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Thanks for joining us for episode 131 of The Ancestral RDs podcast. If you want to keep up with our podcasts, subscribe in iTunes and never miss an episode! Remember, please send us your question if you’d like us to answer it on the show.
Chris Kresser is the CEO of The Kresser Institute, the co-director of The California Center For Functional Medicine, the creator of ChrisKresser.com, and the New York Times Best Selling author of The Paleo Cure. He’s known for his in-depth research uncovering myths and misconceptions in modern medicine and providing natural health solutions with proven results.
Chris was named one of the 100 Most Influential People in Health and Fitness by Greatest.com and his blog is one of the top ranked natural health websites in the world. He recently launched The Kresser Institute, an organization dedicated to reinventing healthcare and reversing chronic disease by training healthcare practitioners in functional and evolutionary medicine. Chris lives in Berkeley, California with his wife and his daughter.
Our nation’s current healthcare model is showing itself to be of no match against the epidemic of chronic disease affecting both individuals and society at large. While many feel powerless against the seemingly insurmountable odds, there is hope.
Join us for a powerful discussion with Chris Kresser who has sent out a call to action to reinvent healthcare in his book Unconventional Medicine.
Today Chris explains his new model of healthcare that focuses on preventing and reversing disease instead of attempting to manage it. You’ll hear how functional medicine and ancestral diet and lifestyle within a collaborative practice model is the promising solution to sustainable healthcare and reversal of the course of chronic disease.
As Chris shares how the collaborative practice model benefits healthcare practitioners in addition to patients, he also provides guidance to present and future practitioners on deciding where they best fit into the model.
Whether you’re a healthcare practitioner or patient, you’ll be inspired to join the revolutionary paradigm shift that can truly make a positive impact in our lives as well as future generations.
Here is some of what we discussed with Chris:
- [00:04:27] What drives Chris’ passion for changing the way our society implements healthcare
- [00:06:36] The difference between conventional and unconventional medicine, and how Chris got into practicing unconventional medicine
- [00:10:44] How Chris blends pieces of conventional medicine into his functional medicine practice
- [00:17:37] Chris’ Functional Medicine Pyramid and how he implements it in his practice
- [00:23:06] How the time allotted in appointments is the biggest limitation within the conventional medicine paradigm and how Chris envisions a multi layered system
- [00:26:45] How Chris’ functional medicine practice has transitioned from micro practice to a collaborative practice
- [00:32:09] The difference between a micro practice and collaborate practice and which type of practitioner may prefer one or the other
- [00:37:47] How The Kresser Institute’s goal of building an ecosystem of practitioners with shared perspective is filling a crucial need
- [00:43:58] How the Functional Medicine Systems Model illustrates how disease progresses from the inside, out
- [00:49:56] How to identify what type of practitioner you’d like to be within a collaborative practice model, and if Chris would have taken a different route
- DrCowansGarden.com – Use the code “ancestralrds” for 20% off your order!
- Chris Kresser’s book Unconventional Medicine
Laura: Hi everyone! Welcome to Episode 131 of The Ancestral RDs podcast. I’m Laura Schoenfeld and with me as always is my co-host Kelsey Kinney.
Kelsey: Hi everyone!
Laura: We’re Registered Dietitians with a passion for ancestral health, real food nutrition, and sharing evidence based guidance that combines science with common sense. You can find me, Laura, at LauraSchoenfeldRD.com, and Kelsey over at KelseyKinney.com.
We have a great guest on our show today who’s going to discuss with us a new model of medicine that focuses on preventing and reversing disease rather than just managing it. His model provides meaningful and rewarding work for health care practitioners and saves money and resources for governments and societies. This is such an important topic for both healthcare providers and the general public to understand, so we’re really excited to dive into it.
Kelsey: If you’re enjoying our show, subscribe on iTunes so that you never miss an episode. And while you’re there, leave us a positive review so that others can discover the show as well!
And remember, we want to answer your question, so head over to TheAncestralRDs.com to submit a health related question that we can answer or suggest a guest you’d love for us to interview on an upcoming show.
Laura: Before we get into our interview, here is a quick word from our sponsor:
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Laura: Welcome back, everyone. We’re so grateful to have Chris Kresser here with us today on the show! He’s the CEO of The Kresser Institute, the co-director of the California Center For Functional Medicine, the creator of ChrisKresser.com, and the New York Times Best Selling author of The Paleo Cure. He’s known for his in-depth research uncovering myths and misconceptions in modern medicine and providing natural health solutions with proven results. Chris was named one of the 100 Most Influential People in Health and Fitness by Greatest.com and his blog is one of the top ranked natural health websites in the world. He recently launched The Kresser Institute, an organization dedicated to reinventing healthcare and reversing chronic disease by training healthcare practitioners in functional and evolutionary medicine. Chris lives in Berkeley, California with his wife and his daughter.
Welcome to the show, Chris! I feel like it’s been several years since we started our little podcast on your website, so it’s great to finally have you.
Chris Kresser: It’s great to be back, Laura and Kelsey. It’s always been a pleasure to work with you over the years and I’m looking forward to our conversation.
Kelsey: I think for me it was 2011 that I started working with you, and I think, Laura, you were shortly after me I believe.
