In Chapter Ten, we examined several differences between a conventional medical practice, and a collaborative practice model. In this chapter, we’ll dive more deeply into the practitioner’s experience of the ADAPT Framework.
The Clinician’s Experience
Let’s explore a day in the life of a clinician—we’ll call her Anjali—who has recently made the transition from conventional medicine to practicing Functional Medicine within the ADAPT Framework.
Looking forward to the day
Like many other physicians, Anjali was feeling burned out and drained in her conventional practice. The days were long, and she never felt that she truly helped her patients. After several years of this, she began to wake up on work days with a sense of dread. This was especially hard for her since she is naturally an optimistic person with a positive attitude.
But this morning, as Anjali prepares for her day, she can hardly wait to get started. She’s excited because she knows she’ll be able to offer her patients real solutions to their problems, rather than just suppressing symptoms with drugs. On a typical day in her conventional practice, she might have seen up to twenty-five patients; today, she has only eight visits scheduled: three new patients, and five established patients.
Plenty of time to prepare
Because of this lighter schedule, Anjali has plenty of time to prepare for her new patients. Her appointments don’t begin until 10:00 a.m., so she sits down with a cup of coffee in her home office and reviews the intake paperwork and lab tests for each of her new patients. As she reads each patient’s detailed medical history and examines their test results, she creates a report of her findings, which lists the underlying pathologies she believes are contributing to the patient’s complaints, makes recommendations for further testing, and outlines the treatment plan. Once she completes these reports, she feels much more confident about her approach; when she walks into the room with them, she’ll be prepared with not only a thorough understanding of their case but a comprehensive plan for addressing their problems. This is a dramatic change from her previous practice, where she rushed from one appointment to the next, always feeling like she was just skimming the surface and offering Band-Aids rather than real solutions.
A better work environment
When Anjali opens the front door, and enters the waiting room of her office, she smiles to herself. Instead of the harsh fluorescent lights, sterile white walls, and harried vibe she encountered in her previous practice, Anjali’s new office is beautiful, peaceful, and relaxing. It’s infused with natural light, with earth-toned walls, tasteful and comfortable furniture, and a small fountain in the corner. She heads back to the small kitchen to make herself a cup of tea, before entering her consultation room. This room has wood floors, a window facing a garden, a desk for her to sit at, and a sofa for her patients. It has soft halogen lighting, several plants, and tasteful artwork on the walls. Anjali opens her laptop and reviews the documents she prepared earlier for a few minutes before her first patient arrives.
Solving problems and offering hope
Anjali’s first patient, Maya, has severe rosacea that hasn’t responded to conventional treatment. Maya had seen several dermatologists, including the chair of the dermatology department at the local medical school. She’d tried topical antibiotics, sulfa-based face washes, and even isotretinoin, a medication with potentially serious side effects. None made a significant difference. During Anjali’s review of Maya’s labs, she discovers that Maya has severe SIBO. Anjali knows that this is a key finding, since she had recently read a study indicating that SIBO is common in patients with acne rosacea, and that treating it leads to either complete resolution or significant improvement in most cases (Butterworth et al. 2006). Anjali prescribed a botanical treatment for SIBO that has been shown in studies to be as effective as the pharmaceutical treatment, with fewer side effects and risks. For the first time in many years and numerous visits to the doctor, Maya left feeling hopeful and encouraged that she finally had a solution to her skin problem.
Anjali’s next patient, Aidan, is a fifty-eight-year-old male complaining of brain fog, memory loss, difficulty with word recall, and decreased cognitive function. Aidan is VP of business development of a technology company, and he’s alarmed by the decline in his ability to think clearly, retain information, and perform at work. Aidan’s PCP referred him to a neurologist, who ran some tests and told him that his genes predisposed him to a higher risk of dementia and Alzheimer’s and that these symptoms may reflect the onset of those conditions. This didn’t sit well with Aidan because his symptoms had started rather abruptly after he moved into a new home about six months ago. Anjali had also noticed the timing of the onset of Aidan’s symptoms in her detailed review of his history. What’s more, Aidan indicated that he noticed musty smells in this house, and that the crawl space has visible mold growing on the walls. A few months before this appointment, Anjali attended a seminar with Dr. Dale Bredesen (whom we met earlier in the book), where she learned about a type of dementia and Alzheimer’s disease that is caused by exposure to toxins like heavy metals and mold. Anjali had included some biomarkers for this in the initial testing she ordered for Aidan, and several of them came back positive. Anjali explains to Aidan that his symptoms may be related to exposure to mold in his new home. She recommends a reputable mold assessment company locally that can test Aidan’s house and make recommendations for remediation. She also prescribes treatment to support healthy detoxification, reduce inflammation, and restore cognitive function. Aidan leaves Anjali’s office feeling empowered and optimistic. After his visit to the neurologist, he felt hopeless as he contemplated the inexorable decline in mental health that he knew happened in dementia and Alzheimer’s patients. But now he not only had an explanation for his symptoms that made sense to him, he had several steps he could take to reverse those symptoms.
