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RHR: A New Model of Care for Chronic Disease

Post From https://chriskresser.com/a-new-model-of-care-for-chronic-disease/

revolution health radio

In this episode we discuss:

  • Schweig and the California Center for Functional Medicine (CCFM)
  • Shortcomings of the episodic model of care
  • Changing how care is delivered
  • The collaborative care model
  • Technology advancements in collaborative care
  • Giving clients more resources and access to more professionals
  • Hiring a health coach and registered nutritionist
  • Group treatments and reducing the feeling of isolation
  • The Berkeley Fire Department pilot wellness program

[smart_track_player url=”http://traffic.libsyn.com/thehealthyskeptic/RHR_-_A_New_Model_of_Care_for_Chronic_Disease.mp3″ title=”RHR: A New Model of Care for Chronic Disease” artist=”Chris Kresser” ]

Hey, everyone. Chris Kresser here. Welcome to another episode of Revolution Health Radio. This week, I’m excited to welcome back Dr. Sunjya Schweig. He is my co-director at the California Center for Functional Medicine. And in this episode, we’re going to talk all about a new model of care, specifically for treating chronic disease. Now, in my book, Unconventional Medicine, I mentioned that conventional medicine is fantastic at dealing with acute trauma, emergency care-type of situations but really lousy when it comes to addressing chronic disease. So the obvious question is, what is the best model for treating chronic disease? And I outlined that in my book Unconventional Medicine. But I wanted to ask Dr. Schweig to come on the show to talk a little bit more about how we are implementing that at the California Center for Functional Medicine, so you can get a better idea of what it actually looks like in practice. I’m really excited to have him back on, and I hope you enjoy this episode.

Chris: Sunjya, it’s a pleasure to have you back on the show.

Sunjya:  Yeah thank you. It’s a pleasure to be here. I’m excited for today’s topic.

Chris:  So, you have been on the show before, and I think some people have met you that way, but there are probably several listeners that haven’t. So, why don’t we start with your background, how you got into medicine, and then how you transitioned to functional medicine.

Dr. Schweig and the California Center for Functional Medicine (CCFM)

Sunjya: Yeah, so I grew up here in Northern California and had a very alternative upbringing. Lots of focus on alternative medicine as our main option for care in the family as well as diet; vegetarian and pluses or minuses on that, but also organic, really conscious thinking in terms of how my parents were putting everything together. And as I made my way up through high school and into college, I pretty much knew in high school that I wanted to go into medicine, and, however, I also knew, especially towards the end of my college years at Berkeley that I didn’t want to practice mainstream medicine.

And I did some work at UC Berkeley learning about medical anthropology and religious studies and was very passionate about trying to understand other people’s explanatory models. Sort of what did they think was happening to them and why and transitioned and did some work abroad in Ecuador expanding on that, but then also starting to interview and work with some of the indigenous people on some of the folk medicine or herbal medicines that they were using. And so I made my way through, up through med school after that at UC Irvine and then my residency at the UCSF Santa Rosa Program, and the same thing.

Basically, I knew that I wanted to do medicine, I love science, I think science is amazing in many regards and I’m passionate about it. And at the same time, I kept plotting my course and making sure, and also hoping, there’s a little bit of risk there, but hoping that I came through the other side and could integrate everything into alternative, functional, complementary medicine practice. And my plan came to fruition. I would do whatever coursework and electives during my studies, but then immediately after I graduated from residency, I started a Functional Medicine practice with a friend and colleague, Brian Bouch, who was always a mentor for me from even before I started. So it was nice to be able to jump in with him.

Chris: And so you were practicing Functional Medicine in that clinic, and I imagine that was going well for the most part, but what led you to transition from that situation?

Sunjya:  Yeah, so I think with any career trajectory, there’s different phases and that served me really well for a number of years. I was there for about seven or eight years. And it took a little while for me to get launched and got my feet under me. And then I started working more intensively with patients with chronic infections after my wife was diagnosed.

People don’t struggle to change because they don’t know what to do; they struggle because they don’t know how to do it. Collaborative care can help.

Chris: Mm-hmm.

Sunjya:  And that’s sort of like a pretty serious training ground for this type of medicine because of how complex the patients are and you really have to use any and all avenues that are available. And so that’s happened, I got more busy, started doing more lecturing and teaching. And it was around that time that I found you. We met and started kind of talking, and we had also moved. So geography was part of it. We had moved from Sonoma County down to the East Bay where my wife and I had met at Berkeley. So came back down here and the idea of commuting back up to Sonoma County for work was not a long-lasting solution. So things evolved from there and that’s kind of the birthplace of CCFM really—the pinnacle conversations that you and I had.

Shortcomings of the episodic model of care

Chris: Right, yeah. So I remember that quite well, because … And we met down on Fourth Street, in a restaurant there, and we had a kind of similar experience and a shared vision, I think. We had both been practicing Functional Medicine, me on my own and you in a group practice but kind of in a solo fashion, it seemed like, for the most part. And we both had had some successes, we were … The Functional Medicine model is really powerful and patients were getting better. And at the same time, we both also were aware of some things that were missing. I know that one of the first things that we connected on was the shortcomings of the episodic model of care for people who are suffering from really complex chronic illness. And I know you like to say this, we both do, that many of our patients are not sick enough to be in the hospital, but they’re too sick for just seeing a doctor or practitioner once every three months for a half hour. That really didn’t cut it for a lot of our patients. And yet that was the model that we were employing and that we were familiar with because I think that’s just how it was done. Granted, we had longer appointment times than in the conventional model with eight- to 10-minute visits, we were seeing patients for 30 minutes, 45 minutes, or even an hour in follow-up, so that was very different. But even that, every three months just wasn’t enough.