Laura: I think it was like early 2012, so five or six years at this time. It’s hard to believe.
Chris Kresser: Time flies.
Kelsey: Yeah. Obviously you’ve been doing this work in functional medicine for I think over a decade now, Chris. Can you tell our audience why you’re so passionate about changing the way society implements healthcare?
Chris Kresser: Yeah. In short, we need to, we have to. We’ve reached an inflection point where we can’t afford not to act anymore. 1 in 2 Americans now have a chronic disease and 1 in 4 have multiple chronic diseases. And it’s not just affecting adults. Almost 30 percent of kids has a chronic disease which is up from just 13 percent in 1994. So that’s a profoundly disturbing change just in less than 25 years.
We’re on a trajectory that’s not good and it’s not just a question of individual health, which of course is important. It’s really actually a question of the survival of our society as it currently exists because the rising medical costs really threaten to bankrupt our country. We’re spending almost 20 percent of our gross domestic product on healthcare expenditures. If we look if we continue along our current trajectory, it’s just not going to be sustainable at all, not only for individuals, but also for our society at large.
It’s really urgent at this point. But we don’t tend to realize it because it’s just our life. It’s like the proverbial frog in the boiling water as we’re just kind of grown accustomed to it. We think that it’s normal for so many people to have chronic disease and we don’t really realize the severity of the problem and how much it threatens our way of life.
Kelsey: Yeah. Those consequences are really dire at this point in terms of how the current medical system works. You mentioned some of the not only monetary aspects of this, but just that people aren’t feeling better. They’re managed, they’re not healing.
Can you talk a bit about the difference between conventional medicine and the “alternative” or as you call it, unconventional medicine? What’s the difference between the two and why did you get into the unconventional side of this?
Chris Kresser: Conventional medicine evolved during a time when the top causes of death were all acute infectious disease. In 1900 we had tuberculosis, pneumonia, and typhoid were the top causes of death. Then the other reasons that people would see a doctor at that time were also acute in nature, so a broken bone, or an injury, or a gall bladder attack, or an appendicitis. The treatment for those problems is relatively straightforward. It doesn’t always work, but it’s pretty simple. It’s set the bone in a cast or remove the gallbladder, appendix, and once antibiotics were developed, use one of those to treat the infection. It was like one problem, one doctor, one treatment, and that’s it.
Conventional medicine really does excel at this. If I get hit by a bus, I definitely want to be taken to the hospital, not an acupuncturist, not a functional medicine doctor, at least not right away. We can restore sight to the blind. We are beginning to be able to reattach limbs and fight cancer with nano robots. Things like anesthesia, and antibiotics, and vaccines have led to some pretty incredible changes in terms of our lifespan and quality of life.
I’m not arguing that we don’t need conventional medicine. I’m saying that it’s not actually the best approach for what our current challenge is, which is no longer acute problems. We still have them, but 7 of the top 10 causes of death are now chronic diseases and 86 percent of the dollars that we spend on healthcare go toward treating chronic disease.
We are using a medical model that evolved in the context of acute emergency care to try to address chronic health problems, and it’s really not working at all. Because as you pointed out, Kelsey, the conventional model is really based around suppressing symptoms with drugs and managing disease after it occurs.
What we need is a model that can actually prevent disease before it occurs. That’s the ideal, of course, but even be able to reverse disease after it’s occurred instead of just putting Band-Aids on the problems. And that’s really where both functional medicine and an ancestral diet and lifestyle can come in.
Kelsey: Yeah. I think at least for me, and I’m sure this is probably the case for you, too, Laura, one of the reasons I was drawn to your work in the first place was the fact that you didn’t totally discount conventional medicine. Like you said, that’s where you want to go if you get into something that needs to be treated acutely. And that’s really where conventional medicine excels.
I love that about your approach. You even I think use some pieces of conventional medicine within your functional medicine practice, if I’m not mistaken.
Chris Kresser: Certainly.
Kelsey: Yeah. I think that’s really, really important because I know in my practice, and Laura, this is probably true for you, too, we get a lot of people that are afraid of conventional medicine almost. They’ve been to so many conventional doctors, haven’t gotten any help, they’ve just been thrown prescription after prescription, and nothing works and it almost makes them worse. They get all these side effects from the prescriptions that they’re on. At that point they get scared and they go over to the functional medicine side or the alternative side, but then they don’t want to consider any piece of conventional medicine at all.
Can you talk about the balance that you see between conventional and alternative in terms of like how you actually use both sides of this within your own practice?
Chris Kresser: Sure. I think it’s partly a problem of language. At some point we’re just going to have medicine. It’s not going to be conventional or functional. The way I like to put it is I believe in the treatment that is most effective and causes the least harm. If you frame it that way, then it changes the conversation because it’s not so much about functional versus conventional medicine. It’s just about good medicine.
Another way to look at it is if you consider functional medicine as a larger framework, the point of functional medicine is to address the underlying cause of disease rather than just suppressing symptoms.