Anjali’s third patient is an eight-year-old boy named Tyler, who suffers from a long list of allergies (to both foods and environmental antigens like dust and pollen), asthma, and frequent colds and flus. Tyler’s parents had consulted with his pediatrician, an immunologist, and a pulmonologist. Not surprisingly, these practitioners prescribed several medications. Some of the drugs were at least mildly helpful, but none made a significant difference in Tyler’s condition. Tyler’s mother discovered Functional Medicine in her online research about his condition, and she was immediately drawn to it. Although Tyler’s issues are not uncommon among kids today, his mom always felt that there must be a reason for this: she intuitively knew that it’s not normal for kids to have such compromised immune function. Anjali ran a similar panel of tests that she had used with her adult patients, Aidan and Maya. She found that Tyler had a severely disrupted gut microbiome, with low levels of beneficial microbes and high levels of pathogenic bacteria and yeast. Anjali was not surprised by this because in Tyler’s intake paperwork his mom noted that he was born via cesarean section and was not breast-fed—both factors that are associated with a disrupted gut microbiome. Anjali also found that Tyler was deficient in several nutrients critical to proper immune function, including magnesium, zinc, selenium, vitamin C, and vitamin D. Finally, Tyler tested positive for intolerance to gluten and dairy, foods that he was still eating because the immunologist they consulted said that Tyler wasn’t allergic to them. Anjali explained to Tyler’s mom that intolerance and allergy are not the same thing, and that although allergy typically produces a more serious (and sometimes even life-threatening response), intolerance can also provoke significant symptoms, including immune dysregulation. Anjali prescribes an ancestral diet that is strictly gluten- and dairy-free, botanicals and supplements to reduce the pathogens in Tyler’s gut, probiotics and prebiotics to increase his beneficial bacteria, and some supplements to improve his nutrient status. Tyler’s mom leaves the appointment feeling relieved that she’s finally found some answers, and hopeful that this new plan will enable Tyler to get off his medications and begin to truly heal.
A collaborative model with more support for patients
As Anjali finishes her last new patient appointment for the day and heads across the street for lunch, she reflects on how different her experience as a doctor is now. Three years ago, if these patients had come to see her when she was working in the conventional model, she would have had little to offer them other than a prescription for a drug. She wouldn’t have had the time to do a thorough intake and review of the patients’ history; insurance restrictions would have prevented her from ordering the lab tests that were instrumental in her diagnoses; and even if she had been able to correctly diagnose the problems, she wouldn’t have had the training to treat them effectively or the infrastructure to support patients in making the necessary changes.
Fortunately, in her new practice, Anjali has both the knowledge to treat these conditions as well as the freedom to prescribe the interventions she thinks would be most helpful (rather than being tied to those that the insurance company has decided to reimburse). Moreover, she has a nurse practitioner and a health coach (who is also a nutritionist) on staff who can provide an additional layer of support for her patients. This turns out to be especially helpful in Tyler’s case; he has two brothers and a sister, so his parents have a lot on their plate and they are feeling overwhelmed by the magnitude of the changes Anjali is asking them to make. The health coach will be able to work closely with Tyler’s parents, giving them handouts that walk them through the supplement protocols, making suggestions for healthy foods that Tyler will eat on his new diet, providing recipes and meal plans, and offering moral support when needed. The nurse practitioner will also be available to help answer any follow-up questions related to the treatment protocol, address any side effects that Tyler may experience, and adjust dosages or change supplements as necessary.