Sunjya:  Yeah, yeah, absolutely. Yeah, I mean, the fact is that as a clinic ourselves, and I think Functional Medicine doctors in general tend to acquire and collect the people who really haven’t been served by the system. They were still sick despite seeing 10 or 15 doctors, and our friend and colleague, Mark Hyman, I love his phrase, but he says that the people who see the holistic doctor are the people with the “whole list” of medical problems.

Chris: [chuckle] Yeah, exactly.

Sunjya:  Right? So, yeah, so, you’re absolutely right, and then that was one of the real key factors that you and I started discussing from the outset, which is that this, even though we think and we hope and we get some feedback to the point that we’re helping people frequently, it’s certainly not an optimal system.

And when we have patients that have this huge long list of symptoms, and I spend the first 15 or 20 minutes of the appointment just saying, “Okay how’s your headache? And how’s your knee pain?”

Chris:  Right, right.

Sunjya:  “How’s your brain working? And what happened when I gave you that supplement for your GI tract?”

Chris:  Yeah.

Sunjya:  And that’s just not a great use of anybody’s time or resources, especially given where we’re at this point in time with the ability to leverage technology.

Changing how care is delivered

Chris: Yeah, and it’s interesting to me because I think that that episodic care model is just like a carry-over from the conventional approach. And we’re kind of in this process of reinventing all different aspects of how care is delivered. Functional Medicine is really a paradigm shift, shifting from suppressing symptoms with drugs to addressing the underlying cause of the problem. But I think along with that, what we realized is, it’s not just the medical paradigm that needs to shift, it’s how care is delivered. And it felt a little bit to me early on like we had adopted this new paradigm, but the model that we were using for delivering the care was still kind of based in the old way. And there is a disconnect there. Just as an example, if we recognize that diet, lifestyle, and behavior change are really at the core of addressing complex chronic illness, which I know we both agree on, how do you really successfully support patients in making those kinds of changes if you’re just seeing them once every six months? That’s a total disconnect.

We know that behavior change, it’s not just about information, it’s not just about telling people what to do. You can’t just hand someone a list of 42 recommendations and expect them to go and be successful with 100 percent of them. There need to be frequent touch points and check-ins and support that are offered over the next several weeks or months that they are going to be implementing those things. When we had lunch that first time and we’re chatting about this, we both … I was really excited, I remember feeling really excited because I was like, yes! This is right. This is exactly the way it should be and it can … there is nothing stopping it from being this way.

Sunjya:  Yeah, absolutely. I remember that lunch well. I remember other sessions that we had. For example, I remember I parked myself at the, I think the library at UC Berkeley. At one point I was working on a lecture that I was going to give at the Eye Labs conference, and you and I had gotten involved with a Google Doc, just kind of batting ideas back and forth. And it was just an exciting moment. I just felt like it’s the start of this new era. and I remember that document. We were, we’re still in the process of implementing it, but that document largely focused around this idea of building in these extra layers of support.

Chris: Yeah.

Sunjya:  So we’re doing this exciting thing in Functional Medicine. We’re offering this care to people that we always were striving to get to the root cause of what’s happening. But you’re right that we’re still working within the mainstream system. And sure, we might have longer visits to offer people, but still, and we might catch on more lifestyle pieces, like, hey, I think you should meditate. I think you should focus on this diet and you should be doing this kind of exercise. Or this kind of psychospiritual work. But to tell the patient that okay, that’s a step in the right direction, but to tell them that without giving them the fabric and this sort of community network of support around that work, we’re not in any way approaching the efficacy that we could have.

Chris: Absolutely. As you know, Sunjya, I’ve been kind of a behavior change geek. And when I was researching for the practitioner training program, and even more now with the upcoming health coach training program, and when you look at the research on behavior change, it’s just so clear that, as I said, information is not enough. People don’t struggle to change because they don’t know what to do, they struggle because they don’t know how to do it. [chuckle]

Sunjya:  Yeah.

Chris:  And I would even extend that and say they don’t have the support they need to do it.

Sunjya:  Absolutely.

The collaborative care model

Chris:  It’s not because people are lazy or unmotivated or ambivalent, even although those can be factors in some cases, but they’re really the minority. It’s more just not knowing how to actually change. That’s like a huge cornerstone of this collaborative care model, that I wrote about in Unconventional Medicine and that we’re really trying to implement it at CCFM. And it hasn’t been perfect, but I think we’ve made some strides. First two years … The first year really was about, for me, building out the capacity to serve more patients, because I think we both had the same situation when we started, where we had really full practices.

I think my waitlist was like a year or a year and a half at that time, and it was painful not to be able to help people who needed help.

Sunjya:  Yeah.

