:

I had a patient today who has been getting weekly IV nutrient therapy based on a seemingly endless number of tests to look for deficiencies. This patient has been getting weekly nutrients and glutathione at $200 bucks a pop for seven years. It’s just so disheartening. I asked her did it help at all and she said no. There’s something very broken if a clinician hasn’t stopped. I mean after a few treatments you ask “is this working” and they say no, so you keep doing it for seven years? For a patient to have be so scared of these deficiencies and pieces of paper that had a few red marks on them that she spent, I just pulled up a calculator, $70,000 if she truly got it weekly for seven years. I mean, it’s just, it’s outrageous.

DrJM:

The more we can get away from that, and the more we can move towards the practical solutions that we all know, and I’m sure the listeners know too, that that gets patients better, the better off everyone will be. I think most importantly, Functional Medicine is really screwed if this is what most people think of when they think of Functional Medicine. 15 supplements and endless tests and not really getting better, the field is dead. So those of us who really care about getting the root cause better and getting patients better practically speaking, we have work to do guys because that sort of endless nutritional therapy, endless supplements, more, more, more is horrible.

Practical Solutions

DrMR:

Fully agreed, of course. You know, you said something that I want to dig into a little bit, which is practical solutions. I think sometimes a patient who is more chronic, severe or progressed thinks, the practical stuff won’t work for me because I’m a complex case. I would argue quite strongly that is actually the more chronic or severe cases that the Functional Medicine model hurts because it’s for the patients that are the most progressed or the most severe. You have to get back to this hierarchial focusing on one thing at a time and making sure you have the practical pieces in place. What I think happens is, for the easy responding patients, anything works. For the patients that are not easy to respond, that’s when you have to really go slow and dig and figure out, does this work, does it not work?

DrMR:

Or this thing gave us 20% gain. Now we’re going to integrate along with that another therapeutic. And we’re going to kind of piecemeal together a plan that will fix you. That only happens in this model that does not happen in the copious testing and tons of supplement model. What ends up happening there is they are probably reacting to the unequal number of things as they are being helped. They never really get a chance to discover the therapeutic plan that will help them because it’s obfuscated by all these bells, whistles and red herrings that accompany all the other noise. For the chronic patient, first of all, we try to un-label them as chronic, and instead say that they’ve been mishandled. Secondly, when we say practical, it doesn’t mean the practical solutions won’t help you. In fact, they’re probably more likely to help.

DrJM:

Yeah. Let me jump in because this is something I think about every day and I’m just really passionate about it. It’s the therapeutic hierarchy. How many patients do we see that have come in? They’ve tried some herbal antimicrobials for SIBO. They’ve tried one probiotic here, one there. When you really look at their case, no one has done a diet. Their sleep is all sorts of messed up. There’s chronic stress all the time. They’re starting treatment in the wrong place. They need lifestyle first. When lifestyle doesn’t get them all the way, you then move on to the therapies that we all know work on the gut. Get that squared away. So many patients are made better there. Then if there are other remaining issues, if there’s MCAS, histamine, mycotoxicity, those things really only can be healed appropriately when the gut is working.

DrJM:

When the sympathetic imbalance is toned down. When they’re sleeping. Helping patients unwind. A lot of times, start over and start from the beginning with an emphasis on the fundamentals. It’s one of the things I love about this clinic because we are able to help people that have been mismanaged for many, many years. It just speaks to the power of the model and doing things at the right time for the right patient. We have the time to be able to help people figure out what’s been missed and where to start.