The support of the health coach and nurse practitioner is not only a game-changer for Anjali’s patients, it also dramatically improves her experience as a clinician. Her patients are far more likely to follow through with her recommendations, which in turn leads to much more successful outcomes. And since Anjali doesn’t need to provide this support herself, she is able to maintain a manageable schedule while still offering a very high level of service to her patients. In fact, since she hired the health coach and NP, Anjali has been able to drop a full day of clinic time each week, which she has used for research and continuing education, spending more time with her family, and beginning to realize her long-time dream of learning to play the piano.
Streamlined operations and more time with patients
After lunch, Anjali walks back to the office to prepare for the afternoon’s appointments. She has five visits with existing patients; two forty-five-minute appointments, and three thirty-minute appointments. Three of the visits are in the office, and two are virtual via a HIPAA-compliant videoconferencing platform.
By this point in her day in her previous job, Anjali was already feeling exhausted. She went from one brief appointment to the next, with hardly enough time to say hello to patients, much less do a thorough review of their symptoms, lab tests, and treatment protocol and explore their diet, lifestyle, and behavior. Anjali’s prior employer did use an electronic health record (EHR), but it was plagued with problems and rather than speeding up workflow and providing more time with patients, it always seemed to have the opposite effect.
In her new practice, Anjali is using a different EHR that is optimized for Functional Medicine and the ADAPT practice model. All of Anjali’s established patients fill out a progress update form prior to their visit, which asks them to list any medications and supplements they’re taking; to rate their overall health on a scale of 1-10; rate symptoms like energy, pain, and cognitive function since their last appointment on a scale of 1-5, with one being worse, and five being better; document any significant changes or updates since their last appointment; and list the three most important issues or questions they want to discuss during the appointment, as well as other concerns they’d like to cover if time allows.
Anjali’s EHR also allows her to quickly access the appointment notes from any visits with the health coach or nurse practitioner that Anjali’s patients may have had between appointments with her. This makes it easy for Anjali to stay informed about her patients’ progress and provides important continuity of care.
Independence and autonomy
As Anjali moves through her afternoon visits, she is free to make recommendations and prescribe treatments she thinks are best in each situation, based on her research and ongoing study. That wasn’t the case in her previous practice where she was bound by standard of care and limited to the treatments that the insurance company would pay for (what I referred to as “reimbursement-based medicine” earlier in Chapter Three). Anjali knows that many of the newest scientific discoveries related to diagnosis and treatment take years, if not decades, to be adopted by insurance companies and primary care groups. She is grateful that in her new practice she has not only the time to do research and stay abreast of the latest developments but also the freedom and autonomy to order these new evidence-based tests and treatments for her patients.
For example, one of Anjali’s afternoon patients has Crohn’s disease. The typical treatments—and the ones insurance companies will pay for—are steroids like prednisone, aminosalicylates like mesalamine, or biologics like infliximab. While these medications can be helpful in reducing inflammation, and are sometimes necessary, they do not address the underlying cause of the problem: autoimmunity. They also have significant side effects and risks, especially in the case of steroids and biologics. Anjali used a different approach with this patient that involved an antimicrobial protocol to treat a previously undiagnosed gut infection, a special diet to reduce inflammation in the GI tract, and a low-dose of a medication called naltrexone, which is used at full dose to assist with opioid withdrawal, but has recently been shown to regulate the immune system and even induce remission in patients with autoimmune disease at lower doses. She is happy to hear that her patient is doing well and has not needed to take any of her previous medications, which included prednisone and mesalamine. In her previous practice, Anjali would not have had the autonomy, time, or support she needed to use this more holistic protocol.
Meaning, purpose, and passion
The differences I mentioned above between Anjali’s conventional practice and her current ADAPT Framework-inspired practice are so dramatic that her experience at work is almost unrecognizable to her. Whereas before she felt a sense of dread at the beginning of the day, and exhaustion before she had even made it to the end of the day, now Anjali literally jumps out of bed with excitement. Like Sherry, the clinician we met in Chapter Six, Anjali was considering a career change prior to discovering this new approach; she simply couldn’t imagine another decade of conventional medical practice. It had taken a huge toll on her health. She had gained weight, was starting to show early signs of diabetes, was having trouble sleeping, and didn’t have any energy left over for her husband and kids in the evenings or on the weekends.
