Our current medical model is clearly broken. The conventional system is buckling under the weight of misaligned incentives, broken payment models, inefficiency and bureaucracy, and a paradigm that is not well-suited to address chronic disease. As we’ve seen, patients don’t get enough time with the doctor, nor receive enough support in between appointments. Clinicians are dissatisfied with their inability to provide high-quality care to their patients and are suffering from disillusionment and burnout.
Functional Medicine enables practitioners to uncover the root causes of patient illness, opening the door to true healing rather than just suppressing symptoms with drugs. An ancestral diet and lifestyle empowers patients to prevent and even reverse disease by changing what they eat and how they live. The third element of the ADAPT Framework is a new medical model that better supports the delivery of both Functional Medicine and diet and lifestyle interventions and addresses the problems that plague our “sickcare” system today.
I call this a collaborative practice model. It consists of several elements. First, it embraces a more streamlined operation, which reduces overhead and bureaucracy and provides a higher level of care for patients and a better work environment for clinicians. Second, it refers to a practice that offers both in-person and virtual (via telephone and video conference) appointments, which gives both patients and practitioners more flexibility and allows practitioners to expand their practice beyond their immediate geographical area. Third, as the name implies, it suggests a model that incorporates both licensed providers, like medical doctors and nurse practitioners, and non-licensed allied providers like nutritionists and health coaches, to provide additional layers of support for patients beyond what they typically receive in today’s episodic care model.
Let’s take a closer look at what this model looks like in practice.
Independently Operated
Most Functional Medicine practices operate independently. Unlike conventional medical doctors, who must work within the confines of a cumbersome system, Functional Medicine practitioners often work as solo practitioners in private practice, or they belong to a group of physicians practicing together. In either case, Functional Medicine doctors make their own decisions, ranging from how they deliver patient care to billing procedures, business operations, and hiring decisions.
The Micropractice Option
Some Functional Medicine practices choose to function as a micropractice. A micropractice typically consists of just one doctor, who may be assisted by a coach or a nurse practitioner. That’s the model that’s probably going to work for most clinicians. A micropractice simplifies the primary care office to its most essential components so that it’s capable of delivering patient-centered, collaborative care. Functional Medicine focuses on delivering the best quality of care for our patients, and this is often contingent on reduced overhead.
My own clinic is larger, with four clinicians, a nurse practitioner, a health coach, two nutritionists, and thirteen administrative staff, but many of our strategies on reducing overhead lend themselves well to the micropractice model. For instance, we cut costs by not having a large, centralized location with the staff onsite. I sublet an office in a larger office. My personal office is adjacent to a waiting room with aesthetically pleasing furniture and beautiful lighting. It’s a restful, peaceful environment. Prior to coming, my patients will have filled out whatever forms they need to fill out online. If they had any questions, they’ve been answered via phone or email by one of my staff members who’s not onsite. They’ve been given instructions for how to go to the office and what to do when they get there. They wait in this lovely waiting room, have a glass of water or tea, and sit there until I’m ready. After I finish with my previous patient, I walk out into the room, say goodbye to the person I was just meeting with, greet the new patient, and we go back to my office.
If I need to order labs, I can send them to a local blood draw station, which means we don’t require an in-house phlebotomist. If I order supplements for my patient, we drop-ship them from a distributor or from our own online store, which means we don’t require a large space or additional staff.
This setup is quite different from what clinicians traditionally experience in a large, centralized medical practice. I don’t have a huge space to lease and pay for. I don’t have a large staff onsite. I can hire people in different locations who work virtually. I don’t have to struggle with high expenses or provide a low-quality patient experience. Cutting costs this way can help clinicians earn more without working more, and simultaneously improve the patient experience.
Lean Operation
Within the conventional model, clinicians don’t have much autonomy in determining what tests they can order, what treatments they can prescribe, and what they can suggest to patients. Many of the limits come from the rules established by insurance companies. Working with insurers is not only limiting, it’s difficult. Sometimes an insurance company will simply refuse to pay for a procedure, treatment, or visit that the physician recommends in the patient’s best interest. Interacting with insurers can be frustrating and exhausting. It requires staff whose sole purpose is to deal with the bureaucracy, paperwork, and seemingly arbitrary regulations related to insurance. The experience on the medical end can be maddening.