DrMR:

Yeah. That’s another one of the most empowering things for me as a clinician. I used to be intimidated by those complex cases. There were a few early cases where I said, well, I know all these tests that the patient wants to run are BS. So I’m not going to do that. I’m just going to slow down, take this one step at a time and make sure that we do a fundamentals up approach. So we haven’t missed anything. What do you know? A chronic case got better, and then another and then another. Depending on the case we may say we’re going to use a probiotic trio, but we are going to start them one at a time. Because they’re more likely perhaps to have reactions and there might be a little bit of a need for troubleshooting or this or that. But essentially they follow the same trajectory that these other patients do. Oftentimes they think that they have to go to the end phase, speculative therapeutics, their clinician buys in on that and then it’s just this whole thing where you are in a mud field trying to build a house on top of that and you don’t figure out or you can’t figure out why everything keeps crumbling on you.

DrJM:

Yeah. I tell people that oftentimes they are talking about straightening the picture on the second floor while there’s a hole in their foundation. They have just completely missed what’s important. They need to set the foundation first. They need to be sleeping eight hours. They need 20 minutes in the sun. They need an appropriate diet, whatever that is for them. We both move on from there. But basics first, particularly in the more complicated patients with multiple autoimmune diseases or toxicity where it’s even more critical.

DrMR:

Yep. Fully agreed, of course. Rob, I know you had a case study that you wanted to maybe mention. There was the case study and the hierarchy but we talked about the therapeutic hierarchy. I think we’ve covered that pretty well. Are there a few nuggets from one or two case studies that you think may be salient to share with me?

DrRA:

Yeah. With the therapeutic hierarchy, I just find it fascinating that this is what we were talking about four years ago. This is what I saw you were implementing which has continued to be refined. The last thing I’ll sort of say to patients to kind of close what you and Joe were saying, is the importance of not rushing that process. Really, truly understanding the potential risks and benefits of all the treatments that could be considered. So we, as the clinicians, the reason we want to focus on the foundation first is those are typically the things that carry the lowest risk and starting there. If we can get you all the way there with the lowest risk treatments that have some potential benefit, then that’s what we should use. That’s the whole model that we’re adopting is working at a foundational level with the lower risk treatments that could likely be beneficial. Then moving up later on to potentially those that may achieve a benefit, but may carry a higher risk with them.

DrRA:

The way I’ve kind of conceptualize it and tell patients and what we’re describing, and it’s just artifactual that the levels don’t matter. When you think about the complexity of a patient, a lot of more “complex” patients come in with what I consider like level three, level four, level five disease processes. In Functional Medicine, it can be very challenging to immediately want to jump to well you need level three, level four, level five therapies, which may be IVs and hyperbaric oxygen. All of these more complex treatments that carry a degree of potential risk, both the financial, as a resource risk, but also other risks. The case I want to highlight in terms of therapies that carry seemingly safe therapies that actually carry risk was a case of a gentleman who had been working very extensively with a well-meaning functional provider who was over-testing and over-treating SIBO or perceived SIBO per testing with herbal antimicrobials.

The Risk of “Safe” Therapies

DrRA:

That the gentleman developed Clostridium difficile, a very severe diarrheal infection and was quite sick. You know, herbal anti-microbials are not the most benign treatment. They carry some risks, especially when they’re applied over a very continuous period with someone who continues to not symptomatically respond or is being over-treated because of a misuse of a testing modality. So this gentleman came to see me with this acute, starting to resolve, but acute Clostridium difficile, not from prescription antibiotics, but from continuous use of herbal antimicrobials. We developed a sort of step-wise approach that started with foundations, some dietary modifications, some probiotic therapies, eventually did a few very, very targeted herbs for a short period of time and, and he saw great benefit. That’s where we really have to understand as clinicians, but also understanding as patients, we want you to be better. It can seem like, well, why don’t we jump to doing XYZ right now, if that can make me better, and I totally get that.

