Telemedicine delivers comfort, care, continuity, and connections

Interview with Dan Kalish, DC

Hello everyone and welcome to Field Notes, an exploration of functional medicine. I’m Rob Downey, a family practice MD and an Institute for Functional Medicine certified practitioner. I’m coming to you from Seaworthy Functional Medicine in Homer, Alaska.  We are fortunate enough to have Dr. Dan Kalish here with us today from the Kalish Institute. Welcome, Dan!

Thanks for having me. I’m really excited!

Well, I’ve been so looking forward to getting to spend this time with you. You’re one of my clinical heroes, and also a hero to me for the huge amount of help your class and service provided for me last year to prepare for this juncture. It’s a big moment! I’ll start by trying to summarize your bio, but please add to it if there’s anything that people should hear or know about you that I don’t include. 

You’re a functional medicine doctor and an Institute for Functional Medicine certified practitioner.  You provide care to patients, and have done so for many years. In fact, you were in on the ground floor of functional medicine 25+ years ago with Jeff Bland and David Jones, and all those folks. As if that wasn’t enough to do, you’ve also trained 2000 medical providers in the service of functional medicine. This includes training practitioners to build viable businesses so we can deliver a safe, sane, sensible model for ourselves and our patients. Here we are now in 2020, and we’ve got a pandemic and a real need for telemedicine. I think that brings us into this moment. Is there anything I should add?

Just that I’m still in practice and I still work with patients on the phone. We were talking about this earlier. I’ve been conducting a phone practice for 15 years and teaching a model that helps doctors do that. Now, of course, everyone’s being pushed in this direction. I think one of the rosy parts of the current coronavirus crisis is that it will result in a permanent change towards telehealth, which will help people in a variety of ways over the long term. Especially in a place like Alaska where you practice, where it’s very difficult for people to meet with physicians one-on-one easily.

Gosh, yeah! We’ll want to talk about that today. I’m breathing a big sigh because I thought, with your permission, we might take a moment of silence at the beginning just to acknowledge the blessing of having a job and being able to serve when some people are having so much fear and loss. It would perhaps be a good loving kindness gesture if we can do that briefly at the beginning.

That sounds perfect. 

We’ll just take a brief moment of silence for those who have lost, those who suffer, those who fear, and we’ll have a nondenominational sense of positive intent that they have safety, and health, and peace. 

Thanks so much, Dan, I really appreciate that. My listeners should know that I took your business class in functional medicine last year, but I find that I describe it more as a service class. As my business coach, you explained to me that the business of functional medicine and the service of functional medicine are essentially the same. They may be multifaceted, but they are the same. With many of us needing to deliver via telemedicine now, it’s such a good navigational principle that I established with your help over a year ago. If this serves patients, then proceed to the next step! That’s kind of how it feels. 

What are you finding now as you’re teaching people how to quickly accelerate their practice, as they translate from how they were previously operating before COVID-19? You’ve practiced telemedicine for many years, so what do you think is really important about delivering effective, quality functional medicine when you can’t be in the room with the patient?

We have a large group of doctors who are getting trained now. They’ve come in since COVID-19 started, and they’ve been forced into doing a telemedicine practice because of the circumstances. They’re taking my Kalish Institute Program because they basically don’t have any other choice, because their regular clinics are closed. It’s interesting, and it’s almost like a little research study, isn’t it? They’re not self-selecting. Over past years it would usually be people who may have thought, “Oh, I’d like to take this class. Maybe I will. Maybe I won’t.” 

This current group consists of a random assortment of people who have been forced to do this, not because they wanted to. What’s very interesting is how surprised they are at how much better telemedicine can be, in certain ways, than seeing patients in person. That’s because the perception of telehealth or telemedicine is that it’s going to involve losses, not gains. You’re just doing it because you have to.

Once you start providing telemedicine for a while you start to realize that there are a huge number of benefits. Here is a simple example. Imagine the patient being in their home with their loved ones around. Maybe their daughter is in the other room, or maybe she comes into the room and talks. That’s a lot different than waiting in a hospital waiting room and having that whole white coat tension, high blood pressure problem that we all have. Just that, in and of itself, is a benefit. It’s also helpful to see what the person’s like in their native environment. Did their husband come into the consult? Is he a really friendly, supportive, and loving person, or not? I think you get a glimpse into the person in a different way. It changes your interaction with them because they’re more disarmed, more relaxed, and more able to be themselves. They’re not in a foreign environment that puts them on edge. That’s just one simple example of a hundred different things. 

What’s very interesting is how surprised practitioners are at how much better telemedicine can be, in certain ways, than seeing patients in person. It changes the interaction because they’re more disarmed, more relaxed, and more able to be themselves.

I like what you’re saying and I’m experiencing that in my practice. We talked last year about my service area consisting of around 16,000 people in the vicinity of Homer, but Alaska has a population of roughly 740,000 people. Given that the span of Alaska roughly equals the span of the lower 48, I needed to be doing more telemedicine for me to deliver service within my medical license zone, which is Alaska. 

