AFMCP Teaching Model 1

8/12/2019 AFMCP Teaching Model 1

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At the heart

of medicine lies the

individual and each

patient’s unique story…

At the heart

of medicine lies theindividual and each

patient’s unique story…



That Story Is Typically Told As…

Chief Complaint (CC)

History of Present Illness (HPI)

Past Medical History (PMH) Family History (FH)

Dietary History

Supplement and Medication History

Lifestyle, Social, and Exercise History

Physical Exam Findings

Laboratory Evaluation



In conventional medicine, the aimis to arrive quickly at the diagnosis

This emphasis on diagnosis is particularlycritical in the acute care setting; rapid

diagnosis leads to rapid treatment Treatment in this setting must be prompt,

as it is often designed to ―lock down‖and control physiology

The chief complaint and history of thepresent illness become the critical aspectsof the story; the rest of the patient’s story istruncated when other information is seen assuperfluous to reaching the diagnosis



Example #1Chief Complaint:

Wheezing

Diagnosis:Asthma Attack

bronchodilators corticosteroids

tightness inthe chest

suddenonset

asthmatichistory

shortness ofbreath

History of Present Illness



Example #2Chief Complaint:

Chest Pain

Diagnosis:Heart Attack

angioplasty thrombolytics

sweating

armnumbness

shortness ofbreath

History of Present Illness



The clinician proceeds directly to the diagnosis –naming the disease – in order to identify as quicklyas possible a medication to treat that disease

THE RESULTS:

Little attention is paid to the patient’s story beyondthe chief complaint and history of the present illness

The patient’s whole story is not understood

Each complaint becomes a discrete issue,dealt with in isolation from the others

Problems arise when the acute-care model isused to address chronic long-term health issues



Hypercholest-

erolemia

Statin

Gastroesophageal

Reflux Disease

H2 blocker

Depression

SSRI

HypertensionACE

inhibitorMigraines Triptan

Osteoarthritis

NSAID

Irritable BowelSyndrome

Dicyclomine

…the result is a focus on

treating each symptom complexas a separate and distinct

―disease‖ with a separate anddistinct treatment.



Hypercholest-

erolemia

Statin

Gastroesophageal

Reflux Disease

H2 blocker

Depression

SSRI

HypertensionACE

inhibitorMigraines Triptan

Osteoarthritis

NSAID

Irritable BowelSyndrome

Dicyclomine

Each individual

diagnosis becomes a

distinct entity unto itself.The patient’s whole story

never has a chance to be

heard and understood

In context.



It is apparent that – in its rush to diagnose – conventional medicine is focused on the branchesand leaves of the tree, and not the trunk and roots.

Cardiology Pulmonary

Endocrinology

Gastroenterology

Neurology

Organ System Diagnosis

Urology/Nephrology

Hepatology

AllergySigns and Symptoms

Fundamental Clinical ImbalancesHormonal and Neurotransmitter Imbalances

Redox Imbalance + Oxidative Stress + Mitochondropathy

Detox/Biotransformation/Excretory Imbalance

Immune Imbalance

Inflammatory Imbalance

Digestive/Absorptive and Microbiological Imbalance

Structural Integrity Imbalance

1. Communication

- Outside the cell

- Inside the cell

Mind and Spirit

Genetic PredispositionExperiences, Attitudes, Beliefs

Psycho-social Physical ExerciseTrauma

Diet, Nutrients,Air/Water

Xenobiotics

Micro-organismsRadiation

Environmental Inputs

2. Bioenergetics/Energy Transformation

3. Replication/Repair/Maintenance/Structural Integrity

4. Elimination of Waste

5. Protection/Defense

6. Transport/Circulation

Fundamental Physiological Processes



Functional medicine should not be viewedas an alternative, but as a bridge to a more

effective chronic-care model.



Where does the symptom come from?

That is, what are the antecedents and triggers?

What keeps it going?

That is, what are the mediators?

And what can be done to change that dis-eased

homeostatic balance point the patient is locked into? That is, what are the underlying points of leverage

where intervention can be most effective?

In the functional medicine model, thepatient’s full story is of central importance

Instead of a preoccupation with how to namethe disease, the critical questions become:



First, the full story must be understoodwithin the context of

antecedents, triggers, and mediatorsantecedents and triggers

mediators

To answer these questions requires a newperspective on the chronic-care model



Infectious micro-organisms

Structural or

physical damage

Nutrientinsufficiency

Xenobiotics

Disrupted lightcycles—circadian

dysrhythmias

Radiation

Emotionaltrauma

Spiritualangst

Nutrient excess

Food toxicants

(allergens, stimulants, etc,)

Drug sideeffects

Adiposity

Toxic metals

Aging

Situational

stress –fear,anxiety, worry

Genetic pre-

disposition(SNPs)

Hyperglycemia

Hypoglycemia

Excessiveexercise

Excessive noise

Dysbiosis

The story is no longer just the CC and HPI, but

is expanded toencompass all the

patient’s history thatmay reveal the source(s)

of symptoms.