Chris:  Because I’d been in that situation myself as a patient, and to have to turn people away and to not even really have many other practitioners to refer them to was painful. So I hired Dr. Amy Nett who was working earlier on in her career as a radiologist at Stanford and had seen the limitations of that model, was tired of doing scans of obese eight-year-olds.

Sunjya:  Tragic.

Chris:  Tragic with markers for type 2 diabetes at eight years old and just figured, hey, this is probably not the best way that I could help them. If I can get involved earlier and prevent this from happening in the first place, I’m gonna have much bigger impact. And so she joined us … Gosh, two-and-a-half years ago I think, now.

Sunjya:  Yeah, that’s about right.

Chris:  And it’s been amazing to have her on staff, and she’s now treated hundreds if not thousands of patients, just is … amazing to have her expertise with radiology as well. We sometimes now rely on that with a NeuroQuant, and other things that we’ve expanded into. And then I think … Did you hire Ramzi before I hired Tracey? Or is that right around the same time?

Sunjya:  Yeah, a little bit before. Ramzi joined us, I first met him in the summer a year and a half ago, then he joined us last fall. Yeah, so Ramzi’s another really interesting case. And we’re seeing this a lot and I love how you approach it in your book Unconventional Medicine you were just talking about, and it’s sort of a truism in Functional Medicine that so frequently doctors within the mainstream system are aware that their hands are tied, but they don’t know what to do about it and they’re becoming increasingly frustrated and burnt out. And Ramzi’s a great case in point.

Here’s this really smart, passionate … he’s just a great, great person working in mainstream infectious disease, and he’s basically realizing that he is joined with these incredibly sick people. He’s frequently recovering them from either death or severe, severe illness using his infectious disease skills, antibiotics, infection control, etc. But he’s not really moving the needle in terms of helping people really get better. And so he on his own had been very passionate about Functional Medicine, was working his way through the Institute for Functional Medicine training programs. And when I met him it was like another one of those ah-ha! moments. We talk about in our clinic that we want to work with the best of the best, and you and I, I think, have really developed our intuition in terms of getting a sense of, is this person an A player? Are they going to be a great addition?

And as soon as I met Ramzi, I was like pinching myself. It was like, oh my goodness, this guy is amazing and just would love for him to join our practice. So that’s been a great transition on our end and again I think we, like Amy with her radiology knowledge, we’re really leaning on Ramzi for his infectious disease knowledge as well. And so many of the patients that we treat with these multi-system illnesses, so much of the time there’s some kind of infection in the background that’s triggering them. So, yeah, he’s been a wonderful addition to the team as well.

Chris: Yeah. And that’s been amazing for me, just this team approach to care that we have. If I have a patient with a tick-borne illness or a complex chronic infection, for example, one patient comes to mind who was working in the Peace Corps down in South America and came back with a very mysterious illness and nobody could figure it out. And even though I have my own experience with mysterious illness that I acquired while traveling abroad, that’s not my particular area of expertise. But of course, Ramzi used to work for the WHO and has worked in Africa and South America and does have expertise in this area. And so it was amazing to be able to get ideas about what kind of testing to run. He has friends at the CDC that he was able to contact and get advice on a pretty unusual … I think it ended up being a gallbladder fluke or a liver fluke. And just to have that expertise that I can rely on is amazing.

And we’re constantly going back and forth. I’m asking you questions about the finer points of Lyme, and you’re asking me about advanced lipidology and cardiology, and we ask Amy about her opinion on radiology scans. And it’s just … for me as a practitioner, that’s certainly a gratifying experience because it keeps me on my toes, I get to continue learning, and I get to offer a much better range of care to my patients.

Technology advancements in collaborative care

Sunjya:  Yeah. The patients really appreciate it and the thing that’s so fun for me also is how we’re leveraging the technology for this. And so as some people might know, I’m not sure, I think most of our patients know about the community at large, we are a distributed clinic. And we have our five practitioners spread out across from Palo Alto to Berkeley to Marin to Sacramento. So we’re not face to face with each other all of the time and so we’re using technology like Slack for example––a great communications system. And so we’re basically in there, we all have our Slack channels open, and so if I send out a question to one of you guys, almost always the answer comes back super quickly and we get the information that we need, sort of what we call in medicine like a curb-side, where you ask a question and get an answer from another colleague or a specialist. And then same with our staff, right?

So our staff who are all working from home, we have over 10 people now mostly in California but spread out across the U.S., and we have a channel on Slack called “urgent patient needs.” And so if I’m running late or the patient’s not there in the office, or I need a lab result, I put that in there and usually within one or two minutes one of the staff picks it up, answers the question, pulls the lab in, and calls the patient, whatever needs to happen. And so I remember at my old clinic, I used to have to get up, open the door, walk out to the front desk and say, “Hey, this lab’s not in the chart. Can you please call the lab?” and go back in the room and then maybe hopefully by the end of the visit, we’d get a hold of the lab.

Chris: Oh, right, because they have to open the file drawer and then thumb through all the files to find the file, and then the file is not there [chuckle].

Sunjya:  Or call.

Chris:  Yeah.

Sunjya:  The lab. I get this whole …

Chris:  And then yeah, and then the lab has to fax it over and you’re like, “Wait, are we in 1985 here? What’s going on?” [chuckle]

Sunjya:  Somebody would be standing by the fax machine pulling the paper off of the fax.