That concept then blossomed and evolved into a system that we built where we have our patients be really clear as to who their primary care doctor is. We elected to have them initially be cleared by a primary care doctor and declare who that is, and repeat that process every two years. They then set the stage with me the first day we meet on telemedicine, wherever they are. Whether it’s within or outside of my service area, they know where we’re heading with the case and that I’m their telemedicine consultant in functional medicine.

I find that it’s a pretty neat feeling, as you say, to meet somebody in their home environment. They’re more at ease. It also brings up this issue that part of functional medicine is about being flexible and resilient. Sometimes with young patients, the camera’s wobbling, or their pet cat’s hopping on their head, or they’re walking around the house, or I’m looking down at the top of their head, or up their nose. It’s very organic! I’m finding that as long as I really attend to them over the telemedicine link the same way I would in person, that I’m focused on them. I’m attuned to what they’re doing and saying and I’m not distracted by the keyboard as I might be in a traditional visit. The connection is very good! It feels very strong, very therapeutic, and very safe. It’s good news that it works so well!

Yes! In my experience, and I think it’s true for all the doctors I work with, there’s not a loss of intimacy or connection just because you’re not in the same room. It’s surprising, but that doesn’t happen.

Yes, and it is good news. I think some of it comes from some of what David Jones has espoused for a long time, in that it’s really important to put ourselves into an attentive and harmonized state to get ready to attune to the person we’re working with. I think it would be more challenging if that skill set wasn’t strongly in place. For the practitioner coming out of the gate, it might be a little tougher. The technology then might  amplify that. 

Our listeners may be thinking from the patient perspective. What have you and the folks that you’ve trained heard over the years about patient satisfaction with telemedicine? Is it a mixed bag? Are there pretty high satisfaction rates?

Every year we have two or three patients who just don’t want to work over the phone, and they’ll end up asking for a referral to a local doctor. That’s roughly 2-3% of the people that we work with who just don’t like that modality. They want that in person, face-to-face experience. Everyone else reports that they like a bunch of things about it. They like the convenience.  Depending on what state you’re in, there may be parking, traffic, and pretty dramatic driving hassles that are avoided. It’s the ability to keep their appointment and not completely ruin their whole day. There are so many times during my phone consults that a person will say, “Oh, can you just give me a minute? I have to go into the break room,” or, “I have to close my office door.”

When I go see a doctor in person, I have to miss a half day of work. By the time I get in the car, drive there, park, wait, see the doctor, and then come back, it’s a lot. It’s not only about convenience, but you might tend to put appointments off when they take a half a day. If your patients can sneak a half hour consult into the end of their lunch hour, it’s much easier in some ways to keep people compliant and staying on their programs. It’s easier for them to keep in touch with you because of the ease of the process. 

This reminds me of eighth or ninth grade when I had my first girlfriend. We would talk for hours on the phone on school nights because we couldn’t see each other. We lived in different parts of town, which was probably like a mile apart, but it seemed like forever. There is something about being on the phone that’s a little disarming. It’s more connected in some ways that are intangible and hard to describe than meeting in person. People are less self conscious. There’s less analysis of your office. Is the room clean? What kind of a jacket is he or she wearing? It kind of smells funny in here. Forget about the whole COVID issue, where people are paranoid about getting sick. They’re analyzing you in so many different ways that are unnecessary. Where am I going to put my purse down? Where do I hang my jacket? All these kinds of things. In a phone call session you just immediately, honestly within a few seconds, go directly into the consult.

I don’t say this anymore, but I used to tell my patients when I was trying to convince them to do telemedicine that I actually have analyzed this. It takes two, three, four minutes for someone to walk into a treatment room, put their purse and bag down, figure out where to sit, and for you to greet them and for this whole appointment to start. And then at the end, if you’re having a polite social interaction you can’t just get up and leave! You have to wind things down. So there’s at least four to five minutes of every consult that’s wasted in social interaction when you’re meeting in person. When we’re doing telemedicine we jump right in and say, “Hi, how are you doing? Let’s look at your lab,” and for some reason it’s not rude or weird to do that. The person’s already prepared, and they’ve already settled in place. They’ve got their pen and their lab test out and they’re ready. It’s also more economical in a way, because it just costs the patient less. You’re not spending as many hours with people as you would otherwise.

Thanks for all of those insights. One of the things I flashed on while you were sharing was that one of my patients mentioned recently that their treatment plan had unraveled a bit over time. An important concept I learned from you last year was your nine step process of providing excellent service. One of the last steps is to proactively and preemptively anticipate when the person is going to need some support at the 6-12 month mark in their maintenance plan. This patient very much endorsed that if that step had been in place, along with the ability to do telemedicine, it would have been radically transformative for the ongoing sustainability part. That to me was just revelatory. This person’s eyes lit up when they said, “Oh, if I could do this when I’m traveling, seeing my kids, and doing business, I would just need that half hour to jump on and keep everything rolling!” I thought, “Wow, it’s not just resonating with this person. This is needed by a lot of people!” 

It’s so important to proactively and preemptively anticipate when a patient will need support in their health journey. That combined with telemedicine is radically transformative for ongoing sustainability and continuation of care. 