Let’s use an example. Let’s take a patient with IBS, irritable bowel syndrome, a very common condition now, second leading cause of people missing work behind a common cold. Really epidemic. If that patient goes into the conventional medical system, they’ll go to the doctor, they’ll report the symptoms, the doctor will tell you they might do some tests to rule out other structural problems like inflammatory bowel disease, or diverticulitis, or something like that. And then if those are ruled out, they’ll end up with a diagnosis of IBS.
But then all of the treatments are geared only towards helping the patient live with the symptoms. So if they have constipation, they’ll get a pro-motility drug to help with that. If they have diarrhea, they get an antidiarrheal drug. If they have pain, they’ll get an analgesic to help with the pain. They might get prescribed an antidepressant to help with the psychological aspects, co-morbidities. But the all of all of those treatments are geared towards just suppressing symptoms.
Now in functional medicine, we’re of course going to look at diet as a starting point, but then we’re also going to look at underlying mechanisms like SIBO, bacteria overgrowth in a small intestine, or parasites, or fungal overgrowth and things that we know can contribute to and cause IBS.
Here’s the answer to your question. In that investigation and treatment we might actually use a pharmaceutical drug like Rifaximin to treat SIBO. But the difference is that drug is being used to cure or treat an underlying cause with the intention of reversing that condition. That’s very different than using a drug forever that is just used to manage symptoms. The Rifaximin, the antibiotic to treat the SIBO, isn’t taken forever. It’s taken for a distinct period of time with a beginning, middle, and end, and a goal attached to it of reversing the condition.
Whereas in the conventional approach, the drugs are used indefinitely in many cases. If you go into the doctor and you have high blood pressure or high cholesterol, you get prescribed a drug and the understanding is it’s not going to reverse or cure the condition. It’s just something you’re going to take for the rest of your life.
I think that’s an example of how it’s not so much about the particular treatment that’s chosen, it’s about the paradigm, or the overall approach, or the context that you’re using those treatments and the goal of what you’re trying to accomplish with them.
Laura: It’s interesting that you use SIBO as an example because I feel like Kelsey and I both see that happening so frequently with our IBS clients where we know what kind of tests for them to get done, we find that they do have the positive SIBO diagnosis which makes sense with their symptoms.
But then when it comes to the treatment, I know a lot of times I’ll recommend that they find a GI doctor to work with to see if they can look into the antibiotic option. So many people I’ve worked with they’re just like, there’s no way I’m taking antibiotics, that’s off the table. I’m like well that might be your best choice. I don’t know if the antimicrobials are going to work as well necessarily for you.
It’s just one of those things where getting that balance between using conventional medicine when it’s appropriate and not always thinking there’s going to be a natural cure or that diet can fix everything, which as a nutritionist a lot of times it seems weird to hear us say like maybe the diet is not going to fix the problem.
Chris Kresser: Right, yeah. I mean we can extend this example further because there’s a perception that botanicals are always safer than drugs. That’s just not the case. I mean they often are. I would say that that’s generally true. But for example, with Rifaximin, that medication only 99.5 percent of it stays in the gut and is not systemically absorbed. It’s pretty safe in terms of its effect on the colonic gut flora because it acts mostly in the small intestine. Some studies have shown that bifidobacteria and lactobacillus, which are beneficial species of bacteria in the colon, actually go up after taking Rifaximin.
Chris Kresser: I totally agree. There’s a phrase “skillful means”, which means using the best tool for the job in every situation. In most cases I will say that that is diet, and lifestyle, and behavior change when it comes to preventing chronic disease. But there are certainly situations where the answer to that question could be a pharmaceutical especially for short term, but in some cases even long term.
Low dose Naltrexone is another good example of a pharmaceutical that actually does improve the function of the body instead of just suppressing symptoms and has provided enormous benefit to people with autoimmune disease.
I think when you compare it against some of the other drugs that are prescribed with autoimmune conditions…if a patient has multiple sclerosis or rheumatoid arthritis and their choice is to take low dose Naltrexone for the rest of their life, or Methotrexate, or Prednisone, then it’s obvious what the choices is, at least in my mind.
If they can take a low dose of Naltrexone for the rest of their life and be more or less symptom free, I wouldn’t have a problem with that as a practitioner, or even as a patient myself if I had that condition. That’s just smart use of whatever is available that again is the most effective and causes the least harm.
Kelsey: Absolutely. I know you’ve created a functional medicine pyramid where you talk about kind of the order in which you deal with different facets of disease. Can you talk a little bit about that and how you use that in your practice?
Chris Kresser: Yeah. In the decade that I’ve been doing this and also the decade prior to that when I was dealing with my own health issues, I’ve come to see that one of the arts I guess of functional medicine is learning how to structure and layer treatment. You can’t obviously do everything at once. And the good news is that’s not only not necessary, it’s not beneficial because the human body can only process so much at one time. People can only get their heads around so much at one time. Trying to do too many things at once leads to not doing any particular one thing very well.
And so as I started to think about training clinicians, and also my own practice and continually improving the way I treat patients, I began to think in terms of a pyramid where if you think at the bottom of the pyramid, what are the things that will provide the most benefit for the greatest number of conditions for the greatest number of patients? And those are the things that I want to start with in my training program because it’s the 80:20 rule in effect. It’s like if you do these 20 percent of things, you’re going to help 80 percent of the patients or clients that walk through your door.