Many clinicians are choosing to move to a cash-only or a cash-plus-insurance practice. We operate on the cash-plus-insurance model—if testing can be run through the patient’s insurance, we do that. If the patient’s insurance doesn’t cover it, the bill goes to the patient instead of the clinician; this dramatically reduces the practice’s overhead, thereby creating a much “leaner” practice. Within this model, the practitioners are the decision makers in terms of what kinds of testing and treatment they make available to their patients—not a remote insurance company. As you might expect, this has major positive implications for patient care.
Unfortunately, the current lack of insurance coverage for Functional Medicine makes it hard to access for patients without the means to pay for it. I believe that this will change over time. As I argued in Chapter Eight, when the true costs of care (without insurance subsidies) are considered, Functional Medicine is far more affordable than conventional medicine. Later in the book we’ll learn how organizations like Cleveland Clinic and Iora Health are demonstrating this, and why it’s virtually inevitable that Functional Medicine will become the default model of healthcare in the future.
In the meantime, there are ways that Functional Medicine can be made more accessible. Some practitioners use a sliding scale pay method to help mitigate costs for lower income patients. Others offer discounts for people with financial need. One benefit of a cash-only model is that it enables clinicians to redirect some of the resources that were being used to deal with the insurance bureaucracy, and instead invest in hiring allied providers. Appointment fees with these providers are often lower than with the primary clinicians. Allied providers can also offer group classes and visits, which are more affordable than one-on-one sessions. For these reasons, the cash-only model can have tremendous benefits for patients if they are able to afford the care.
The combination of the leaner operation model and the use of allied providers can also increase the clinician’s income potential. If clinicians only make money when they’re seeing patients, that puts a hard limit on the amount of revenue that can be earned. If they’re also earning a small portion of money when the allied providers are seeing patients or running classes and groups, they can significantly expand their revenue potential without working morehours.
The leaner practice model creates more flexibility and convenience for both patients and practitioners. A cash-only operation can mean less overhead for the clinician, and increased income potential through working with allied providers. The income is valuable, but the improved quality of life clinicians can access in the leaner model is even more rewarding. Clinicians can work fewer hours, spend more time with their families, take care of themselves, make sure they’re getting enough exercise, manage their stress, and take vacations without suffering financially. The improved quality of life gives Functional Medicine practitioners the time and energy to continually learn, research, stay current with the most recent evidence and then implement those changes into their practice. Free from the dictates of insurance bureaucracies, they can run their practice with authenticity and purpose.
Longer Appointments
If a Functional Medicine physician—let’s call her Dr. Clark—is seeing a patient for the first time, she’ll spend anywhere from sixty to ninety minutes with the patient, over five times as long as a first-time patient might expect in the conventional model. With more time, Dr. Clark can talk to her patients about diet and lifestyle, and get their overall sense of what’s contributing to their disease or illness. Important information can come up in those conversations. A patient might mention something offhand that doesn’t seem particularly relevant to him but raises a red flag for the experienced physician. For example, perhaps Dr. Clark’s patient mentions that he’s staying up late using the computer. He might not think that’s a problem, but Dr. Clark would know that the blue light emitted from those screens can affect melatonin and interfere with sleep, causing a variety of health problems.
Surprising information can come up when you talk with your patients, information you may not get any other way. If Dr. Clark’s intake form asked, “How’s your digestion?” her patient might have written “fine” on the form. While talking to him, Dr. Clark learns he has serious discomfort after eating, and he has reflux. Perhaps her patient also mentions he has constipation or diarrhea, but he’s grown accustomed to it. He says it’s no big deal. He’s learned to ignore it. These are things the doctor needs to know. Sometimes patients hesitate to write down their problems on those intake forms. The only way doctors will learn about lifestyle practices like alcohol intake may be to talk with them, face-to-face.
Key details about family history also may arise during longer appointments. A patient might casually mention that her mother had rheumatoid arthritis, or her grandmother had her thyroid gland removed. Dr. Clark will recognize that both conditions are related to autoimmunity, something a patient wouldn’t necessarily suspect. Because Dr. Clark knows her patient’s family history, she decides to initiate testing of her patient’s thyroid antibodies to see if she had an autoimmune thyroid disease too. These “surprises” can often provide important clues to diagnosing a patient’s root cause issues, but would typically go unexpressed during a fifteen-minute conventional model consult.