Yes, it’s interesting, isn’t it? There’s another thing that used to be a bigger problem. People in their 70s and 80s who are sometimes not as familiar with technology and all that kind of stuff, although now that’s much less of an issue. My mother’s 83. She has an Instagram account and follows all the grandkids, and she knows more about Facebook than I do. I don’t think there’s as much of a technological barrier based on age or generational differences anymore that may have existed even five years ago. 

Yes, I think the technology getting simpler and being more pervasive means that it really is right at people’s fingertips. Now I find that if somebody’s not terribly comfortable with technology, it’s more of a personality type thing or maybe a socioeconomic disadvantage in terms of access to computer technology. I always tease people a little and say, “There’s folks around you that know what button to hit. Maybe you could lure them over when you need help!”

Rent a teenager or something, every teenager knows how to do it!

Other threads that I wanted to pick up today that I think fit into telemedicine include something that I learned from you last year, which is this issue of anticipating people’s needs. We looked at my local bricks-and-mortar practice last year to see who we serve and how we serve. We realized that it was the state of Alaska, but also that people were learning via social media websites, podcasts, and blogs, whether it was about the availability of our services or the concepts of functional medicine themselves.

I thought the core model of my practice was solid, and I was seeking to improve my practice in ways that were the equivalent of getting a new set of tires. Based on this information it suddenly became clear that we needed to strip the thing all the way down to the chassis and rebuild our service model all the way back up. It really helped last year that the content of your class highlighted the idea that people have a need from the moment they identify their own need for a practitioner such as you or me. That’s the pain point, maybe. From the initial consult all the way to the maintenance there’s these nine steps to ensuring that we provide excellent service. 

Another thing we’re doing here with telemedicine is using our telemedicine app to send out reminders such as, “Your three months of adrenal restoration is wrapping up. Your six months of gut restoration and repair is wrapping up. That dispensation of supplements for six months is within six weeks of wrapping up. Do you want to do a little maintenance and transition? Your yearly maintenance plan is coming due.” I wanted to flag that. It’s another one of these concepts that sounds simple, but it’s so important to anticipate! It’s just human nature. There’s a need for ongoing anticipatory support. I think it’s all the more important with telemedicine because you don’t have a captive local geographic audience. They’re not walking past your clinic, or what have you. 

The maintenance phase or treatment is the most important service to keep people well.

Yes, that’s very true! Some of the earlier models of functional medicine depended on people going into clinics for services on a regular basis, especially if the practitioner was an acupuncturist, a chiropractor or an osteopath.  Patients would go in for these weekly specialized treatments and see the supplements that they needed to get there at the office. But if you’re a different type of practitioner and you’re not doing regular structural treatments, or if your patients are in the maintenance phase and you really only need to talk once or twice a year, then people will naturally drift away. Even if it’s something they know is good for them, it will become a lower and lower priority until eventually it’s out of sight, out of mind. Then two to five years later they’ll come back in because they haven’t been maintaining their systems and their problems have cycled back. That maintenance is so important. It’s just like maintaining a car. You don’t just wait until the car breaks down. You change the oil, put air in the tires, and so on.  That maintenance phase, when people are ready for it, is really the most important service to keep people well.

It was a big aha moment for me! It’s sometimes humbling that some of the most powerful aha moments aren’t rocket science. They are things that are just so in front of our face, or for me that’s how it felt during your class. Translating that to practice, I was so happy the other day. I show patients your ‘Transition to Wellness’ diagram that you allowed us to keep from your class. This diagram shows how over a three month period they can get symptom relief, and over six months they can start to have some organ systems reboot. In a year or two they can start turning the corner into resolution, and beyond that they can get into maintenance and optimal vitality. I had shown somebody the diagram and she came back to see me and said, “Yeah, I feel like I’m heading toward that maintenance! I have a compass heading that this is where I’m going.”

So now I have what would be characterized as ‘follow through’ if it were a batter and baseball. It’s like this patient was projecting through the current signs and symptoms she was experiencing, and asking questions to illuminate and navigate the path that lay ahead. Is this sustainable? Is it affordable? Can I remember my supplements? Can I keep eating whole food? Will my spouse support what we’re eating for dinner, even when we’re busy? I gave her a gold star! I said, “That’s so great that you reminded me about this transition to sustainability because after working so hard, isn’t that great to think about how it doesn’t take as much work to stay well as it did to fight to get well?” 

I also realized it was a missing part of my practice. It’s not that we weren’t prompting folks to follow up, but we just weren’t doing it frequently enough. Even just a quick, “Hey, we’ve got that maintenance plan for you.” I know some people will still not elect to follow up on it, but I want to ethically offer it to them. We now schedule it out to say, “It’s been a year, and we’re notifying you six weeks in advance. It’s been a half of a year, and we’re notifying you a month in advance that it’s time to follow up.” We also make sure that the follow up focuses on lifestyle. It’s interesting, but I find that a lot of people don’t remember that they were meditating when they felt better, or that their food plan was a little more tidied up, or they actually were getting eight to nine hours of sleep a night. They’ll say, “Oh yeah, I drifted back to seven hours of sleep because of the Netflix binge during COVID, and now I’m tired. Aha!” I think lifestyle and sustainability are important in bricks-and-mortar practice, but in telemedicine they become paramount because the digital ether is just set up for everybody to drift apart, unless there’s some kind of reminder system.