For me, those are diet and lifestyle behavior changes, the core starting place. But then assuming those have all been dialed in, which can take a long time as you both know. That’s not an overnight thing and it’s an ongoing process. It’s not something that just ends and you’re finished. It continually changes. Then we start looking at the gut, which I know you both focus on a lot because the gut is connected to so many different aspects of health and disease. We look at the HPA axis, which is the system that is most affected by stress and governs our tolerance of stress.
And then I look at a variety of things that can be measured on a blood chemistry panel, so blood sugar, metabolic function, lipids like cholesterol or LDL particle number, nutrient status, vitamin D, B-12, folate, iron, oxygen deliverability – anemia being the pathology there. We look at liver function, gallbladder function, thyroid panel and other hormones. We do a complete workup of what well you might kind of refer to as the basic operating system of the body.
There are a lot of other things that we might eventually look at like heavy metal toxicity, or tick borne illnesses like Lyme disease, or mold. But those things come higher in the pyramid because even if they’re present, we found that addressing those lower order things at the base of the pyramid will provide significant benefit and relief, and even kind of become a prerequisite to successfully dealing with things like Lyme, and mold, and heavy metal toxicity.
Kelsey: Right. It’s probably pretty difficult to help somebody with Lyme if they don’t have those underlying pillars sort of dealt with already or at least in the process of dealing with those things, right?
Chris Kresser: Exactly. My co-director at CCFM, California Center For Functional Medicine, Dr. Schweig who specializes in Lyme, what makes his approach different than some other people in the Lyme community is the kind of classic approach to chronic Lyme, not in the conventional world, but in the sort of Lyme world is just heavy, heavy bombardment with antibiotics without really addressing anything else. Not looking at detox, or gut health, or anything like that. It’s just full on carpet bombing with antibiotics.
Sunjya’s approach is quite different. He actually will start with all of these other pieces that we just talked about to strengthen the body and strengthen the patient with the understanding that infections don’t happen in isolation. They happen in a context, in an ecosystem within the body. And if that ecosystem is not functional and not strong, then like you said, whatever antimicrobial treatment is done, whether it’s antibiotics or herbs, is not going to be as effective and successful.
Kelsey: Yeah. I think if you presented this this functional medicine pyramid to somebody who’s working in the conventional medicine world maybe as a primary care practitioner, their head might explode just by thinking about all this stuff that they have to do in like their 10 to 15 minute appointments with people.
How would you say that the time factor plays a role in this when it comes to conventional versus functional medicine?
Chris Kresser: It’s probably the single biggest limitation with the conventional paradigm right now. I mean the average primary care visit is between 8 and 12 minutes now and the average amount of time that a patient gets to speak before they’re interrupted in one of those visits is just 12 seconds.
Kelsey: Wow. That’s sad.
Chris Kresser: And as I said in the beginning of the show, we know that 25 percent of Americans now have multiple chronic diseases and these are of course the people who are going to the doctor. I think we can all agree it’s impossible to provide high quality care in a 10 minute visit when the patient has multiple chronic conditions, is taking multiple medications, and then is showing up to the office with new symptoms. I mean there’s simply no time.
And it’s not doctor’s fault. Most doctors I’ve met are doing their best within a really crazy system and they feel just as limited and constrained by the system as the patients do. And so it’s really a systemic problem that we need to change because there is no possible way that you can provide that kind of care in a 10 minute visit.
I know a lot of people at this point get really discouraged because they think well how can we possibly change that? The truth is that it’s not the same in other countries. In France I was speaking with a French physician not too long ago who just couldn’t believe it was the way it is here. He couldn’t believe that you could do anything in 10 minute appointment and couldn’t believe that doctors here weren’t incentivized to actually prevent disease as they are in France.
We get accustomed to what we have and we think there’s no way it could be any different. But as I’ve often said, what’s common or typical is not necessarily normal. There are lots of changes we can make to our system that could enable longer visits both with doctors, but also with other care providers like RDs, Registered Dietitians, for example, like health coaches, or nutritionists, like nurse practitioners and physician assistants.
That’s what I argue in my book is that doctors should be mostly doing doctor-y things. Like we need doctors to do colonoscopies, and to remove cancerous tumors, and to do CAT scans, and to maximize their training to the greatest potential of their ability, and background, and scope of practice. But doctors are not really necessarily the best people to be working with patients on diet, lifestyle, and behavior change. And that is the biggest thing that we need to focus on in order to prevent and reverse chronic disease.
I envision a system that is both multi-layered where we still have doctors that are, again, working within their scope of practice to provide the services that only they can provide, but we do a much better job of using dieticians, and nutritionists, and health coaches to support patients in making the important diet, lifestyle, behavioral changes that are going to really make the biggest difference when it comes to preventing or reversing chronic disease.
Kelsey: Yeah. I mean you started your practice as how you call it in your book, a micro practice, where I think it was just you and your office manager, right?
Chris Kresser: Yeah, that’s it.
Kelsey: Yeah, and now you have obviously CCFM which is a much larger practice and you’ve got a ton of allied healthcare providers within that system. Can you tell us a little bit about that transition? Because we have a lot of listeners who they’re trying to figure out where they fit in that system. Maybe they haven’t gone through any sort of program yet, but they’re thinking about which direction they want to go into. I’d love to hear sort of how you use each of those different practitioners within your practice and how people can kind of try to identify which place would be best for them.