DrRA:

We totally understand, but we have to step away from the immediate desire to be better and to understand the process. Why we don’t want to rush it and why we may not actually want to jump to those level three, level four, level five therapies, because they may be more expensive. They may also carry this risk. Sometimes we get pressured, I think as clinicians to jump to those. I think that’s one of the issues that’s happened in Functional Medicine and what was highlighted in the case of the gentleman who developed Clostridium difficile. I know it sounds like we’re on repeat here, but this is why this collaborative is so empowering and so powerful is that we are making those changes internally to help spread into the field. I mean, I would like nothing else for the field than to not have these issues and then we wouldn’t have to be doing these things, but we have them. So we need to rededicate it to this refinement. Why we have to utilize these therapeutic hierarchies and a constant duty to refine the clinical process.

DrMR:

I’m glad you say that it’s something that I had mentioned earlier in the podcast, but I just think it’s helpful for people to hear this reiterated by other people. The desire to help patients is leading well-intentioned clinicians to try to grasp every straw that they can, every test, every supplement, every dietary change. It’s so paradoxical because on its face, that would seem to be the best way to go, but it actually ends up detracting from results and it makes clinicians worse clinicians. It damages patients financially and psychologically, and it detracts from the results that we’re trying to get patients symptomatically. So it’s a real travesty that the things that, in theory, would seem like the best path are actually the complete antithesis of the best path. I understand, I was doing that too.

DrMR:

There were those patients early in my career who were really suffering and my heart would break for them and I would want to do anything I could to help them. So I thought, well, boy, these four tests all together is kind of a lot of money, but I want to make sure I get them results. To give them adrenal support, plus sleep support, plus amino acids for neurotransmitters plus anti-inflammatories plus probiotics plus MTHFR support. It seems like a lot, but I just gotta make sure I help them. It is such laudable thinking, but unfortunately, it’s really not what is conducive to helping the individual.

DrJM:

It’s the same thing early on. I think you have to go through that to convince yourself that those tests really won’t offer that much value. If there’s a tool that’s going to help someone, you want to be comfortable with it. You want to not miss something. I say I have a similar story. I was going in and treating a bunch of patients with chronic markers of Epstein-Barr. I was convinced early in my career that if I would simply just hammer the Epstein-Barr, with prescription antivirals, herbals, if I just hammered it long enough I could get them better. But after tracking those patients, it was very clear that wasn’t shifting things for them. I was missing something. It was right about that time, Michael, that I found your podcast. Sure enough, when I started fixing their gut. It was amazing.

DrMR:

Yeah. Yeah, it is. I went through that same thing where I was really aggressively treating Epstein-Barr for maybe a year, a little over and I just didn’t see the needle move. Maybe two or three cases I can recall. I still wonder if it was the fact that I was using high dose quercetin. A backdoor MCAS, and not actually anti Epstein-Barr. So I hope for the audience that you guys are seeing that this is not something unique to me. It’s a method of thinking, analysis, data organization, and prioritization, and creating a therapeutic hierarchy that really leads to a fundamentally different model of Functional Medicine. It’s more effective. It’s more enjoyable for the clinician. It’s also more profitable. I mean, the incentives are aligned all around where it’s better for everyone involved, and this is why I’m so excited about kind of championing this message.

Access to Care

DrMR:

I’m also wanting just to reiterate for our audience, the clinic continues to have a lot of demand. So I’m assuming at some point, Joe and Rob will be fully booked out and then we’ll have another doctor on board. If you listened to this podcast six months from now, that Dr. may be booked out also, and it may be someone else. There’s a quote by Earl Nightingale that I think kind of speaks to this, which is “once the mind of man has been expanded by a new idea, it can never again return to its original dimensions”. So once you have a chance to see this model, be taught this model, you are a different clinician. So it’s not about how many years of experience someone has in the model per se, although that can help, sure.