It doesn’t take as much work to stay well as it did to fight to get well.

Yes, it’s an ongoing relationship. In a traditional practice you might have a fertility patient. She becomes pregnant, has the baby, and then most doctors will be thinking, “OK, next!” They’ll be looking for another patient. With functional medicine it’s this completely different model of having sustained long-term relationships. One woman who is under my care initially came to me as a fertility patient. This shows how old I am!  We worked through her fertility issues and she had a daughter. Her daughter is now 25 and is also my patient. When we met over the phone I said, “I knew your mom before you were born!” That kind of longevity of having a patient for many years, and now having the opportunity to also treat her daughter is a whole different kind of medical practice. 

It’s not about just dealing with people who are chronically ill and trying to get them better, and then getting another cohort in who are chronically ill. It brings a different sense of meaning to me and to my patients, too. I think about how happy this patient is, in that her original problem of fertility was resolved and she’s had such a good experience that her grown-up daughter is also seeing me. It’s generation two. I think that’s what medicine was like a hundred years ago. When you were a local doctor in a small town, you helped someone with her pregnancy, and then her child would come to see you 25 years later. Sadly, I think that’s been lost, but I think that it forms some of the richness for both the patient and the practitioner. This kind of relationship is really different and unique. I don’t have grandkids, but maybe it’s similar to becoming a grandparent and when this other generation that you’re tending to.

Because I’m at the 20-year mark in my conventional practice, I have absolutely taken care of kids of patients who I’ve taken care of. I’ve also noticed that trend of taking care of a patient’s dear friend or a spouse, et cetera. It does indeed seem to me that this mirrors something medical providers got to participate in years ago. I even have some guesses that it may mirror the experience of healers and human communities over thousands and thousands of years. This relational scenario of a human in ancient times, perhaps living in a grass hut or other shelter. During the drier parts of the year that you’re able to walk, you feel energetic and lit up. When the rains come and pin you down during the wet season, you’re droopy. It’s the healer’s job, even in ancient times, to help restore vitality. Maybe the healer would advise that droopy patient to go out and try walking in the rain to regain some spirit and vigor. Those are guesses I make about what it would have felt like to be a straight up healer. Maybe somebody happens to have the personality and temperament for it, and the community kind of then inadvertently places them into the role of healer over the course of a lifetime.

I think it’s really good that we’re talking about it today because the worry that I have for Americans, because I’m an American too, is that we need quite a bit of active deconstruction of a bunch of stuff. That software that’s running in our head all day, every day takes a toll. David Perlmutter’s recent book Brain Wash really flags this. I think a lot of folks look at this in functional medicine all the time, but a disease management focus, rather than a vitality focus, creeps into many Americans’ lives.  They tend to feel like if their blood pressure medication is keeping their blood pressure down, they’re done. Problem solved. In functional medicine, they’ll find that when they’re walking and getting on top of silent inflammation, and meditating or doing yoga and positive psychology that there’s this whole extra dimension to their wellbeing. You flagged that last year in your course. People are also so appreciative when they get that proactive preemptive heads up, “Hey, we’re at the 10 month mark on some program tune up and maintenance, and I want to touch base.” You reported that so many of them say, “Oh, that’s great! The timing is perfect! Things were just unraveling and need some attention now.” They may say they’re going to go back to eight hours of sleep every night, or find they need to tweak certain practices. They may not enjoy yoga anymore, or crave some other change. Patients sometimes just need some brainstorming.

It’s not just the absence of disease that we’re striving for, but overall optimum health.

Yes, and I guess there’s also different levels. As you were saying, we have these diagrams that illustrate this. In functional medicine we practitioners are getting a patient out of their crisis state, but then in a perfect world we’re trying to drive them to a healthy state, towards what we see as this individual’s best potential health. It’s not just the absence of disease that we’re striving for, but overall optimum health.

At that point we see people shift to more emotional and spiritual growth experiences because they’re not depressed anymore. They’re out now, and they’re involved in the community. They go back to their church group or they decide to go back and get a master’s degree that they always wanted. They’re somehow engaging in their life in a way that’s more complete. Somewhere around year two, for patients that stick around, you can start to talk about spiritual growth and how they’re going to move into that as a project, which is a pretty deep thing for people, right? That’s kind of why we’re here on this planet. We’re not here just to be healthy!

I’ve worked with a lot of really wealthy clients over the years who get to this level of personal health and then it’s like, “That’s it.” That’s a pretty empty and hollow place to be. It’s what we do with our optimal health that matters. People really appreciate guidance with that as well. I’m not talking about being a spiritual counselor, but I’m talking about pointing out the spiritual aspect of our lives that’s important, and engaging with people so that they pursue those things as well. That seems so important. In terms of continuity of care, if we’re not staying in touch and reminding people to come back, then they’re going to miss out on a lot of the richness of this work, which is that phase.