Chris Kresser: Yeah. My vision is, as I mentioned, a collaborative practice model where you have practitioners of all different backgrounds, and trainings, and scopes of practice working together doing what they do best, but then supporting each other in a collaborative way.
I think that’s what we have created at CCFM. We now have four clinicians and then we have a nurse practitioner, who is also a clinician of course, but I’ll say more about you know the difference in how she works with patients. And then we have a health coach and we have also 14 administrative staff that also supports patients in different ways that aren’t just administrative. And then of course we’ve worked with both of you over the years as well. Our health coach happens to be a registered dietitian as well who’s taught at the university level at San Jose State. A very experienced dietitian.
You could do it differently. You could have a separate health coach and a separate dietician, or you can combine them as we have. It doesn’t really matter. But you want to have both of those roles covered for sure because they’re not the same, and I’ll say more about that in a moment.
The first appointment with patients happens virtually via video conference or telephone. It’s a 30 minute appointment and our nurse practitioner, Tracey, does that appointment. The purpose of that is to just meet the patient, get to know them, find out what they would like to change, what their main complaints are, what their goals are, and then order all of the tests that we like to have for new patients in advance so that before they even come to the clinic for their first in-person appointment, which we do require an in-person visit for all new patients, we already have all of the tests results back that we want to look at for that new patient.
And then myself, or Dr. Schweig, or Dr. Nett, or Dr. Asfour will do the new patient visit, a very thorough and comprehensive appointment, and we’ll then prescribe the treatment plan. And then after that, patients will be offered the opportunity to have a check in with a nurse practitioner, or health coach, nutritionist in whatever way works best for them.
Some of our patients are very advanced and they already have the diet piece pretty wired and they don’t really need that support. But for other people, if they come in and have a case review and I say okay, we need you on a ketogenic version of a low FODMAP, Paleo diet and they’re like, what? And so then of course they can work intensively with the health coach and nutritionist. Or if somebody’s got their diet wired but where they’re really struggling is stress management and sleep, then they can work with Danielle our health coach on those kinds of interventions.
I might not see them for three months for the next visit, but in between those visits they’re interacting with Tracey the nurse practitioner who is reviewing their follow up labs and tweaking their treatment protocol, or they’re interacting with Danielle the health coach who’s giving him guidance on lifestyle stuff or nutrition guidance.
There’s a much higher level of support all the way through that which is amazing for us as clinicians because before there was just that three month gap between when we’d see a patient. A lot of patients would fall off the wagon. They weren’t successful in their treatment protocols because they didn’t have the support that they needed. And it’s fantastic for the allied providers because they get to work in a in a clinical setting in a in a collaborative way with other allied providers and licensed practitioners.
For people who don’t necessarily want to have their own practice and to deal with all of the challenges that come with starting your own business and building up your practice, and for people who simply just prefer more interaction on a daily basis with other practitioners and want to be in that kind of collaborative environment, it really works well.
Kelsey: Yeah, that’s awesome. I would love to hear a little bit more about I guess the differences between a micro practice and something bigger like CCFM, meaning how can somebody decide which route they want to go? Obviously people like you said who want more of that interaction on a day to day basis, they might do much better in an environment like CCFM. But is there somebody who is maybe more appropriate for a micro practice that you can think of?
Chris Kresser: I guess what I would say is I think everyone should be working in a collaborative practice model. What I mean by that is that it’s hard to think of a situation where a nutritionist or a health coach would not benefit from having at least a referral relationship with a licensed practitioner and vice a versa.
A micro practice kind of situation where like let’s say a medical doctor just has an office manager and that’s it, and they have their micro practice, but still they should have a nutritionist and/or a health coach to refer people to for additional support even if they’re not technically an employee or a contractor employed by the micro practice itself.
And likewise, I think dietitians, or health coaches, or nutritionists should have someone they can refer their clients to when the nutritional interventions are not sufficient if they have Hashimoto’s, or an autoimmune condition, or something else that would benefit from that kind of testing and treatment that may not be within their scope of practice. Regardless, my vision is for that kind of collaboration.
Now whether someone wants to do that kind of collaboration as employee or a contractor within a larger organization like my clinic and have that kind of day to day contact, and collaboration, and teamwork, or whether they prefer to be on their own in private practice and just have a referral relationship, I think that largely comes down to the person’s personality, and background, and training, and goals.
People who want to be more in a clinical, collaborative setting are probably people who appreciate that day to day interaction, that want to be able to bounce ideas off of other practitioners, and want to be able to you know learn intensively from other practitioners in the practice, want to have maybe more security that comes from being an employee and having consistent…not referral because you’re part of the practice…a consistent source of patients and not have to worry about that kind of thing.
Whereas somebody who wants to create their own brand, their own personal brand and maybe create their own digital products, or learning programs, or teach their own classes and kind of develop more of their own brand, then that probably is going to happen better in a micro practice or in a private practice.