Chris:  Yeah, it’s so bizarre that medicine in some ways is very far ahead technologically, but in other ways, it’s totally in the dark ages.

Sunjya:  Absolutely.

Chris:  Wow.

Sunjya:  Yeah.

Chris:  Yeah. So I haven’t even had a chance to tell you this, but we had… Tracey and I … We’ll talk … come back to Tracey in a second, but we had a patient last week who came to see us who lives in Dallas, and he’s an investor. And he’s really interested in investing in Functional Medicine and healthcare in general. He’s passionate about this. He sees this as the future of medicine and he wants to … In his own way, because that’s his background in finance. He doesn’t wanna become a doctor [chuckle] or enter into it that way, but he wants to use his skill and expertise and resources to support the movement. So he’s really interested in investing in Functional Medicine models. And he paid us such an amazing compliment, which he said it was the most incredible experience he’s ever had

From the beginning, when he signed up as a new patient to when he was sitting in our office, the best experience he’d had with any company that he’d worked with, not just in medicine or healthcare. And he said he actually saved the emails that we send as part of our new patient onboarding sequence because he wants to figure out a way to kind of rubber-stamp that and roll that out in other ways. So I just wanted to let you know that because I haven’t even had a chance to tell you. It’s pretty great feedback because that’s something that you and I have worked a lot on, and you’ve been really passionate about how to use technology to create … to automate things that can be automated, so there’s more time for the things that should never be automated, the actual interaction with patients.

Sunjya:  Yeah, I mean, that’s the promise of technology and it’s an incredible time right now in healthcare. And especially in the Bay Area. As you know, and you mentioned I’m super passionate about this, and I got to conferences whenever I can. Health 2.0, I was over at JP Morgan week and went to a Google investor meeting, and there’s a ton of movement and it’s so, it’s so exciting right now. And the same discussion is happening in the community at large. Which part of this is relevant? Which part of this adds to the medical patient experience? Which parts can be automated and which parts need to be done by humans? And some people get kind of nervous and negative about a thing.

For example, radiology: there’s going to be a takeover of artificial intelligence and machine learning and the radiologist will be extinct in a number of years. And I don’t see that at all. I see what could happen instead would be that care could improve, ability to diagnose things could improve, the ability to track and visualize data could improve, and then the people, the radiologist and the doctors who are in short supply, and you touch on this in your book a lot. It’s like the crisis that we’re in, especially in primary care and certain specialties, we just can’t keep up with what’s out there in the land of chronic illness especially. And so technology on our end, what we’re really looking at is, and again, I think that the way we talk about it is, let’s make our practice both high tech and high touch at the same time, right?

So let’s bring in the technology, let’s develop a really robust symptom-tracking dashboard that brings in all of the wearable data and all the symptoms that are happening to people, and where we can play with the data and visualize it and have this communication with the data back and forth between the doctor and the patient so that care can happen more in real time. As opposed to this episodic care model. So let’s do all of that, but let’s mesh it and let’s add in a nurse practitioner like Tracey, or a dietician and health coach like Danielle. And let’s have it be high touch at the same time so that we can simultaneously be working on and facilitating behavior change with people where the episodic care with the doctor is not going to do it.

Chris: Absolutely.

Sunjya:  So those things meshing together, I think, are what you and I are really transitioning to now. And you talk about in your book as the next phase and the promise of further helping Functional Medicine and its movement really deal with chronic illness.

Chris: Absolutely, and I just want to point out for the listeners, we’re not necessarily talking about AI and blockchain and some of the more revolutionary technologies that in years or decades could really fundamentally transform how, with blockchain, for example, information is stored. We all probably eventually will have our health records on the blockchain and who knows what that will look like. And then AI, like you’re saying, Sunjya, will totally transform diagnosis and even treatment, and will give doctors and practitioners a much better tool set. But I think there are a couple lower-tech examples that are just illustrative of what we’re talking about here. So this new patient onboarding process that I was just talking about. We send out a bunch of emails. And I actually recorded a bunch of videos with myself talking to new patients, just telling them about the clinic, about what to expect, how they should prepare for their appointments, how they … tips for doing the lab tests, which can be really tricky and complicated. And the idea behind this is that these things are the same for all patients, right?

So we recognize that administrative staff was having the same conversation over and over again with every patient and answering the same questions, and so why not use technology to create an email autoresponder and videos and FAQ documents that can be delivered to patients and give them the information they need in a much more efficient way without relying on staff time. And those are all very low-tech methodologies that are readily available now, don’t require any new understanding or technological development. And along the same lines, we have now, I think, hundreds of handouts that we give to patients.

The way I think about it is, if I’m having the same conversation over and over again or I’m repeating myself, that’s an opportunity to create a handout or a video or a course or an e-book or something like that, because that kind of information, there’s not a real benefit in delivering that in a one-on-one session. And that time that is spent telling somebody about the low-FODMAP diet, for example, could be much better spent just connecting with the patient and asking them more questions about their experience, having time to talk to them about whether they’re sticking with their stress management program, or getting enough sleep, or the things that do actually have to be done one on one. So it’s about, as we said, using these technologies to … in an appropriate way and in a way that actually increases the time for the one-on-one interaction that can’t be and shouldn’t ever be automated.