I like what you’re saying so much, because again I’ve witnessed it in my own life. It flags a related principle to me or my way of thinking, which is that the project morphs as we proceed through it, whether it’s our own healing journey or the people that we shepherd and guide on their healing journey. The initial intimidation of being pinned down by fatigue, joint pain, abdominal pain, or a low mood can be worked through. When that’s resolved, if folks can anticipate that the next dilemma or riddle is going to be, “Why am I here?” Answering that has profound implications for sustainable wellbeing, immune function, gut barrier, integrity, the ability to sleep, and brain health. These are very salient to concrete scientific principles. What I love about functional medicine is that we get to do this AND work rather than this OR work. So when we talk with people about meaning and all, it’s so important! It also really helped that you had me read the Soul of Money by a woman who served as the CFO of The Hunger Project.

Yes, I like that book a lot!

Her primary theme that I took away was that you can have $25 bucks in your bank account or $20 million dollars and feel impoverished. And you can have $25 bucks in your bank account or $20 million dollars and feel abundant. Her premise is that the abundance comes from within. It’s not actually the $25 or the $20 million dollars. It’s a state of being. That to me ties into this thing that you identified just now, which is that identifying who we are and what we want becomes a big part of our health once the symptoms settle down. I see folks drop out. If they’re only there for symptom relief they quickly disappear, which is okay. I want to offer them maintenance, but I’m glad we’re preemptively saying the next thing coming is, “Why do you want it?”

Why am I here? Answering that has profound implications for sustainable wellbeing, immune function, gut barrier, integrity, the ability to sleep, and brain health.

I think that’s one of the biggest human fears, is the fear of becoming our potential best self. Why do people not pursue that? Well, because it’s really scary. I think that ‘big immortal self,’ that ‘big energy self’ is intimidating. So we’re often settling for a slightly lower level, a less caring, charismatic version of ourselves, I guess, just because it’s comfortable. There’s a lot of potential risk with breaking out of that, to this higher level.

Yes, if I’m hearing you accurately I can think of some things that I would do. When you see folks that are running into some fear, would you share with us Dr. Kalish how you help people be more comfortable with that juncture?

I’m a Buddhist Catholic Jew by birth, right? My dad was Eastern European Jew, and my mom is Japanese and Portuguese. So I have my religion, although I don’t have a strict version of it. I have a lot of patients who do as well. As a matter of fact today, just before our call, I saw a woman and her husband who are very devout Christians. They do missionary work overseas and all that kind of stuff. I have a female patient in Dubai who’s a Hindu. Whatever religion they may be, it doesn’t really matter. What I try to do initially is find out if they have a strong religious background or belief that they could or would want to return to. That’s probably half the people that I work with, and so we try to reconnect them in some way with whatever they’re missing from that regard.

Then there’s another half who aren’t religious, who are like, “I used to be Catholic, but I don’t really believe in it anymore. I haven’t been to church since I was 10 years old.” These people may need a new spiritual direction. I try to coach them in some way to find a niche for themselves that’s going to work. Something that’s going to allow them to find a community that they can be comfortable with and to pursue that kind of work. I don’t do that work with patients myself at all, but I feel like I can be like the guys at the airport that direct the planes. The airplane marshallers that are out on the tarmac. You always see them gesturing and pointing, and I feel like I’m that guy suggesting and directing, “Over here, we have Zen meditation.”  A lot of times I recommend mindfulness-based stress reduction such as what Jon Kabat-Zinn offers because that’s easily available. It’s non-denominational and compatible with any religion. That’s one of my favorites and people really like it as a practice to get started with. Some people want to be more physical, so we can get them into a yoga class that has breathing. Whatever it may be that’s going to open up that connection. I do feel like that’s the one of the ultimate goals of our job to get people to that point where they’re pursuing that kind of work.

I would add that Tracey Gaudet one of the keynote speakers at the Institute for Functional Medicine annual international conference this year who gave the closing speech, and who just finished getting her MD, flagged that as well. Her advice to everybody attending the IFM conference this year was, “If you’re not talking to people about why they want to be well, you’re missing some really important information YOU need as their medical provider, and you’re missing some really important information that THEY need so that it turns into a compass heading.” And she said that she now does it during the first patient visit.

She says that she hears very specific things. Sometimes the person with arthritis wants to be able to chop vegetables at the counter, or another person wants to feel well and be energetic at eight o’clock when their grandchild is done with Girl Scouts, or another patient wants to continue their career into their later years. Dr Gaudet said having that information is very specific and it frames things differently. And it seems to me that’s kind of a functional medicine example of how a good health history then makes a very human connection. It feels like a prompt again to do good work and provide good support, and ask the person one to three years later, “How’s it going, carrying your business into these years? Are you getting to see your grandchild come from Girl Scouts at eight? How’s the chopping veggies going?” It just becomes very real and very tactile, I suppose.

It’s so important to find out why patients want to be well. It provides both you and your patient a compass heading for their healing journey.

Yes, and it also helps you track people, because people sometimes forget how bad things were, and they sometimes forget once they’ve achieved these goals. So it’s nice to remind people, and then also to present what the next level can bring. Otherwise people get lost and then they don’t come back. They get caught up in life, and then they regress. That’s just sort of human nature, I think.