Laura: I like what you said about just that referral network though because I think Kelsey and I would both classify our businesses as micro practices. I’m just laughing because you at least had an office manager. In my business I’m the office manager, I’m the intake person, I order the labs. I’m a business of one right now.
I do plan to hopefully expand my team a little bit down the road, but it’s tough when you have kind of like your way of doing things and you’re a little control freak about handing it off to people. It can be difficult to build that team.
But I really like what you said about building that network because something that I found really helpful even as a micro practice is having other clinicians that I feel comfortable referring to. Like I said before, with something like SIBO if I feel like a client has to get some kind of pharmaceutical treatment for that, obviously as a dietitian I can’t order medicine. I like having these networks that I can at least send them to especially because with medical practice you usually have to be in person to see that patient at least the first time.
I’ve really liked being able to send people to your clinician directory in the Kresser Institute. It’s been awesome to be able to say go look at that list because I trust that group of people is going to be doing the right thing.
Even just knowing either networks, or local practitioners, or even if they’re not in the same state, at least having some level of network that you build because it is a little tricky to do everything yourself. I think both Kelsey and I have realized over the years that at some point you have to start kind of emphasizing what you’re good at and focusing on what you’re good at and sending people to others who can take control over the medicine side of things or maybe the health coaching side of things just because it can get really difficult to do everything by yourself.
Chris Kresser: I think those are great points and I’d like to speak to that a little bit. Right now a kind of trend that I see is a lot of doctors and clinicians trying to fulfill the role of nutritionist and health coach or dietitian. And I see a lot of dietitians, and nutritionists, and health coaches trying to fulfill the role of functional medicine clinician.
I think that that’s natural in both cases because patients don’t necessarily know who to look for, for what. If a patient comes to me, they’re certainly expecting that diet and lifestyle behavior advice because they follow my work, they know that I care about that and know a lot about it.
And likewise, if a patient goes to a health coach or nutritionist as I’m sure you both experienced, you start working together and then you reach a point where maybe some additional support is needed and yet you don’t necessarily know who to refer to, or maybe you don’t have that referral relationship set up, or maybe you like to be able to do that work yourself.
That’s all natural, but I don’t think it’s optimal. I think eventually and what I’m trying to create with Kresser Institute is to build this ecosystem of practitioners who share the same perspective. That’s been the missing element. If a doctor who is trained in functional medicine and ancestral diet and lifestyle wants to refer to a nutritionist, then that nutritionist better have that similar perspective. They better share the same approach or else there’s going to be a real disconnect for the patient if that doctor’s been talking about the importance of an ancestral diet and lifestyle and they refer them to a nutritionist who’s using ADA or AHA recommendations. That’s not going to work.
Likewise, if the nutritionist has been talking about functional medicine and ancestral diet and lifestyle like you do, and then you refer them to a functional medicine clinician who is mostly advocating a plant based diet and making recommendations that are out of sync, then that’s not helpful. I’s actually harmful. It actually creates more dissonance for the patient.
With ADAPT we started with the practitioner training program because I felt like that was the biggest need. But next year we’re launching a health coach training program specifically for this purpose because I want to have an ecosystem of both licensed and non-licensed practitioners, allied providers that all share the same theoretical framework for how to approach chronic disease. That has three elements: functional medicine, ancestral diet and lifestyle, and this collaborative practice model.
That’s where I think we’ll see some really positive change because you have this synergy not only of the clinicians working together with the allied providers, but when they do that with a shared understanding and framework, that’s when it can be really, really powerful.
Kelsey: Yeah. I definitely have had that happen to me before where somebody comes to me and they need antibiotics, for example, for SIBO. I try to like help them find somebody in their area who is at least kind of functionally medicine minded, but because I work virtually it can be hard to find somebody who’s a perfect fit in that person’s area because, again, they do have to see them in person for that prescription to be filled.
I’ve had experiences like that where you do the best you can to find somebody who is on the same page with you about the dietary philosophies. But you’re right, it can be very, very confusing for the patient who then is hearing kind of different things from their doctor. One of the best examples I’d say of that is like when somebody goes to get antibiotics and then their doctor may be saying well you really just need to be on a low FODMAP diet along with this. That’s not how I practice with SIBO.
Chris Kresser: Yeah, that’s a perfect example. There are so many others. Again, it’s just where we’re at right now. But I think that we can do better and I think we’re going to do better with the whole ADAPT ecosystem. That was one of the main reasons I wrote the book, too, is that the book provides that template or that framework for everybody to understand, so for general public, for allied providers, and license clinicians. The book was written for all three of those audiences because.
We left the patient out of the last section, but the most powerful thing is when the patient, the licensed clinician, and the allied provider are all on the same page when it comes to expectations in what they’re looking for. That really was the primary motivation.
Laura: I can imagine that that would be really helpful especially if the patient understands the Functional Medicine Pyramid because one of the things that I’m often teaching my clients when they first come to me is the concept of foundational versus higher level changes. Because Kelsey and I get so many people from the ancestral health community, we have a lot of very self-educated clients which can be pro and con depending on what they’re looking at online.
Chris Kresser: Right.
Laura: And so just being able to make it very clear to the patient that there’s foundational changes that they might have not even thought of, maybe it’s a sleep issue, or maybe it’s a stress issue that they haven’t really been addressing and they want to jump straight to the top of the pyramid where they’re like supplements, and testing, and all that.