Along with building a framework for understanding the in-depth context of a patient’s health, Dr. Clark also builds a relationship with her patients the longer she talks to them. Practitioners love making meaningful connections with their patients. Most of them entered medicine with the hope of having a discernable positive influence on their patients. They want to help people and form a connection with them. Longer initial meetings make deeper relationships possible.
Longer follow-up appointments can help build trust. Patients who are initially reluctant to divulge certain information might feel more comfortable revealing the details as their relationship with the doctor develops. That’s why follow-up appointments at Functional Medicine clinics are also longer than follow-up appointments in the conventional model. It may not be until be the third or fourth appointment that the patient finally feels comfortable enough to start revealing some of the critical details needed for a thorough diagnosis.
Limited Patient Count
Those long appointments don’t happen by accident. In Functional Medicine, practitioners tend to carry a much smaller patient load than the average primary care doctor. We noted earlier that the average PCP has 2,500 patients. That’s way too many to provide a high level of service, especially when many of those patients have chronic, complex illnesses.
Frequently, PCPs enter appointments with patients they haven’t seen for months. Imagine such an appointment with a patient called Lucia. Lucia has diabetes and high cholesterol, and is taking two drugs: a statin to lower cholesterol, and metformin to deal with her blood sugar issues. In this new visit, Lucia also complains of joint pain and swelling in her hands and feet. Something else is going on, but what? In a brief appointment, it’s going to be enormously challenging to find out. It may be all the doctor can do to properly follow what’s happening with the diabetes symptoms, blood sugar management, and cholesterol. Is he likely to also ask about Lucia’s dietary and lifestyle choices? He probably doesn’t have time.
The PCP is expected to not only accomplish that comprehensive evaluation, but also conduct a thorough intake on the new symptoms to determine contributing factors. After that, he’s charged with helping Lucia deal with those symptoms. Finally, the doctor must make a sound diagnosis and establish a good treatment plan. In twelve minutes. That’s nearly impossible, especially if the first five minutes of an appointment are spent with greetings and preliminary check-up questions. Doctors typically have a paltry five or six minutes to address new symptoms, prescribe a meaningful diagnostic test to determine the cause, and establish a treatment plan for those symptoms. No wonder these appointments so often result in an apparently efficient treatment: a prescription for a new drug.
Clearly, the current model isn’t providing adequate or thorough patient care. Most of the recent studies advocating for a new model of medicine suggest that the maximum number of patients a primary care practitioner can handle, while still delivering a relatively high quality of care, is closer to 1,500 patients, or even 1,000.
Functional Medicine practitioners handle a much smaller caseload, anywhere from 500 to 750 patients, depending on how much additional support they receive from allied providers such as nurse practitioners, physician assistants, nutritionists, and health coaches within the practice. These providers offer an additional layer of support and point of contact for the patient to receive sufficient care. Doctors supported by allied providers can carry more patients than solo practitioners.
Even with a relatively large clinic like mine, we’re able to provide a high level of service to our patients because of the support of allied providers. You can decide what level of patients is appropriate for you. You might want to expand so you can see as many patients as possible at your clinic. Or you might prefer a smaller practice, with simpler management and less complexity. In general, Functional Medicine practitioners meet with fewer patients, for longer times, to optimize patient care.
Connection With Patients and True Healing
We’ve discussed how a lower patient load means clinicians have time to build the relationships that can have a profound effect on care. In some cases, this can lead to breakthroughs that might not otherwise have happened.
I remember working with a patient, Charlotte, who was dealing with a complex, chronic, multi-system illness that was poorly defined. It didn’t fit any of the typical diagnostic categories. She experienced severe digestive distress, intense fatigue, insomnia, terrible sleep quality that hadn’t responded to any intervention, skin break-outs and rashes, depression, and acute anxiety. She had lost interest in many of her hobbies and pleasures, and when I first started working with Charlotte, her emotional tone was consistently tense. She was focused on the diet, supplements, and extensive treatments that she hoped would lead to her improvement—but maintaining those practices made her feel wound up all the time. For the first few months of working together, we did some testing and determined some underlying issues to address, but the results fell short. Certainly, her outlook was not improving. Her diet was severely restricted, and as a result, she wasn’t spending time with her friends. Her world was growing smaller. She felt like she had done so much to try to address her health yet didn’t see much of a return.
