The following is an article I wrote for the Texas Association of Physician Assistants.
1) What got you interested in functional medicine?
When Dr. Jeffrey Bland coined the term “functional medicine”, it was intended to be a hybrid of molecular biology, integrative medicine, and conventional medicine. It was not intended to be “green allopathy” (more on that later), or even a “specialty”.
I grew up in this medical model, and it was because of it that I transformed from a sickly kid to a child that thrived. The primary trigger for my health issues was due to non-allergenic inflammatory reactions to various foods (which was determined based off lab tests). Eliminating these foods allowed my immune system to work properly, and I significantly improved. Thus, I knew the impact of food on health from a very young age!
I knew I’d eventually work in functional medicine (which I consider to be a type of integrative medicine), but during PA school, one of the physicians in my clinical rotations told me that if I ever discussed nutrition or lifestyle modifications with any of his patients, he would fail me from PA school! It was the first time I directly experienced the animosity towards “integrative” medicine. Up until that point, I thought everyone knew the importance of nutrition in health and disease!
My first job out of PA school was in orthopedic surgery, so I could get a better understanding of evaluation and management of musculoskeletal conditions. Towards the end of my time in orthopedics, a woman in her late 60’s came to see me and told me I had changed her life. She was scheduled for a knee replacement, and she was justifiably terrified of undergoing surgery. At her preoperative appointment, I briefly mentioned to her that sometimes eliminating inflammatory foods can improve pain (specifically nightshade foods and grains for joint issues), and she followed my advice. Within a few weeks of eliminating those foods her pain was mostly gone! She scheduled the appointment with me just to tell me “thank you”, and it was at that moment that I realized I needed to get back to my passion for functional and lifestyle-focused medicine.
2) How is functional medicine unique?
I tend to call functional medicine “hybrid” medicine, because we utilize various elements of different medical models. There is no degree for functional medicine, and there is no governing organization that controls who can call themselves a practitioner, which can make it confusing for both patients and my colleagues. However, organizations like Cleveland Clinic, Loma Linda University, and the Mayo Clinic are getting involved.
I utilize my skills as a PA to narrow down a diagnosis, to rule out red flags, and to weigh the risks/benefits of pharmaceuticals. However, I go beyond the standard of care, educate my patients on the pros/cons of conventional vs “alternative” options, and spend a lot of time during and after an appointment to personalize patient care. I am on PubMed and Cochrane Review at least 10 hours a week! Understanding of pathophysiology and biochemistry is part of my daily practice, since I’m trying to identify the CAUSE of symptoms (vs stopping at the diagnosis). It is not an easy model, but I am a complete medical nerd, so I fit in perfectly!
For example, my training as a PA taught me how to diagnose and treat type 2 diabetes, but I know that insulin resistance is at the primary cause of the disease. Besides metabolic syndrome parameters, we were never really taught how to identify insulin resistance in conventional medicine. This is how I initially approach care in these patients:
1. When we think about the function of insulin, we know that it primarily responds to rises in glucose. Thus, a first step in treating a patient with diabetes is to lower the intake of glucose (i.e. sugar and starches), and follow fasting insulin levels. The goal is to get fasting insulin under 7 (in conjunction with lowering blood glucose parameters).
2. I look at patterns in the common diabetic “biomarkers” (e.g. lipids, HgA1c, CMP, hsCRP), and use these patterns to personalize diet/lifestyle habits in a patient.
3. The first step in anyone with diabetes or metabolic syndrome is to educate patients on the World Health Organization’s guidelines on limiting added sugar to 25 grams per day, and explain what “added” sugar encompasses. This is an essential component of treatment, but unfortunately the ADA doesn’t include the WHO’s guidelines in their recommendations, so most endocrinologists or patients don’t receive education on this.
3) Why was it important for you to open a practice?
I never intended to pursue co-ownership of a practice, but as I worked in various cash-based independently-owned clinics, I got to know the positives and negatives of operating a business. I ultimately realized that I needed to be more than a clinician if I wanted to practice what I consider “real” functional medicine and be able to help more patients (without putting them into debt!).