Yes, I do think it might be one of the most important things we talk about today because when it came up last year in class, I felt like, “Why haven’t I been doing that as a functional medicine doctor?” And in fairness, it’s on me because IFM probably flagged it at some point that it was a really good idea. As a family practice doctor, I scheduled follow up visits asking folks to please see me in three months or please see me in a month. So I was absolutely doing scheduled follow up of a sort, but I wasn’t thinking ahead to that human nature aspect. It seems to me that it’s the subjectivity-objectivity issue. And I was really able to get it when I thought about things that I care about, like running, skiing, using a fly rod, being nice to people, or doing yoga with my wife. I felt like these things are either used and maintained like a muscle or they just sort of unravel.

When I have accountability to somebody, such as a person to run with, or doing yoga with my wife, or a healer who’s involved in my life, then I stay on track. I don’t have to see them terribly often, but I sense it out there in the future that I’m going to be looking them in the eyes and reporting how it’s going. If it’s not going well, then I’m going to have to get back on track anyway, so I might as well stay on track. It kind of tightens everything up. 

That is one of the biggest parts of our jobs, the accountability or making people accountable to themselves by having a little bit of pressure. I believe we do that in every endeavor in life though, right? When you go to a graduate school program, medical school, PhD, or whatever they don’t just give you a bunch of books in the library and say, “I’ll see you in five years!” You have to go to classes, you have to interact with people, complete assignments, take exams, and turn in all the things that are due. There’s follow up, follow up, follow up until you’re at the end of the process, and I think that’s necessary.

Yeah. I think a lot of the things that matter that we’re doing have an objective outside mirror that we see ourselves in. It’s not always a lot of fun, but it’s really important that we have somebody kind and compassionate to mirror for us and tell us if things seem to be going well, or that it seems to have kind of unraveled. I find again that mirroring sometimes circles back to meaning. Some of the conversations that have been repeated with patients, or the supplement plans fall apart over and over again. Are you really on your food plan? Are you trying to supplement your way out of a food deficiency? 

Another big aha moment for me was that the plans basically don’t work at all without a lifestyle commitment. We now use your recommendation in the early going and say to folks, “Well, are you ready to have skin in the game? You don’t have to live like a monk, but are you ready to have skin in the game your way? Engagement, healthy food, stress management, social connection, and movement of some form for you?” If they’re not ready we’ll typically just plant a seed then and say, “No problem, but we’re just not going to have much success lab testing and supplementing you out of a non-engagement lifestyle state.”

That has sometimes surprised people. Because I’m coming from a place of kindness, I don’t find that people feel offended. It seems like I’m usually able to frame it as if to say, “Just be aware that this kind of medicine is really different!”

We need to train practitioners to speak to patients about food in the same way doctors were trained in the 1950s and 1960s to have frank discussions about not smoking. The wrong food is arguably as dangerous as smoking for cancer, diabetes, and heart disease. 

I was talking to one of my teachers, Dr. Richard Lord, about this just this morning. He was harking back to the days when smoking became a scientifically objectively dangerous thing to do. All of a sudden physicians throughout the United States were faced with a new reality, which was that they had to tell patients that smoking is dangerous and can cause cancer. I grew up in an era when the dangers of smoking were widely accepted. He’s quite a bit older than I am, so he watched that era go by. He’s like, “Dan, we need to do that same thing now with food! The wrong food is as dangerous as smoking for cancer, diabetes, and heart disease. We need to train physicians to speak to patients about food in the same way they were trained in the 1950s and 60s to speak to people about not smoking.”  The advice from a doctor to a smoker back then wasn’t like, “Okay, Fred, why don’t you cut back from three packs a day? And good luck with that!” It was this serious conversation basically telling the patient, “Your life’s on the line. We need to make this lifestyle change. We need to figure out how we’re going to get you to stop smoking cigarettes.” That really struck me because it’s so obvious to all of us now that a doctor telling you not to smoke is sage advice, and people take it seriously. How can we get there with food, which is objectionably as important or probably even more important for people’s health? How can you have this authoritative and science-based explanation, but still motivate people to make a change that is really, really difficult?

I’m glad that you articulated that, and I’m glad you shared that lucid and apropos moment you had with Dr. Lord, because I think now my practice has changed.  Again, it’s a bit humbling and sobering that it’s taken a while to have some of these aha moments. I noticed seven years ago that if I offered people supplements, lab testing, and a food plan during the first visit they tended to focus a great deal on those labs and supplements, perhaps because it was happening in America. I had some people work with me and say, “Rob, don’t do that. Just talk about lifestyle during visit one. Have it really be a branch point for the person. Just be very honest. You don’t have to implement a perfect food plan after the first consult. It can be as simple as just switching to chia pudding. It can be a little tiny snowball at the top of the hill. It’s incremental. We’re always going to be talking to you about what’s happening with lifestyle. Visit after visit, month after month, year after year, what’s happening with your lifestyle? 

I love that the promise we can keep to patients after we get their attention is that it’s going to be a path of joy, not hardship. My favorite takeaway from the IFM annual international conference this year was the unapologetically delicious aspect of food. When you’re on a whole food plan it needs to be unapologetically delicious, or you’re probably on the wrong track.