I intuitively understood Charlotte needed more joy and pleasure in her life. She needed a deeper connection with herself and a more meaningful way of managing stress. The answer for her was probably not going to come from supplements, treatments, or lab tests. We needed to shift gears.
I asked Charlotte to let go of some of the supplements she was taking, many of which had been prescribed by previous practitioners. She had long questioned whether they were helping her anyway, and simply managing the dosing schedule was practically a full-time job. I asked her to let go of some of her dietary rigidity, which she also wasn’t sure was helping much. Then, I asked her to make a list of all the things that brought her joy and pleasure. Her new treatment was to commit to doing at least one of those activities a day.
Essentially, we designed a program for joy and pleasure. Charlotte immediately felt that this approach was right. She was at a point where she had tried so many methods of treatment, both with previous practitioners and myself, that she didn’t have much energy to continue in her current direction. But a joy list? That was a plan she could get behind.
Six months later, she seemed like a different person. She looked relaxed. She smiled and laughed more. She appeared less tense, more at ease. Although the “joy plan” didn’t resolve all her physical issues, Charlotte appreciated being able to relate to her health in an entirely different way. She felt hope and happiness that she hadn’t felt for years. She restarted some of her hobbies and began traveling again. In fact, she even made a career change. Because she felt like the focus on lifestyle and behavior had been so crucial to her improvement and recovery, she decided to become a health coach, hoping to help others through the same methods that helped her.
My intuitive sense of Charlotte’s true problem only developed because of the amount of time that we had spent in appointments together. The answer arrived because of the relationship we had developed.
Telemedicine
Seeing patients in person is invaluable, but it’s not the only option. Telemedicine can be part of the mix. Admittedly, video may not be the ideal way to maintain a doctor/patient connection. Video meetings, however, are a close second to meeting in person. You can see the patient, they can see you, and you can have a rich conversation. Insurers are beginning to recognize the value of telemedicine; video conferencing is now reimbursed in many states, and others are moving in that direction.
Options like telemedicine offer convenience not only for practitioners but also for patients with busy lives. If a patient in San Francisco wants a thirty-minute appointment in my office in Berkeley, they may prefer to meet by video conference rather than deal with an hour’s worth of traffic and the Bay Bridge!
Practitioners love the flexibility telemedicine affords. They can work occasionally from home, or even while traveling. Clinicians can also see patients they wouldn’t have even known about in a traditional setting. Telemedicine expands the geographical boundaries beyond the local area. At our clinic, for example, approximately 70 percent of our patients live outside our immediate area. These patients will either drive or fly in for the first appointment and do it in person.
We require that first face-to-face meeting. It’s the best way to establish a relationship. After that, patients can do their follow-up appointments via video conference; once a year, we ask them to come back for another in-personappointment. Telemedicine allows patients who can’t access the healthcare services they need in their home town to get the help they need, and you have access to a vastly larger pool of potential patients. That contributes to income stability for your clinic, and reduces time spent advertising—it’s easy to promote a telemedicine practice using an online platform, such as a blog, podcast, website, or a social media outreach effort. In fact, this is the only “advertising” I have ever done for my practice, which has been closed to new patients for the better part of the last several years due to high demand and low turnover.
MDHQ
One area of dissatisfaction and pushback among doctors is with electronic health records (EHRs). Initially, there was a lot of enthusiasm for EHRs, but the way they’ve been implemented in conventional medical settings has been horrific. There’s a steep learning curve, and some software has increasederror rates. A lot of doctors don’t like having to look at a screen the whole time they’re with a patient.
But those problems are solvable. We use an electronic health record called MDHQ, which is specifically designed for Functional Medicine and for this type of practice. It’s streamlined. It doesn’t contain a whole bunch of features and things that you don’t need in a Functional Medicine practice. It’s also got a patient portal, where the patient can access their record. It has a lot of features that make it easier to get things done without having to stare at the computer the whole time you’re with a patient.