To get started, I needed to define what was going to set me apart from other clinics and why I needed to become a business owner. For anyone interested in pursuing ownership, this is an important step! For me, I wanted my clinic to follow these 3 key principles:
1. Stop the practice of “green allopathy”. Green allopathy is the practice of recommending a “natural” pill for every symptom or abnormal lab. The art of functional medicine is in the education we provide, and the patterns we identify via lab results. For various reasons I cannot go into, many need supplements because our diet does not provide all the nutrients we need. However, a supplement is usually not addressing the cause of illness, and we don’t have enough evidence to support the benefits – let alone the risks – of “poly-supplementation.”
2. Less is more. Just like conventional medicine, we must correlate symptoms with lab results. Although it’s good to “test not guess”, chronic symptoms and diseases are mostly rooted in poor lifestyle habits. We do not need to run a lot of expensive complex labs on everyone. The first steps in evaluation and treatment of a patient with chronic conditions starts with comprehensive blood work (often covered by insurance), addressing environmental exposures and lifestyle habits, and optimizing digestion (which often requires a stool test to see how digestion is working).
3. Cost transparency. The high costs for functional medicine come from 3 primary factors: office visits, labs, and supplements. When I created the mission statement for the practice, I wanted patients to save money. This is done by keeping office visits brief yet effective, by charging at cost-prices for labs, by offering discounted high-quality supplements via an online professional dispensary, and by minimizing the use of labs/supplements. In order to obtain these goals and maintain my license as a PA, I needed a good physician partner with whom to embark on this journey. After speaking with half a dozen or so physicians, I serendipitously found my current physician partner. He has practiced all nuances of integrative medicine for over 30 years (so he knows what works and what doesn’t), he has a good “moral compass”, and he has a high success rate with his patient outcomes. He also loves to educate, and wants to create the practitioner “internship” program that is on our 5- year-goal list!
4) What challenges have you faced?
As I was creating the business, I made a list of everything I did and had to do, even down to getting toilet paper for the space I rent out! Challenges that were specific to my position as a PA in Texas included:
1. Legal “stuff”. Texas Medical Board rules for PA’s fall under multiple codes, and it is a daunting process to read and find these! For example, I was 90% through the process of creating the practice when I learned that, according to Business Organizations Code 301.012, I couldn’t be an officer of my own company. What that meant is that I couldn’t make any business decisions in the company I co-own! Since my physician partner just wants to practice medicine, I determine most of the business operations, but he has to approve all decisions so we abide by the TMB laws. Hopefully HB4066 will pass (which will allow me to be an officer of my own company), and that will make this process easier [update – this did NOT pass…but we hope to include it in the next round of proposed changes in legislature (this is why it is so important for PAs to pay dues for their local PA associations, dues which pay for lobbyist’s to do the work to generate support for bills that can impact the PA profession)].
2. Challenges of being an “underdog”. The functional medicine model is routinely criticized and ridiculed (mostly due to the lack of understanding of the model, and the lack of regulations). Not only do I have to prove my capabilities as a PA and be a “minority” business owner (not many PA’s co-own practices in Texas!), but I also have to prove the efficacy and true nature of the functional medicine model.
3. Erosion of collegiality. I encountered this in online forums, where I was trying to learn more about PA- and NP-owned clinics. I learned that many physicians see PA and NP clinic ownership as a form of controlling how a physician practices medicine. They also see ownership as a gateway into independent practice, which many physicians adamantly oppose.
4. Marketing. In mainstream medical practices that take insurance, the insurance companies basically provide the “marketing” for the practices. Patients need a practitioner that takes his/her insurance, and the insurance companies provide a list of practitioners for the patient. But insurance then controls a lot of the business and clinical operations of the practice. My practice is cash-based (insurance is utilized for labs, and super-bills are provided for reimbursement purposes). In functional medicine, word-of-mouth, social media, colleague referrals, and my reputation are the primary ways I have to promote the business. It is a challenge to promote myself and my business without sounding like a salesman!
I have seen so many “miracles” by utilizing the functional medicine model, but not every patient or practitioner is a good fit for this model. Our current medical system addresses chronic disease with pills or procedures, but we all know that chronic conditions can be improved with the right education and instruction for improving lifestyle habits. I chose the name Center for Collaborative Medicine, because the way we treat patients is a collaborative effort with both the patient and the practitioner, and this often includes multiple practitioners and multiple medical modalities. If you want to collaborate, please reach out to me!
And, of course, referrals are the best compliment!
Meg McElroy MS, PA-C