DrMR:

But you’re much better off having someone with three months training in this model as compared to 10 years of training in the standard Functional Medicine model. I really do mean that. You can have that person, as I’m sure Joe and Rob also get frustrated with, that person who has been treated for Epstein-Barr for a year by their doctor that’s been in practice for 15 years. We’re thinking, well, you probably should have figured this out by now. Unless that mechanism of self appraisal and self criticism isn’t in place and therefore they’re not finding their way to this. So again, I just want to make sure people are on the same page that anywhere here at the center, we’ll able to really help you. We can’t guarantee that, but I’m really confident that with our model we’ll do as much good as possible and mitigate any risks, psychological, financial, and also, medical or health. In terms of not using some experimental therapy until we’ve really worked to that point and made a case for it.

DrRA:

I think one point to make with that for potential patients, and I think current patients will speak for this, is that one of the obvious concerns in conventional treatments, and this is built into education, is that it is incredibly formulaic. Traditional medicine loves flowcharts. If you go to UpToDate it’s like let me find the demographics and where this person’s blood value is. and then this’ll tell me what to do. And that is okay and it’s well meaning we “don’t want to make mistakes”. Functional Medicine, in similar ways based on how it’s been taught, can become way overly formulaic. Everyone who comes in basically has this diagnosis, so then they get this treatment. What we are describing with this, with our formula, with our therapeutic hierarchy is not formulaic treatment.

DrRA:

It’s a conceptual framework with how to think about things in an iterative and practical way. It still entirely embodies the personalized medical structure. But it pushes aside the sometimes overly expansive Functional Medicine “What the heck do I do? Let’s just shotgun, everything” way of thinking. It gives a formula for thinking about things and an iterative, sequential framework. So you get the personalized care and the personalized elements, and you don’t get the cookie cutter formula. You know, you do this detox and then you do this. It’s so far removed from that, but it’s a framework and that’s why it can be taught. I can speak for myself. I’ve been practicing this model beginning in residency in 2017 and into my own clinic now. I feel so fortunate that the first, almost four years in my practice have been with this model and I’m getting better outcomes because of it.

DrRA:

Yes. Does my personal background and the things that I do as a clinician help. Yes. I’m not discarding that, but it’s the model that I’ve been trying to implement from the beginning with Joe and with Michael, that that are the key elements. It is these conceptual frameworks. It’s not cookie cutter, either conventional or functional. The point I was trying to make is it’s just so refreshing to do that. And learning from the patients, the patients are gonna tell you if what you’re doing is working. Not really the labs. Labs have a time and place, but the patients are going to tell you if what you’re doing is working. So we’re trying to learn from our patients.

DrMR:

Yeah. I mean, it’s something I’ve said many a time, which is, with the right model, you can learn from your patients. If you’re just training labs, it’s much more difficult to learn from that because you’re, in a sense, focusing on the objective measures, which unfortunately, as we discussed, many of these are fallacious. Then you’re not really looking at the symptoms as such an important, crucial part of that whole process. As we said before, the symptoms give you indications of if you’re correctly treating the cause, which is the paradigm translation we have to make. So obviously, we’re in agreement on this.

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The Patient Dashboard

One of the things that we’ve talked about is the hierarchy. The other thing that, and as you guys both onboarded into the clinic officially, at least my observation anyway, perhaps I’m being a bit self-aggrandizing, but I think that you guys found it useful the way I was organizing and laying out the data into kind of this patient dashboard. Where you have at your command kind of everything that you need was very helpful in making better decisions. You know, is there anything there that you maybe want to speak to me or that’s wrong? We’ll start with you, Joe.

DrJM:

I think I probably whined about the charting the most at the beginning, but now that I’ve been into it for a little while, I absolutely love the format and how it’s working. We’ve touched on here in our conversation, how important it is to kind of think through how the patient may react and what are the likely steps that we’re going to want to take with the patient. So whether, a patient is seeing myself or one of you we’ve gone through and listed what we think are the possibilities that could be going wrong with you so that we don’t lose sight of them as we are working with the patient. The other thing that we’re doing is listing out the treatments in the order, in which we think that they’re going to help the patient.