Giving clients more resources and access to more professionals

Sunjya:  Yeah, yeah, absolutely. And I think that really dives into, you’ve done such a great job in your ADAPT training program also looking at learning theory. I’m thinking about how do people absorb information.

Chris: Right.

Sunjya:  We know it’s been, there’s tons of studies on it if you look in Pub Med on what happens in a doctor’s visit and what information does a patient absorb. And particularly in situations where there’s something negative or scary, where the patient gets this piece of news, like, they shut off.

Chris: Right.

Sunjya:  They go into …

Chris:  Fight or flight.

Sunjya:  Reptilian brain, fight or flight, amygdala activation.

Chris:  Yeah, yeah.

Sunjya:  And I think that’s where they don’t hear anything you say after that.

Chris:  Right, right.

Sunjya:  So we certainly dive in and tell people, walk them through what’s happening. But from the onboarding sequence all the way through the whole care model, the more information that we can give to people in different formats, the richer the experience becomes. And then like we’ve been talking about augmenting that with that live person, that hand holding, that warm touch. And I think that again it’s just, it’s certainly not perfect. We’re still working our way through some kinks, but it’s certainly the way of the future.

Chris:  Yeah.

Sunjya:  It’s really an exciting time.

Chris: Yeah, yeah. So, let’s come back to this, where sort of CCFM is the case study for this larger model that we’re both so passionate about, as it should be. I would be concerned if we weren’t doing what we envision at our own clinic. So the first step that I … There was the urgent priority for me was being able to serve more patients because that was the biggest thorn in my side at that time. And so we hired Amy and you hired Ramzi, so then we went from two clinicians to four clinicians, which was a big leap and essentially doubling our capacity to serve more patients, which was awesome. But then, we both were still at the point where we hadn’t … we realized we still hadn’t executed on that vision of the collaborative model, where we had more support in between appointments. When I first started with Amy, she was helping, she was also seeing some of my established patients, and she still is. And so there was … they could, my patients could not only see me for follow ups, they could also see Amy. So there was… That was a step in that direction. But we still didn’t have a health coach on staff and we still didn’t have another practitioner, a nurse practitioner, or a physician assistant that could help provide another layer of support for patients.

And so, that’s when I hired Tracey, Tracey O’Shea, who is IFM-certified nurse practitioner. And I realize that you and I, I think we might often assume that everybody knows what a nurse practitioner, physician assistant is or all these different designations, but I don’t think that’s the case so I’m gonna explain. Nurse practitioner is a … in California, is a fully autonomous practitioner with a scope of practice that’s very close to that of an MD or a DO. So they can prescribe medication, they can do lab testing, but they also have more training in, I think what we could just call patient support. Because they function in that role assisting doctors, but also working side by side, and they could have their own practice too. And they can work fully autonomously in California. And that differs from state to state. But here in California, they have a lot of autonomy. And Tracey was working at a pain clinic in Sacramento and was already, saw the limitations. There’s a common theme here, right? Saw the limitations of treating pain from a conventional perspective and was taking IFM courses and becoming certified and then just not feeling like she was able to grow as a Functional Medicine practitioner at the clinic that she was working at. And so she applied to come work with us and I’ve been incredibly happy to have her.

It’s amazing, the support that we have now where she is with me in my case review appointments with new patients and they get a chance to meet with her and connect with her. She’s doing the initial consults, which are the first 30-minute phone or video visits where we collect information about the patient, what their needs and concerns are, and then order the lab tests, so she gets to know them there. And then, once we get them started on a treatment protocol, I ask them to check in with Tracey every couple of weeks while they’re on the protocol. Just brief check-ins because, as you and I both know, these protocols are complex and they have a lot of moving parts. They can be challenging in some cases and cause symptoms related to the protocol. People often have a lot of questions.

And before, what was happening was a patient would have difficulty and they might not even ask a question or they didn’t have the support between appointments and now I’d see them three months later and I would say, “What happened with the protocol?”  And they would say, “Oh, I had a reaction to a supplement and so I just stopped.” [laughter] And I’d be like, “What? No, wait! You should have called or contacted us. We just lost three months that we could have been doing something there.” And now that doesn’t happen because the patient checks in with Tracey. If they’re having any kind of reaction, she’ll adjust the protocol accordingly. It’s just a much better way of providing that support between appointments. She’s accessible. She’s got more open spots in her calendar. Patients can often get appointments within a day or two. I finally feel like with that, we take a big step forward to this collaborative practice model.

Sunjya:  Yeah, and the other nice thing about it, that you and I are both passionate about, is number one, how can we help more people? But number two, how can we make this care more accessible and affordable to more people?

Chris: Yeah.

Sunjya:  And it’s clear that a lot of people can’t afford the visits; however, when you bring in additional practitioners, nurse practitioners, coaches, PAs, etc., what we’re able to do is to charge a little bit less for those appointments. Have them be a little bit shorter, have them be check-in appointments, and it really leverages the time of ourselves and of the doctor, the head clinician, to be able to focus more on the higher-level problems and not be doing the busy work that’s really not a good use of our time and the patient’s money.

Chris: Yeah.

Sunjya:  So that’s an exciting shift also.