But perhaps the biggest and most important difference for Anjali has been the strong sense of meaning and purpose that she now feels in her work. Like many physicians, Anjali chose medicine because she truly wanted to help people. As a young child, she displayed unusual empathy and concern for other people, and she entered medical school feeling idealistic and inspired to make a difference in her patient’s lives. But even before she finished medical school, this clear sense of purpose had become a vague memory. The reality of her residency—short appointments, an almost exclusive focus on pharmacotherapy, and little time to form meaningful relationships with patients—turned out to be far different than her dreams of what being a doctor would be like.
Fortunately for Anjali, through Functional Medicine and the ADAPT Framework, she discovered a way of practicing medicine that restored her lifelong sense of purpose: to be a healer who truly transforms her patients’ lives. She has a renewed passion for her work and cannot imagine retiring because it feeds her so deeply. This is the potential of this approach for all healthcare practitioners.
The Allied Provider’s Experience
The ADAPT Framework offers physicians the opportunity to help patients achieve lasting, curative healing. Patients, likewise, are freed from chronic illness and buoyed by the support of a collaborative healthcare team. But what about the other members of that team? What does it offer the nurse practitioners, physician assistants, coaches, and nutritionists who are also participating in the patient’s healing?
ADAPT offers allied providers a methodology and a framework. In many other contexts, allied providers find themselves in a situation where they don’t know where to start, or how to structure and layer an intervention with patients. They might recommend a diet change here, or supplement there, or lifestyle change there, but it’s not systematic. It’s not based in a framework or methodology, or even a narrative that makes sense to the patient or theclient.
Allied providers trained in the ADAPT Framework have an immediate place to start in providing a narrative to the patient. When allied providers explain the mismatch concept and importance of an ancestral diet and lifestyle to patients, they offer a firm rationale that puts the changes they’re making into a larger context. Having this context empowers patients to identify other areas of their lives where there may be a mismatch. Simply having that framework supports the changes; patients start to see their lives and choices from a different perspective. Certain behaviors or diet choices or lifestyle choices may have seemed normal because it’s all they’ve ever known, but now they begin to see that those choices are not “normal,” even though they’re common. Those choices contribute to their health problems. With the help of their support team, patients realize they can take meaningful steps toward better choices. They learn why they need to change, what they need to change, and how to make those changes.
Licensed allied providers—such as nurse practitioners and physician assistants—are also given the Functional Medicine tool set, to be able to diagnose and identify underlying causes of disease. Suddenly, these providers can do more than just suppress symptoms, ultimately making them far more effective at their jobs. As the doctor shortage worsens, allied providers are going to be increasingly on the front lines in ordering tests and prescribing care. They are the ones interfacing most often with patients, and do most of the legwork. Training in the functional approach and methodology is crucial for their ability to help their patients.
It’s also important for the non-licensed providers—like nutritionists and health coaches—to understand the core principles of Functional Medicine, even if they’re not ordering tests and writing prescriptions. The fundamental paradigm of practicing root cause medicine, understanding that diet, lifestyle, and behavior are at the root of all chronic disease, is tremendously empowering for non-licensed allied providers. Seeing healthcare this way reminds them they’re the most important link in the chain. These non-licensed providers work intensively with clients to accomplish the most necessary changes in their treatment.
Like patients, non-licensed providers need a support team. Too often now, nutritionists and health coaches have no regular way to communicate with the licensed providers in their practice. When a patient appears at their door, they may not know about medications the doctor has prescribed. Similarly, when the patient returns to the doctor, he or she might not mention the supplements the health coach recommended. What if the medication and the supplements are at odds? That’s problematic for everyone involved.
The ADAPT model advocates frequent communication and a close working relationship. In this model, allied providers experience more respect and likely more consistent work because they receive frequent referrals from the licensed provider. Some allied providers might get to experience working inside a collaborative clinic environment with other providers, receiving a salary and benefits. Many health coaches and nutritionists feel isolated at times because they work independently coaching clients; they miss the collaborative process of bouncing ideas off other colleagues. The ADAPT model advocates for close collaboration within a team of physicians and allied providers, recognizing all the advantages that come from doing so.