DrJM:

So we have those two pieces of information side by side, and it’s very, very helpful then to, as you’re working with a patient, particularly if it’s a complicated patient that has been through multiple physicians, you can click off items in your differential diagnosis. What things have you conclusively rolled out? What things are you think are less likely and what treatments have you maybe missed or haven’t broached with the patient yet. It really is very helpful in this model to have that mapped out at the beginning of a case. So at the beginning of the case takes a bit more work on our end. And a little bit more work on the patient to start the treatments, but that’s been so helpful. So absolutely helpful to all be on the same page and growing in the same direction there.

DrMR:

That’s one of the things I had said it earlier in the podcast before it was the round table, which is doctors, we don’t remember everything. So I know a patient likes to think that seven months in, we remember all this stuff that you remember about the time you got the stomach flu in Paraguay and whatever else. But we don’t remember all of that. There are limitations in our memory capacity, but if we can do all the heavy analysis on the front end, right after the initial exam and history visit, that’s when we do have that all percolating and circulating in our memory. That’s where we can make that hierarchy and so now, six months from now, we are making the best decisions because we’ve had all that mapped into the plan and then organizing the dashboard.

DrJM:

Yeah. It really helps down the line with the patient that’s not responding as most patients would. I think it’s important for patients to kind of realize that we often think of things in probabilities. We may see a particular patient presentation. I may thinking in my head, man, I throw this person on a paleo diet and give them three probiotics, I think that there’s a 70% chance that they’re going to be significantly better in two months. So what happens then is hopefully I’m right. But if they’re that 30%, then I have, the step two, three and four that I thought I might need to go into if it didn’t work. So it really helps problem solve with patients. Maybe it’s the patient who is the one out of 10 where we’ve tried a couple of things that really haven’t stuck.

DrJM:

It’s like, wait a minute. You know what? This patient really has had a ton of antibiotics, a ton of herbal anti-microbials, they’ve been doing a lot of fasting, but I don’t think this patient ever has had a really good trial on intestinal support and GI nutrients. Maybe this patient is really needs some time rebuilding their gut and that’s something that we done. So you can go back and problem solve with the patient. Sometimes, more often than not, the answer is somewhere there in the hierarchy that we’ve, we’ve already mapped out.

Clinical Studies

DrMR:

You know, again, guys, as I said before, if there is a magic sauce to this whole thing, it’s really the hierarchy construction, the data organization, the data analysis, and a lot of that heavy thinking on the front end. It’s just been so incredibly helpful. One of the other things that I want to make an announcement about is one of the other objectives that we had in this joint venture, which is collecting data and then analyzing that data for research publication. I’m happy to say that we’re now getting geared up for collection. I don’t want to say too much, but we’re going to be collecting data on SIBO and I guess we could say a new therapeutic in SIBO that has not yet been studied and we’re hoping to publish some data there.

DrMR:

What I foresee happening, and I think we’re all on the same page here, happening is the clinic will continually be collecting data on something and it may be item X for four months. Then after that, we say what is the next question that needs to have some answers provided for it? Then it’ll be item Y for six months. My hope is that we can start, through data generated from our office, publishing good answers to these questions that are not answered. So that clinicians have somewhere to go in terms of, well, I’m not sure what I should do now. Maybe I’ll do XYZ. We can start providing answers. There seem to be a number of things in the field that because there’s no evidence for or against, they just become these archaic remanence of the model. I know we all agree on this, we would love to know, should this be something that remains, or is this something that really is an artifact of speculation from five years ago? It has a lot of theoretical plausibility, so it remains in the model, but no one’s actually ever collected data to show that it had no appreciable impact on symptom survey X or on objective lab finding Y. So that’s another thing that I know we’re all very much so excited about, which is really, really trying to steer the field in a better direction. We harp on Science. Now we can also prove some of our hypothesis here with actual hard science

DrJM:

I think we can use the research to keep simplifying and perfecting the model. Where we are wrong we’ll be able to have the evidence guide us and let us change our practices. Our model is not about this therapy, this one supplement this one lab test. It’s getting patients better. So that was probably the thing that I’m most excited about when it comes to this venture. Starting to generate case studies, trials, papers to help guide the field away from this over-testing, over supplement nightmare that it too often has become.