Hiring a health coach and registered nutritionist

Chris:  Right. And so along those same lines, we also took another step forward toward with this vision in hiring a health coach who’s also a registered dietitian and nutritionist. And this is Danielle Cook. And I’m excited about this. Of course, as many people know, I’m a big believer in health coaching, and I think it’s gonna play a critical role in the future of not only Functional Medicine but medicine in general. And in fact, even very conventional organizations like the CDC and National Board of Medical Examiners have come out and said, “We need health coaching.” [chuckle] We realize now that the cause of chronic disease is environmental, not genetic. And therefore, changing diet, behavior, and lifestyles is really kind of the most important step we can take to prevent chronic disease, and there will never be enough doctors to do that. There aren’t now and there just won’t be. And even if there were enough doctors, they’re not really the right people to do that.

That’s not how they’re trained and they need to be focusing on the things that only they can do, that a health coach can’t do, like order labs and interpret them and prescribe treatment and do procedures and colonoscopies and endoscopies and remove cancerous tumors and all the doctor stuff. We need that and we’ll always need that, but health coaches can really fill the gap where patients need that support because again, it’s not that they don’t know what to do, it’s they don’t know how to change, and they don’t have the support they need. And so Danielle has joined us recently and I’m really excited about the role that she’s able to play.

Sunjya:  Yeah, Danielle has been an excellent addition. Also very, very excited to have her on board. And it’s also teaching us some interesting things about what we want this to look like. Danielle has a really deep experience. She was actually functioning in large part as a provider previously where she was the director of integrative medicine at a clinic down in the Santa Cruz area, South Bay area. But so she came in, in some degree with this sort of mindset of solving problems, etc. And we’ve been working together and kind of talking through with her as she’s been doing more training on sort of what does it take to facilitate behavior change in people. So that’s another update point that you brought to our attention that we’ve all been talking about is that it’s very complex of why do people end up in chronic health issues and in a state of chronic illness. And certainly a lot of it is lifestyle and diet and exercise and infections, etc. But a lot of it is in part, there’s some psychological loading that happens and it could be that they had adverse childhood events. What was their ACE Score? It’s a big predictor for chronic illness and autoimmune illness. And so really we need this sort of fabric and this network of people and coaches to really dive in and help people, again make that incremental change. Hold them accountable, understand what’s their motivation, what would get them to take the next step, what would get them to stick with a plan. And we have, one of my favorite things about my job is that we get really, really smart and really, really motivated patients. And I learn a ton from my patients.

Chris: Yeah.

Sunjya:  They bring information that I hadn’t been aware of and they teach me, I teach them, there’s this collaboration. But almost always they need that hand holding and they have this sort of broad understanding of the information, but they still need the nuts and bolts. Both the calling the shots from the doctor’s side of what do I do for my protocol, but also, hey, help me make this change, help me implement it well, help me find out my barriers, etc. So I’m having a lot of fun. I’ve been working with Danielle. So one of our models for this is a company called Iora and Iora has really built this model where the coach is the point person and the coach is in every visit with the doctor. And the doctor is sort of like the spice on top, but the coach is really the main meal, the fabric of that system. And that’s one insight that you’ve been really pushing us in that you wrote about in your book also. So very, very excited about that piece.

Chris: Yeah, me too. The flipside of … We have super-intelligent, educated patients, many of whom are nutritionists [chuckle] or dietitians and practitioners in their own right. And on the other hand, I think as our practice has grown and expanded, we’ve also … We have more patients who are not experts necessarily. And they’re just people working in other professions. They haven’t gone down the rabbit hole of reading all the health blogs and listening to the podcasts and attending the summits and all of that. And then in the appointment, if I prescribe an autoimmune protocol diet and heart rate variability monitoring and other forms of stress … And a sort of high-intensity, the strength training program … I’m just making stuff up here, but that’s a lot of new stuff all at once and that’s totally overwhelming for some people. And in the past, even though my initial visits are long, an hour, hour and 15 minutes, and we have longer follow-ups, that’s not enough time to go over all the labs, to talk about those results and what they mean, then to prescribe a treatment protocol based on those results, and still have time to go into a lot of detail on the particulars of the autoimmune protocol or a ketogenic diet if I’m talking about that and some of the lifestyle modification.

It’s impossible. We’d be there for three hours. And even then, it would be just too overwhelming. And now I can say, “Hey, if you need support for this, we have a fantastic health coach on staff who’s also a registered dietitian. She can help customize your diet plan for you and give you support on the lifestyle piece.” And that’s just so… It makes me feel so much better. I’m not leaving the patient in a lurch. And I know that they are gonna be able to get the support that they need. That’s been our focus so far, but very recently we also, I think, both of us realized that there’s no reason that Danielle shouldn’t be available to people who aren’t already patients. Because as you said, it can be expensive to work with a Functional Medicine provider and some people don’t necessarily need that. They just need some support. They have some minor symptoms and they need some support dialing in their diet and lifestyle. So we just started offering sessions with Danielle, for people who aren’t already patients at CCFM. So I’m excited about how that will unfold too.

Sunjya:  Yeah, I’m very curious about that to see how that’s taken up. Because I think again, there’s a huge need out there. And as you’re moving into training more health coaches in your next iteration of your training program, it’s going to be a good case study for us to see how that works.