I think just having the understanding that if they don’t deal with the base of that pyramid, then they can’t go to the top of the pyramid successfully. The more understanding there is around that concept, I think the better expectations and results that the patients will have.
Chris Kresser: Yeah, I agree. I would also say there’s another model in the book which is the Functional Medicine Systems Model, and that’s the series of concentric circles. I created that to illustrate the way the human disease progresses.
In the middle of the circle, the core is the relationship between our genes, and our diet, and lifestyle and behavior. And then from that next circle out is pathologies like SIBO or insulin resistance that give rise to diseases and syndromes, which is the next ring out, which finally give rise to symptoms which are the way that we subjectively experience everything that comes before, and also signs which are the ways that we can objectively measure what we’re experiencing.
I think the crucial thing for people to understand is that disease moves from the inside, out. It starts with that diet, lifestyle, and behavior, and then pathologies, then diseases and syndromes, and then symptoms.
Even in functional medicine, we’ll often get patients who come in and say do you treat X or do you treat Y? Like thyroid problems, or multiple sclerosis, or gut issues. Or I have these symptoms, can you help? There’s a reeducation process that happens there because in functional medicine we don’t treat particular diseases and we don’t treat particular symptoms or signs. We treat the mechanisms that give rise to those conditions and that’s what makes it so much more powerful for chronic disease than conventional medicine. Because when you approach it from the outside, in as conventional medicine does, you end up just focusing way too much on the symptoms, and the signs, and maybe the diseases. The inevitable result of that is that you’re playing whack a mole with the symptoms.
Say the patient has high blood pressure. You use a drug to lower it. A patient has high cholesterol. Use a drug to lower that. A patient has constipation. You use a laxative. A patient has diarrhea. You use an anti-diarrheal. You end up playing that game and you’re dancing around the outside of the circle just trying to suppress the symptoms and you never actually get to the root cause of the problem.
I find it that diagram is really helpful, too, even for fairly experienced practitioners. Sometimes even in my training program six months in I’ll hear a question from a practitioner that’s like what do we do about this condition? Or what do we do about that condition? And the answer is always the same. You investigate what the root causes are. You look at the mechanisms. You look at the diet, lifestyle, and behavior. But it’s quite a paradigm shift and so it can take a while to really get your head around that.
Kelsey: Yeah. I think that’s, like you said, it’s even a problem for practitioners to really think about, too. I think that’s partially because we get clients and patients coming to us who are also very focused on the symptoms, so they’re asking those questions. How do I deal with X symptom?
Chris Kresser: Yeah.
Kelsey: But they know that they want to get to the root cause of it. But of course because they’re feeling those symptoms every day, that’s sort of their focus. I think that’s kind of probably how conventional medicine at least sort of came to be is that the patient, they want to feel better immediately. And the best way that we can do that like really, really immediately is to focus on symptoms versus root cause.
Chris Kresser: Yeah, and I do want to say that that’s appropriate for patients. You can’t necessarily expect patients to understand all of these things, although we can educate them. Again, that’s the book, my blog, and all of the other resources I’ve put out over the years because I do think it’s important to educate our clients and patients in terms of what to expect. Because if a patient expects a drug to solve all their problems, then of course that’s what they’re going to ask for.
We’ve trained patients to expect that in this country. People aren’t born expecting that. We train them to expect that through direct to consumer drug advertising and of the other ways that big pharma influences our healthcare system, or our sick-care system rather. So we can absolutely train them to expect something different.
But I do think that as practitioners, I don’t mean to say that we don’t care about our patients symptoms, or we don’t pay attention to them, or even that we don’t do things to help temporarily provide relief while we’re addressing the underlying cause. For example, if a patient has Lyme and they’re unable to sleep because of that and that’s one of their main complaints, I’m absolutely going to use supplements, and botanicals, and whatever I need to use to get that patient sleeping better because the Lyme isn’t going to be addressed overnight and they need to sleep actually in order to shore up their immune function and be able to actually deal with the Lyme. That’s a case where a symptom of a deeper problem can actually become a deeper problem itself. It’s not always super straightforward.
One other kind of visual representation I like to use is a tree with roots going into the ground and branches extending from the tree. In functional medicine of course we want to focus on the roots of the problem. But at the same time in some cases where the branches are symptoms that are so disruptive that they interfere with the patient’s life and also start to become roots on their own, like sleep as I just mentioned, then we have to actually address those right off the bat while we’re continuing to look at the root cause of the problem.
Kelsey: Yeah, absolutely. That makes perfect sense. I think that’s a really good visual to think about.
I want to go back for a quick second because I had asked a question before about sort of deciding if you’re somebody who is wanting to go and become some sort of functional medicine practitioner or coach and deciding where you best fit into this collaborative model that you’ve outlined in your book.
I know for me, and I still think about this, and maybe it will happen someday, I maybe should have gone and become either a nurse practitioner, or a doctor, or a physician’s assistant because I like the more medical side of things rather than the coaching aspect of it.
I’d be curious to hear from you if you would have done anything differently yourself in terms of how you are licensed, and then how you think people can identify what their best at if they want to fit somewhere into this collaborative model. Big question, I know.