Oh, that’s really true, isn’t it? The healthier I eat, the more I enjoy food. It’s so counter-intuitive, I can’t even tell you.

I wonder again if that’s an Americanism. I don’t know if we’d run into that if we were in the south of France, Italy, Europe, or all kinds of wonderful places in the world that boast incredible whole food cuisine, such as Thailand, et cetera. I think many cultures have a very intact whole food tradition that maybe a hundred years ago we would have experienced here. 

Yes, and they’d have a little bit of skepticism around Captain Crunch for breakfast, right? Here we’re like, “Oh yeah, that’s how I grew up!” Whatever are people even thinking? Most French people and in fact many people don’t really consider it to be food, and yet we’re giving that to kids every day! It’s so weird!

Yes, these food-like substances! I’ve thought about your background in Buddhism. Buddhist principles have been so helpful to me when I’ve had people assume that I take impeccable care of myself. I tell them it’s been a long journey. And I remind them that my taking your class last year upped the ante. Again, you highlighted the idea that I needed to be a living manifestation of the Institute of Functional Medicine principles, and that then led to another round of housekeeping. 

I love that the promise we can keep to patients after we get their attention is that it’s going to be a path of joy, not hardship.

A lot of religious traditions have examples of naysayers that sometimes become the most effective messengers because they have a big reversal of some kind. One of my favorite stories from Buddhism is about a thief that Gautama Buddha encounters on the road. The thief’s a murderer, and he’s chasing Buddha through the forest, but then there’s this sort of reality shift where the thief can’t catch Buddha to kill him.

The thief cries out in frustration, “Why are you running?” Buddha says, “I’m still. You’re the one that’s running.” And then over the years this disciple becomes one of the most effective embodiments of the message. I think a lot of the things that I did in my twenties, including eating plenty of Captain Crunch and cookies, overindulgence in red meat, and eschewing vegetables has made me more effective right now. It’s because I can relate to it. I think maybe Tara Brach is right. There’s a sort of torpor or a trance that we can end up in. When we awaken out of that trance, it feels like, “Oh, wow! I was asleep at the wheel on some of that stuff!”

Yes, it’s so true! Literally, figuratively, metaphorically, and for real because especially with meat and sugar, you get into a different state of mind and they’re so addictive. You don’t realize you’re compromising your state of mind by consuming them over and over again until you’re free from them long enough that you gain some clarity. Then you realize, “Oh, I’m coming out of this now!”

Yeah, these are little sort of ‘stuck loops’ that reiterate and run invisibly. I sometimes feel in functional medicine like we’re snipping little threads in these stuck loops. As those start to abate, patients start to sort of pop up to the surface and feel brighter and more clear-eyed. They’re struck by it. “What happened? I just started sleeping more and eating whole food. I’m not eating Captain Crunch now, I’m taking a few supplements, and I had a pretty illuminating adrenal test and a ton of things got better!” 

To me, that’s another great thing about functional medicine is that it can feel very simple. It has to be decisive where the points of leverage are, but often it’s those little stuck loops that quit feeding themselves under the surface.

We had two students in class this week. One guy gave a whole 10 minute soliloquy to the group about how important circadian rhythms are. This is of course something that I’ve been talking about forever, but he somehow just got the memo. He was like, “I can’t believe how well this works! I corrected this guy who’s had a lifelong insomnia problem. All I did was get him to go out in the sunlight at 9:00 am for two to three minutes, and again in the evening between 5:00-6:00 pm for two to three minutes outside in the light. Rain or shine, cloudy or clear, it doesn’t matter because you’re getting that exposure to UV light.” He’s like, “It completely fixes insomnia!” He was so excited. How much does that cost? It’s free, right? There’s not even a cost for that.

We had another student, a nurse practitioner, and she’s like, “I’m working in this community one day a week and nobody can even afford supplements, let alone labs. All I could do was talk to them about how to eat, to take the time to choose, take the time to relax, take the time to eat. Not even healthy food, but to take the time just to chew your food and have better habits that allow for better gallbladder secretion, pancreatic secretion, and HCL secretion. That’s all.” What miracle she’s having, and people aren’t even changing their diets. They’re just changing how they eat and making sure they can produce the normal secretions that we need to break our food down. She’s been getting some miracle cures from that. So it’s often these simple things that don’t even cost anything.

When you’re a practitioner, these types of things seem like they wouldn’t do that much. Or, it seems like, how could being outside under UV light for two or three minutes twice a day correct insomnia? Once you understand the mechanisms and the science behind it, it starts to kind of make sense. Once you do it for a while, you realize the power of these seemingly simple things. I think there’s just so much skepticism on both sides, from patients and doctors, that it’s become a block against initiating these kinds of ideas as a program. It can seem like we’re not giving them enough advice, or because they’re paying for our time they feel we should do something a little more profound than tell people to get outside, you know?