Group treatments and reducing the feeling of isolation

Chris: Yeah. So let’s talk a little bit more about our future vision because we’re not done yet. [chuckle] We’ve definitely made some progress, but you and I are always looking toward the future and how we can continue to improve things. One thing I’m excited about is classes and groups. I’m excited about them for a few different reasons. Number one, doing a group for example, for patients with autoimmune disease or patients suffering from chronic Lyme, can make care much more accessible. Just because the group dynamic is more affordable for people and it’s a fantastic way to deliver information and support that doesn’t have to be one on one.

So if you have common diet recommendations or lifestyle recommendations or behavior modification recommendations that tend to be consistent across a particular group of patients like autoimmunity or weight loss or chronic infection, then those can be delivered in a group just as well as they can be in a one-on-one session and certainly, much more efficiently from a cost perspective. And then the other thing is just reducing the sense of isolation that people who have chronic illness often feel. And when they have a chance to get together either in person or virtually in a kind of like a Zoom video conference with other people that are dealing with similar challenges, that can really make them feel less alone.

Sunjya:  Yeah, and what’s exciting for me there also is that I envision leveraging the expert patient. So if we identify patients who have come through a protocol successfully and who are well-resourced and who like to educate and reach back out, if you put those people in the mix as well, then what you get is just sort of, rather than it being top down, the information, you get this sort of really rich kind of cross-pollination and people helping each other. And the expert patient feels really good helping the other people.

Chris: Yeah.

Sunjya:  The new folks feel hopeful because they see an example of somebody who has kind of made it through to the other side of what they’re experiencing. So it’s really win-win in a lot of ways. And building that kind of community around this care is something that doesn’t really exist right now in a lot of ways. There’s Facebook groups. Unfortunately a lot of the support groups out there, especially with Lyme disease and a lot of chronic illness, they tend to be really scary places. They tend to be, the loudest voices are the sickest people because they’re still searching. And the people who got better are like, hey, I’m done. I want out. I’m not going to necessarily be in that chapter for a support group. So really building that structure and that support is a win for both sides.

Chris: Yeah. Another thing I know you, in particular, been really excited and passionate about is how we can continue to evolve the technology so that we can chart the progress of patients over time graphically, have their lab values displayed in a chart-like format so that both patients and practitioners can quickly take a look and see what kind of progress they’ve made over the course of their treatment protocol, and just continuing to leverage technology in ways that actually enhance the patient care experience is something we’re both, I think, looking forward to.

Sunjya:  Absolutely and it comes out of being point on our end, which is just that we generated a ton of data, it’s hard to kind of see the patterns, and in addition we’re missing a lot of data. If we can get patients reliably tracking their symptoms over time, if we can bring in their wearable data, we can understand what their movement patterns are like, what their sleep patterns are like, what their heart rate variability is like from a parasympathetic–sympathetic nervous system balance point. Correlate that with their lab studies with what they’re eating, track their diets, etc., and also have them filling out standardized questionnaires like the SF-36 or pain scale, or the severity scale. So we have the potential there to generate a huge amount of data, which probably is going to be overwhelming, and it can be a little bit too much to look at.

But I think the promise there is to start to make that more significant and statistically significant, and over time dial it down. Boil it down into a few different metrics that can serve as a dashboard, sort of like a warning light on the dashboard if you will. And we have so much data out there that’s not being correlated, not being collected in a structured way to where we can use it. And there’s a lot of people who are really, really smart in the States who are seeing a similar vision. And so, again, I see that as our future. It’s similar to your investor patient. I had a meeting a couple weeks ago with a group, a local group who are struggling with some of these health issues in their own family, but they are in the financial sector and they’ve built this computerized dashboard to track their financial metrics in an incredibly robust and insightful way. And they’re saying basically, hey let us know what you need and we’re happy to adapt our model and bring in all the health variables and see what kind of insights we can build.

Chris: That’s so cool.

Sunjya:  Yeah, super exciting.

The Berkeley Fire Department pilot wellness program

Chris:  Yeah. Let’s talk a little bit about our pilot program with the Berkeley Fire Department. I think it’s a way of kind of bringing this all together and showing what this model could look like, at least in terms of scaling it up to bring this approach more into the mainstream.

Sunjya:  Yeah, this has been a super-fun project. To their credit, they contacted us, which is so fun. We got a call last summer from one of their officers, Amore Langmo, who has his personal story. He’s benefited in large part from adopting a Paleo ancestral diet and changing his movement patterns, and his health really shifted in a lot of positive ways. So he knew about all this and he knew about some of the work that Robb Wolf has done over in Nevada working with first responders, police, and fire departments. So he reached out to us and said, “Hey, we are bringing in this class of new recruits. There are going to be 10 people, and we want you to build a wellness program for them.”

So we went through the process of submitting proposals and fine-tuning those and when that was accepted, the program started in October. And again, credit to the department. Really impressive group of people. The training chief, David Sprague, and the recruit training officers totally on board with this. And basically we built out several different modules—the first one focusing on nutrition and then on stress management and on healthy sleep, and gratitude and happiness, resilience, etc. So we basically delivered these modules over one month at a time. There were check-ins with the health coaches. We layered in robust technology solutions. We had my friend at Iora, the wearable ring company, donated their products.

