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Friday, April 3, 2015

Functional Medicine: Healthcare’s Future

Time & Attention

If I had just one word to describe patient care at CFM [Cleveland Clinic's Center for Functional Medicine], it would be "thorough," with "unhurried" a close second. Four-hour visits are the norm, and CFM clinicians are free to take as much time as needed for physical exams, extensive history, and clinical guidance. There is no waiting room full of restive patients, no harried staffers.

Deep listening is an essential diagnostic tool, and at CFM it is guarded as such.

Prior to a first visit, patients must complete a 28-page questionnaire that goes deeply into personal and family history, and a host of diet, lifestyle and psychosocial variables. At CFM, information is power, and patients are encouraged to be highly active in their own care.

Dr. Hanaway said patients come with a wide variety of unresovled illnesses. Roughly half have advanced autoimmune diseases, with chronic systemic inflammation. Others have cognitive, behavioral, or mood-related issues.

"Melissa" is a 45 year old woman with a long, complex medical history beginning at age 10 with surgery for a congenital heart condition.

She sought help at CFM for three main issues: Disordered sleep affecting her memory and cognition; Hormone imbalances causing severe emotional volatility; and a pervasive, sometimes extreme sense of anxiety. In addition to ongoing conventional care, Melissa has explored many non-conventional options—with varying degrees of success.

Dr. Hanaway said one of the first steps in working with patients like Melissa is to figure out what not to do.

"I'm trying to gather data that helps me understand how to help this patient make a phased transition, moving from where she is currently--on four meds daily, four additional meds on a PRN basis, and seven different supplements. She's still having symptoms. So first off, what of those 15 different things ISN'T working?"

But he stressed that changes need to be made very carefully. "I could precipitate a crisis if I suddenly pull all of those 15 different things and start new things."

After the initial interview, Dr. Hanaway recommended several tests including the Genecept assay showing interactions between neurotransmitters and genetic expression; Genova's NutrEval, a urine test to assess Melissa's need for antioxidants, minerals, B vitamins, probiotics, and essential fatty acids, and the GI Effects stool analysis.

Dr. Hanaway noted that he'll also be looking carefully at Melissa's hormones,

"Based on my experience, I'm 95% sure she's going to show low progesterone, and she's going to benefit from progesterone. That said, I've had cases where someone's progesterone was fine but they were cycling it all to make cortisol because they're so stressed. The end effect is the same--no downstream feeding of androgens and estrogens, but the treatments are different."

A Hybrid Approach

Ultimately, he and the CFM team hope to guide Melissa toward a healthier anabolic-catabolic balance. He emphasized that the nutrition counseling provided by Brigid Titgemeier and the coaching from Laura Vuicich, are essential factors in achieving this long term goal. Nutrition counseling is non-negotiable at CFM; every patient gets a thorough dietary evaluation, nutritional work-up, and ongoing coaching.

In the short term, Dr. Hanaway encouraged Melissa to focus on her sleep issues, and recommended she substitute a standardized lavender extract called Lavela, for the Ambien she had been taking (visit www.holisticprimarycare.net and read "Lavender: An Effective Non-Drug Alternative for Anxiety & Depression").

"I will at times use herbs or nutraceuticals as substitutes for prescription medications, yes definitely," said Dr. Hanaway of this decision. Though he generally avoids the simplistic "this herb for that drug" approach, he says there are some instances—like this--where such switches make good clinical sense.

"This patient said she was taking Ambien, but was concerned about its impact on her cognitive capacity. I know Ambien can have that effect, and I know that Lavela won't." Down the road, behavioral and nutritional changes related to sleep hygeine will be important. But in the near term, "if I have something that can help her sleep, and balance neuropeptides, I'm going to recommend it."

Reflecting on her visit, Melissa told Holistic Primary Care, "I feel safe here. I like the idea of this hybrid approach. Its so segregated otherwise. Nobody's looking at the whole person. If you're into holistic care it can get very confusing." She added that she likes the objective measures that are part of functional medicine.


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