Chris Kresser: It’s tough because it’s 20/20 hindsight, it’s a tricky thing.
Kelsey: For sure.
Chris Kresser: If I say yes, I wish I would have gone to medical school, it’s very possible that we wouldn’t even be having this conversation because I would have been so busy in medical school and in that intense nature that environment. It changes you. I think it’s possible that I would have been influenced in a different way in medical school and I wouldn’t have had the time or even the inclination to go in the direction that I’ve gone.
On the one hand I can say, yeah, if I was starting from scratch and I was 22 years old again, I would probably have gone to medical school. But as soon as I say that, I have to introduce that caveat because I may not have ended up here in this place.
I work with patients in a variety of ways. Actually, it’s funny that you mention that because I find myself kind of going even more in the health coaching direction, if you will, in the sense that the more I work with patients, the more I come to believe that diet, and lifestyle, and behavioral change are really the crucial drivers for most people.
That might sound strange coming from me, a functional medicine practitioner and also someone who trains clinicians in functional medicine. I still very much believe in that approach, of course. I told some stories in the book about this, situations where we’ve done almost everything we can think of in the functional medicine framework and the patient is still not getting better. Almost always in that in that situation, it comes back to the basics. It’s some aspect of their lifestyle or behavior that is not working.
It might be that they feel really isolated and alienated socially and their diet is so restrictive that they haven’t been out with their friends in years because they feel like they’re so limited. They’re not having any fun. They have no pleasure in their life. It might be something like that. And so I will actually put aside the functional medicine toolset at times and just focus and put on my health coach hat and have more success that way than I would have if we just kept doing one lab test after another and one treatment after another.
But to answer your question in a more general way, I have actually done webinars on this question that last an hour and a half. I’m going to do my best to summarize. But I think that the crucial distinction that you need to make at an early stage in the process is deciding whether if you want to be able to order lab tests, interpret those lab tests, and prescribe treatment based on the results of those lab tests, then having some kind of license is going to be necessary. I think that’s the first most important distinction.
If you are content to work with people on diet, lifestyle, and behavior, which is a vast, vast area…I mean you could do that for your whole life with somebody and never run out of things to do…and you want to be able to have a certain kind of relationship that comes with that where you actually do have more time to talk about the social, behavioral, psychological, and even spiritual aspects of health, and you don’t necessarily need to be the person that’s ordering the lab test and prescribing treatment based on those results, then becoming a health coach or a nutritionist would be an excellent choice.
That’s the first distinction, I think. Part of what goes into that decision is of course where you are in your life, how much time and money you have to devote to training because generally pursuing a path that leads to licensure is going to be longer. Becoming a medical doctor in many cases is going to be 6 – 7 years plus or more if you have to go back and do post back pre-med training.
That plays a role, of course. But even more important I think is just getting clear on how you want to spend your time with people. That’s really what it comes down to.
Laura: It’s kind of funny that you mention the health coaching thing. Obviously both Kelsey and I are dietitians and so we both started at the same entry point into the functional medicine world. But I think as time has gone on, my business and my practice has started to go heavier towards the coaching side of things whereas I almost feel like Kelsey’s practice has started to go more towards the functional medical practitioner.
It’s really cool because you can kind of like choose your own adventure as a dietitian where you get to really go really deep into that lifestyle stuff if you want. I’ll spend an hour and a half with my clients on their first call just covering all the different areas of their life that could be impacting their health.
But if you get to a point like it sounds like Kelsey’s at where maybe you want to go deeper into that medical side of things, you’ve already gotten part of the way there as a dietitian and you might just need to get another degree that is able to order labs or medicine.
I think that’s one little hat tip to the dietetics field is that it really does let you kind of pick what you want to do because you are licensed, but also you can really dive into that health coaching aspect if you want to.
Chris Kresser: Absolutely. I think one of the best ways for people to figure this out is to go observe people doing different things. Find a doctor that you can shadow. Find a nurse practitioner that you can shadow. Find a health coach that’s only doing health coaching and isn’t also a licensed practitioner that you can shadow because that’s going to give you a much better idea than just sitting around thinking about it.
Kelsey: Yeah, absolutely. This has been awesome, Chris. I just want to do a little shout out to your book which recently came out; Unconventional Medicine. We’ve been talking about a lot of the concepts and ideas that you cover in that book. If people want to dive deeper into this stuff, definitely check out Chris’ book, Unconventional Medicine.
Chris Kresser: That’s right.
Kelsey: Alright. We’ll link to everything. But thank you so much for being here today, Chris! This was a really, really interesting conversation that I think our audience will very much enjoy what you’ve had to say here and it probably gives some of the people who are thinking about getting into this world a little bit to think about in terms of what direction they want to go in.
Chris Kresser: Thank you both so much. I really enjoyed this conversation. And I always loved working with you both and I love the work that you’re doing in the world, so you’re part of this ecosystem, of course. I think we can all work together to continue to expand it so that we can help the millions of people who are suffering from chronic disease and not getting answers in the conventional system.
Kelsey: Absolutely. Thank you, Chris.
Chris Kresser: Thanks, guys. Take care.