We had our friend Yaron Hadad of Nutrino bring in his technology for tracking diet, we had them wearing continuous glucose monitors to track their blood sugar, we did fitness interventions, we did lab studies, baseline and follow-up on a subset of those people. And so we generated this huge amount of data which was really, really exciting. We’re still working through putting that all together, wrapping our final module next month to do wrap-up and data presentation. But already the feedback that we got, and these recruits are in their 20s and 30s, relatively, you would think, young, healthy men. This group is all men. Sometimes they do have women in those classes. And we found some really interesting things under the hood that were sort of smoldering fires either on lab studies or on sleep patterns, or on heart rate variability tracking. And the work that these guys are doing is so, so important. We know that more than ever. And at the same time they have a very stressful job with the shift work, etc. So it was very, very exciting to look at that and just see that we’re identifying some things here that nobody would’ve found, nobody would’ve known about.

Chris: Yeah, yeah.

Sunjya:  And we’re intervening in a systematic way. We’re offering them opportunities for change, and they’re noticing the difference. They’re saying, wow yeah. I noticed I feel better and I feel stronger, I want to eat cleaner, and I noticed that my total sleep time or deep sleep is a certain marker, then I feel more alert and more ready to go, etc. So very, very, very fun.

Chris: Yeah. Yeah, that’s so exciting. I’m so jazzed about this project and what it can mean for other opportunities in the future. Not only for our clinic, but for other Functional Medicine clinics. It’s a great way to reach out in your community and provide a service and also attract new patients. This is really a … It’s just exciting to see, you and I, Sunjya, for so long have been kicking this around in our head, and so it’s really exciting just to see it manifesting in the real world.

Sunjya:  Absolutely, absolutely.

Chris:  Yeah, all right, so thanks for listening, everybody. Before we finish up, I do want to let you know that we are accepting new patients at CCFM. I know, for a lot of you folks who’ve been following me for a long time, you’ve seen some of the drama with the … my practice would open up and then it would fill up within a few hours and there would be a year waitlist and it was crazy. And I … Frankly, I hated that. [chuckle] It was really stressful. 

Sunjya:  Yeah, it’s stressful for everybody.

Chris:  It was really unpleasant to have to turn people away. And yeah, it was stressful for the staff and it was stressful for everybody who was interested in coming to see me as a new patient. And so, I realized that I had never sort of announced that it’s not like that anymore. [chuckle] We’re so busy focusing on expanding the capacity, I don’t think that I had ever really let anybody know that we now do have a much greater capacity.

And because now we have, instead of just two practitioners, we have five and … including a nurse practitioner, and then we have a health coach, and we have a big administrative staff to support that. We’re now able to accept many more patients. And I still get emails like, “I know you’re not taking new patients, but …” And I’m like, “Wait, I actually am taking new patients [chuckle] for the first time in a long time.” I am, Amy, Dr. Nett is, Dr. Asfour, Ramzi Asfour is taking new patients. Danielle is seeing clients now for health coaching, even if they’re not new patients. Tracey’s not yet accepting new patients on her own but she will be very soon. Sunjya, I know you’ve been pretty full lately. Where do you stand on that?

Sunjya:  Yeah, you and I have had some conversations on this. I think a really important point that we’re trying to build with the way we’re structuring our clinic is that we’re really trying to make it so that the people we surround ourselves with, the practitioners who we bring in and train, are really high level, very, very smart, very motivated people. And we’re trying to build this really tight-knit fabric within our clinic so that patients can feel like if they want to see either you or me as their primary focus, which is understandable given our experience, that they could be as well served by seeing one of our other practitioners. Because, in fact, we’re directly involved with that care, we’re supervising that care, there’s constant conversations and cross-pollination that’s happening. So on my end I’m working to adopt the similar model to what you are, so I can bring in more patients myself. But really that’s going to look like a community model where we have the practitioners, we have Ramzi, we have Tracey, we have Danielle and all of us are working together to provide that optimal level of care so that we can get more people the care they need. So it’s really one thing we’re passionate about.

Chris: Absolutely, absolutely. And this sort of team approach to care really is the future of medicine. We’re seeing it not just at our clinic, but at many others, because it’s much … it’s actually a better model for patients. It’s a better model for practitioners because we get the full support of the team. I get to rely on Ramzi’s expertise on infectious disease and yours as well, Sunjya, and Amy’s expertise in radiology, and Tracey’s expertise in pain management, and Danielle’s expertise in nutrition and health coaching. It’s just phenomenal. I feel it’s kind of like getting to see five practitioners instead of one, [chuckle] at this point, which is really amazing.

So if you are struggling with a chronic illness and you just haven’t been able to find help and you’re stuck and you can use some additional support, this … we’re here for you at CCF Med. That’s ccfmed.com for more information and to apply if you want to come be a patient at the clinic. We work with people all over the United States. We do require an in-person visit for that first visit to just to establish the relationship. But after that first visit, we can work remotely via phone and video conference in most cases. So keep us in mind if you need that kind of support or if a friend or family member does. And thanks, everybody, for listening. I hope this was helpful. I hope you’re as inspired about this future model for treating chronic disease as we are. And thanks for listening. Continue to send in your questions at chriskresser.com/podcastquestion. And Sunjya, thanks again for being here.

Sunjya:  Yeah, it was very fun. I really appreciate the opportunity.

Chris:  Great.

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