Episode Wrap-Up

DrMR:

Yep, amen to that. I guess we’ll start with you Rob. Do you have any closing thoughts you want to leave people with?

DrRA:

I guess two thoughts. Again, this is probably more directed for the patients and the patient type folks in the audience. We as clinicians understand, if it isn’t already clear, all of the resources, financial, emotional, and mental components to someone’s total bandwidth, that must be considered in order to support you. We recognize that financial resources can go towards clinician time, that could go towards a health coach, that could go towards food, supplements, labs, other forms of care services. It could go to so many things that can be nourishing to you. We want to constantly be taking inventory of where is the most value for you. If it’s actually not with us in the clinic at that moment, let’s make sure we make that clear and direct you more towards say the health coach or a regimen of a dietary approach, or if we are in the place now where labs make sense.

DrRA:

I just want to share that so that even if you don’t work with us, you have a framework of understanding all of that matters. That’s why Michael wrote the book that he did. You can put emphasis and resources to many different areas. We just want you to know that all of those areas can matter. We take those into account in working with you, cause at any given time, at any stage of healing, some of those are probably more important than others. We can’t necessarily do everything at once. I mean, I don’t treat very many people with infinite resources, both financial, emotional, and mental bandwidth that can just do everything. As we were saying earlier, that actually is sometimes the antithesis of what we’re really trying to do. Embedded in there, the simplicity of this model is where the magic happens. How I see it and how I’ve been explaining this and we talk about our treatment is at the most simple level we’re trying to supply the cells and the body with elements that it needs and is deficient in and to be more nourished.

DrMR:

And to remove the elements and barriers that it doesn’t need to function. Any sort of therapy we apply is somewhere on one of those two sides of the level. We’re trying to dig in with clinical symptoms, sometimes with labs and other modalities to understand where the therapeutic should be on either side of that level. Using that understanding that there are many different areas you can put your energy into and it’s not right or wrong to only do one or two, or to not do one in this moment. It is an iterative process. I just see a lot of people banging their heads on walls, feeling guilty because they can’t do this, this or this, or they try to do all of it instead of just focusing on one. You’re not getting it wrong if you don’t do all of them at once, you can implement them at different stages. We understand that.

DrMR:

Thanks, Rob, Joe.

DrJM:

All right. I guess I’ll just close with, I think we’re kind of all in lockstep with how to get patients better, but if patients want to see the handsome doctor, they have to come see me.

DrMR:

This is true. Well, your wait list just went up a little bit.

DrMR:

Awesome. Well guys, thank you so much. I want to thank you both for making me feel like I’m not insane because there was definitely a point in time when I was seeing these things in the clinic and no one else seemed to be talking about them. I thought that perhaps I was just the idiot. Like man, maybe everyone else understands how to use these labs and I don’t, I’m just too stupid to see how this all maps out. Then I started writing about this in the clinician’s newsletter and we both kind of met around that same time. You guys were frustrated by seeing some of the same things and were applying some of these concepts and seeing some of the same results. That really helped me be much more confident in levying the criticisms that I have and in making some of these proclamations toward reform of the field. I should really acknowledge that you guys helped me immeasurably in that way. I’m so happy to be working together to be building this clinic that will continue to grow with other doctors, clinicians, and health coaches. I’m just really looking forward to the impact we’re going to have there on individuals. Also with the research that we’ll continue to publish together. So just want to close by thanking you guys for the good work and the great minds that you’re bringing to the table.

DrJM:

Here’s many years of keeping all of us together. We’ll all try to keep each other sane. So cheers guys.

DrMR:

All right. Thanks again, guys.

Outro:

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Discussion

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