Collaborative Care Model
Physician appointments are only one part of providing care. The ADAPT Framework also employs a team of allied providers in a collaborative care model. Here’s how it works: During a patient’s initial appointment with the clinician, he or she would likely receive several recommendations about diet and lifestyle. A small percentage of people easily take those recommendations and run with them independently. Most don’t know how. To help patients implement those recommendations, the clinician will suggest a follow-up appointment with a coach, a nurse practitioner, or a physician assistant. These allied providers can spend more time with patients reviewing the nuts and bolts of behavior change and making a plan for the patient to reach his or her goals. Allied providers also follow up with patients regularly for brief check-ins to help them adhere to their lifestyle changes.
In our practice, a patient first meets with a nurse practitioner via phone or video. The nurse practitioner (NP) collects important information from patients, such as why they want to be seen, what their main complaints are, what they’ve tried so far, what’s worked and hasn’t worked, what other practitioners they’ve seen, any labs or other testing they’ve had, and so on. The NP also collects some basic health history, reviews body systems and symptoms, solicits information about diet and physical activity, and asks about exposure to toxins, infections, and other environmental influences.
The information collected during the initial consult with the NP directly informs the first in-person appointment with the patient, which we call the “case review.” The clinician reviews the patient’s past and present lab testing, detailed intake forms, and health history before entering the room, and prepares a report that outlines the underlying patterns the clinician thinks are contributing to the patient’s complaints, recommendations for further testing, and a treatment plan. This approach enables us to see the whole picture and make more rapid progress than in the conventional model.
At the end of the initial case review appointment, the clinician makes a series of recommendations for the patient. The proverbial ball is then handed back to the allied providers. If the patient needs additional support with implementation right away, the health coach can walk them through it and answer any questions they might have. The coach may also offer additional resources for changing diet, exercise, and stress management habits.
Approximately two weeks after the patient starts the treatment protocol, he or she might have a brief fifteen- to thirty-minute check-in with either the nurse practitioner or the health coach. The allied provider asks how the protocol is going and about any challenges that they’re having. He or she will then make recommendations for adjusting the approach, and provide much-needed moral support. These check-ins are key to the success of the ADAPT Framework. In a conventional model, or even many Functional Medicine practices, the patient might see the doctor two to four times a year, with no contact in between. The paradigm assumes doctors can simply give you information and you’ll go do it. As we know, that rarely works.
The ADAPT Framework assumes the patient needs support, and therefore we set up regular check-ins between the patient and the allied provider. We also have emergency appointments available, so if a situation comes up that the coach isn’t licensed to handle—perhaps the patient needs an adjustment of her medication, for example—she can have a timely appointment with the nurse practitioner or other licensed allied provider.
Allied providers can also share their expertise with more than one patient at a time. Some practices hold group visits or classes run by allied providers. For example, a nurse practitioner might teach an eight-week class on pain management for patients dealing with chronic pain. The nurse practitioner and health coach work together to create the curriculum, consisting of diet and lifestyle recommendations, and possibly supplement recommendations. Local patients dealing with pain-related conditions get together weekly, building a community as they discuss different ways to address their pain. Patients feel much less isolated and alone when they realize others share theirexperience.
Allied providers teaching these classes find them very satisfying. Group offerings give them another way to share their expertise and support their patients. Additionally, these classes provide a meaningful experience for the allied providers and practitioners. Many allied providers say their work is energized by the variety of patient perspectives that come up in these groups.
Health coaches often find working in a Functional Medicine practice more satisfying than maintaining a solo practice. Some coaches enjoy working independently, of course, but many more feel isolated. It can be difficult to build a practice, and many health coaches don’t enjoy the business and paperwork component. They may not be particularly entrepreneurial, and they may miss the collegiality of a team.
Working with other allied providers on a Functional Medicine team offers new opportunities for these coaches, including job security and interaction with colleagues. Many are also happy to be free of the tedious work of recruiting new clients. The main problem independent coaches face is what to do when they’ve reached a plateau with a client. They’ve worked on diet and lifestyle, but maybe the patient has a chronic illness that requires advanced medical treatments. Where do they turn?
When health coaches work with other licensed clinicians, they can offer more resources to their patients. It’s a symbiotic relationship: although clinicians can do lab testing, protocols, and prescriptions, they often don’t have the time or training to help the patient implement diet and lifestyle changes. Coaches are fantastic at behavioral support but can’t do the necessary testing. Working together, they both get better results.