For me that was the tipping point. When my staff said, “If you don’t have a really honest conversation about lifestyle during visit one they’re going to end up off track,” I then followed through. I felt that it was ethically an imperative. At the same time, part of me felt like, “Gosh, I’m not telling them about the labs. I’m not telling them about the supplements.” Again, I had a bit of this American doctor mentality, “I’m not telling them about the proceduralist mechanistic, high- powered stuff.” It was really good that the staff was working with me at that time. They provided the patients and me with a great blessing, because person after person came back to say things like, “Oh my gosh, I feel so much better! I just feel great! I don’t need that lab. I’m not even going to ask you about the supplement because I’m doing so great on the food plan, or the sleep.”

I’ve also found that it’s not hard to stay humble in functional medicine, and that’s true for patients and practitioners. I’d had this sensibility like, “Oh, I’m kind of getting my act together.” Then a week ago at the annual IFM international conference, the circadian rhythm people said, if you’re eating after 6:00 pm and you don’t sleep very well, you’re disrupting your circadian rhythm. And I thought, “You know, that was probably in the diagram Dan Kalish showed in class last year on the adrenals!” The key to the aha moment is not only the right concept, but the teachable student at the teachable moment. In the week or two since the annual international conference, I have been sleeping better just by having my last bite at 6:00 pm, which I’d been sort of playing with anyway. But gosh, there’s a lot of power in lifestyle, unlimited power!

Yeah. It’s surprising how you never arrive there. I think it’s a process. I didn’t start going to bed on time until I was in my late forties. What was that about? Now I’m happily asleep at 8:30 pm every night. I wake up at 3:00 am, and everything’s good. That took a long time to achieve. It’s shocking, you know, and it seems so silly! It’s something that every five year old child has to do, and we have to relearn this in adulthood? We need to get to bed by nine. If I told most new patients that they’re going to have to get to sleep before nine, they would just walk out the door, right? No one would think that’s even sane! You also have to sort of titrate people gradually towards these goals, because the truth of when we should go to bed is just too jarring for people.

Yes, you’ve got to feather it in a little. It made me think about how having podcasts has been so fun because I get to meet my tribe. I ended up becoming a little isolated in Montana and Alaska over the years. Now I get to meet my tribe, which is very enriching and fulfilling for me. A thought leader who I interviewed a month or two ago named Misty Williams said, “I just love my bed, and I love sleeping.” That made me think of the first time I was asked to be the best man in a wedding. 

I was my dear friend’s best man a couple of years ago. We’re both in our early fifties, so I say, “Okay, your bachelor party is just you and I, so we can do anything! We can go out for an extreme adventure in squirrel wingsuits, we can go get in a great white shark cage, or whatever!” And he’s like, “I think a nice dinner will be fine.” We had this really great dinner in Bellevue, Washington, and then I say, “Well, it’s 8:30, so now we can do live music or a movie.” He said, “I’m really looking forward to going to bed.” Just like the woman I interviewed. I said, “Right on! Let’s go home!”

There’s this awareness that there’s going to be a one hour wind down time, and then I might read for half an hour. If I get to sleep at ten versus midnight, then tomorrow I’m still going to feel like a million bucks. That’s a real gift because we’re on vacation where we went to do the bachelor party. I love it that these things are a reframing and a joy and an abundance. That’s probably a good one to wrap up on. We could interview you for three weeks and never run out of incredibly good stuff that you have to share. Are there any key things about people being successful in telemedicine as a patient that I didn’t mention you think might help them to hear? That’s aside from not shaking the camera and having their pet cat bouncing off their head.

I think what makes for a really successful patient is having an understanding that it’s a shared endeavor. 

That’s a good question. What really makes for a successful patient, specifically a telemedicine patient?  I think what makes for a really successful patient is having an understanding that it’s a shared endeavor. It’s the gazillion YouTube videos and all of the patient education resources that I have. I find that successful patients actually listened to these as a reinforcement to our consults, because I have a very high hourly rate. It’s not realistic to talk to me for hours at a time. No one can afford it. So I’ve tried to put almost everything down onto these YouTube videos. When I see super motivated, successful patients, they report that they’ve listened to all of them. They’re like, “Oh yeah, I’m really interested in my kynurenate level because I heard that video.” I’m like, “Really, you know what that means? That’s great!” They’re like, “Yeah, my brain is inflamed,” and I reply, “Yeah, it looks like your brain is inflamed. I think you need some B-6.”
Providing video resources is a way to boost the interaction component between us and the patient, but it doesn’t cost anything, right? And it’s easily available. Once you put these YouTube videos in your archive for patients, it doesn’t even take that much work on the doctor’s part. I have seen my most successful people get invested in putting in that extra time. I guess it’s almost like extra credit homework that you would do in school. It’s a little bit more than just the consult. These successful patients are looking for more information and are more engaged. That then keeps them in this compliant, motivated place that we’ve been talking about.

I think that’s so terrific! It gives my own and other telemedicine patients a homework assignment. Your homework assignments last year led to me getting to this point to where I can serve the way I’m able to serve now. Thank you again!

I’m very excited about that!

It means so much to me, and I find it somewhat humorous that now I have one more homework assignment to cover around 500 hours of content for my patients!

We can talk about that next year!

Have a great evening, Dan!

I appreciate it very much, Rob. It’s really been a joy to talk to you!

Rob Downey, MD

Founder of Seaworthy Functional Medicine