Finally, working in a Functional Medicine clinic can help affirm a health coach’s professional value. Due to the less rigorous health coach certification process, health coaches sometimes feel like they’re not recognized as vetted professionals. Working in a clinical situation with doctors and other care providers adds a sense of legitimacy to what health coaches do, which helps coaches receive warranted validation. In our clinic, we have found that adding health coaches to our allied providers’ team is a win-win for everyone.
THE ROLES OF THE ALLIED PROVIDERS
Allied providers are crucial members of the Functional Medicine team. These practitioners work together with doctors and other clinicians to provide another layer of support and care for patients. Although Functional Medicine clinics work with a variety of allied providers, some of the most common providers and their roles are:
Nurse Practitioners (NP): Highly trained nurse practitioners, who hold national accredited licenses, can prescribe medication, examine patients, diagnose illness, and provide treatment like a doctor. In many states, they can practice autonomously.
Physician Assistants (PA): Like nurse practitioners, physician assistants can examine, diagnose, and treat patients, as well as prescribe medications, though they must be under the direct supervision of a doctor.
Registered Dietitians (RD): RDs complete extensive course work at the bachelor’s level, spend 900–1,200 hours within a dietetic internship through an accredited institution, and have passed a dietetic registration exam.
Certified Nutritional Specialists (CNS): These are practitioners who have completed an advanced degree at the master’s or doctorate level from an accredited university in nutrition, plus have completed 1,000 hours of a supervised internship, and passed a rigorous exam administered by the board for certification of nutrition specialists.
Physical Therapists: Physical therapists, highly educated, licensed healthcare professionals who can help patients reduce pain and improve or restore mobility, can be an asset to a Functional Medicine clinic.
Health Coaches: Health coaches work with patients primarily on behavior change, one of the most crucial parts of the Functional Medicine model in preventing and reversing chronic disease. The classification of “coach” is becoming increasingly standardized. National and international certification bodies have defined criteria for what a qualified coach should know and what the certification process should look like.
Collaborative Care for Patients
Let’s look at one of our patients, Ryan, who benefited from the collaborative approach. He came to see me for a variety of issues. He was forty pounds’ overweight—obese according to the BMI scale. He’d been diagnosed with prediabetes, was getting closer to having diabetic blood sugar levels, had sleep apnea, asthma, and other breathing difficulties, atopic dermatitis with itchy and painful rashes, ulcerative colitis with frequent flare-ups, and insomnia. He was on eight regular medications when I saw him, with inhaler and pain medications added in as necessary.
In Ryan’s initial work-up, we determined that his diet was poor. He was busy and found it hard to eat right. He wasn’t exercising or moving regularly, and wasn’t doing anything to manage stress. We put him on a nutrient-dense, whole foods diet with modifications for weight loss and autoimmunity, and he managed to lose thirty pounds in the first three months that we worked together. We did gut testing and addressed the issues we found. Then we got him doing some simple stress management techniques and taking some supplements to help with sleep and the effects of stress.
You’ll notice I said “we” when describing Ryan’s treatment. It wasn’t just me, the clinician, delivering care. Ryan worked intensively with our health coach and our nurse practitioner to make these changes. He really got a chance to talk about the issues in his life and get clear on how change would be most effective. We then broke these things down into manageable chunks that he could work with.
The collective support made a huge difference for Ryan, and when he started to make those diet, lifestyle, and behavior changes, his symptoms improved simultaneously. He lost weight and his blood sugar went back to normal levels. His sleep apnea disappeared and he no longer had to use his CPAP machine. His dermatitis scaled back considerably, and he started being able to sleep well even without medication. In that three-month period, he got off seven of the eight medications that he took regularly and hadn’t used any of the ones that he took on an as-needed basis.
Collaborative Care for Physicians
Providers like Sherry, the physician we heard from in Chapter Six, can escape burnout by switching to the practice model we’ve described above. Instead of feeling like a cog in a patient mill, and just handing out prescriptions all day long, Sherry now has the time to talk to her patients about ways to prevent and reverse disease. She can utilize allied providers like health coaches and nutritionists to support her patients in making those changes stick. Her new working environment helps her optimize her own quality of life as well. She’s now able to pursue her own interests and incorporate those into her practice. She feels like she’s having an impact on patients that she never could have in her previous practice. I’ve heard the same story from many practitioners who have made the switch.