Structural or

physical damage


Xenobiotics

Radiation

Emotionaltrauma

Spiritualangst

Nutrient excess

Food toxicants

(allergens, stimulants,

etc,)

Drug side effects

Adiposity

Toxic metals

Psychologicaland SpiritualEquilibrium

Hormone andNeurotransmitter Regulation

Detoxification andBiotransformation

StructuralIntegrity

ImmuneSurveillance

Digestion, Absorption,and Barrier Integrity

Oxidative/ReductiveHomeodynamics

InflammatoryProcess

Aging

Genetic pre-

disposition(SNPs)

Next,the patient’s story is

filtered through theseantecedents, triggers, andmediators, which leads to

an understanding of wherekey imbalances may reside

Disrupted lightcycles—circadian

dysrhythmias

Hyperglycemia

Hypoglycemia

Excessiveexercise

Noise

Situationalstress –fear, anxiety,

worry

Dysbiosis

The diagnosis remains useful,

but is less important.

These fundamental clinical imbalances arethe underlying mechanisms of disease…



Exercise

Acupuncture

Manipulative

Therapies

Phytonutrients

Minerals

Vitamins

Diet

Yoga

Drugs

Surgery

Counseling

The expanded model

permits the clinicianto choose from anenlarged toolkit of

therapies.

Meditation



Let’s apply the functional medicinemodel to an apparently simple case…

…a 37 year old female with a chiefcomplaint of chronic headaches.



Diagnosis: Migraines

Treatment: Triptan

Chief Complaint:Headaches

History ofpresent illness

We’ve already seenhow she might be treatedusing the existing model.



But her case maynot be as simpleas it appears…





StructuralIntegrity

Immune

Surveillance

InflammatoryProcess

A variety of potential

antecedents, triggers, andmediators might be present in

a woman with a chief complaintof chronic headaches:

Hormone and

Neurotransmitter Regulation

Digestion, Absorption,

and Barrier Integrity

Oxidative/Reductive

Homeodynamics




Hormone and



StructuralIntegrity

Immune

Surveillance



Oxidative/Reductive

Homeodynamics

InflammatoryProcess

Food allergenFood AllergenFood allergen

Circadian rhythm

Situational stress

Exposure to toxinsExposure to toxins Headachestriggered by food

allergen

Headaches triggeredby menstrual cycle

Headaches triggeredby stress

Headaches triggered

by exposure to toxinsMSG, aspartame,smoke, perfume

Headaches triggered

by changes in sleep

Headaches triggeredby fasting

Estrogen dominance

Circadian rhythm

Hypoglycemia



Psychological andSpiritual Equilibrium

Hormone and



Structural Integrity

Immune Surveillance



Oxidative/Reductive

Homeodynamics

Inflammatory Process

Past medical history

leads to additional clues:

Food Allergen

Food Allergen

Food Allergen

Estrogen dominance

Circadian Rhythm

Circadian Rhythm

Situational Stress

Hypoglycemia

Exposure to toxins

Exposure to toxins

Past or recurrent infections

Adiposity

Surgeries

Surgeries

Surgeries



AdiposityAdiposity

Adiposity

AdiposityAccidents or Injuries

Emotional trauma

Exposure to toxins

Accidents, injuriesAccidents, injuries

Accidents, injuries

Emotional trauma

Emotional trauma

Emotional trauma

Exposure to toxins

Exposure to toxins

Exposure to toxins

Exposure to toxins

Chronic Disease

Chronic disease

Chronic disease

Chronic antibiotic use

Chronic antibiotic use—dysbiosis









Immune Surveillance




Estrogen dominance

Circadian Rhythm

Circadian Rhythm

Situational Stress

Hypoglycemia

Exposure to toxins

Exposure to toxinsSurgeries

Surgeries



AdiposityAdiposity

Adiposity

Adiposity


Accidents, injuries

Emotional trauma

Emotional trauma

Emotional trauma

Exposure to toxins

Exposure to toxins

Exposure to toxins

Exposure to toxinsChronic disease

Chronic disease




Family history may indicategenetic predispositions:

Food allergen

Food allergen

Food allergen

Inflammatory conditions

such as RA, UC, etc.

Allergies

Predisposition to inflammation







Immune Surveillance




Estrogen dominance

Circadian Rhythm

Circadian Rhythm

Situational Stress

Hypoglycemia

Exposure to toxins

Exposure to toxinsSurgeries

Surgeries



AdiposityAdiposity

Adiposity

Adiposity


Accidents, injuries

Emotional trauma

Emotional trauma

Emotional trauma

Exposure to toxins

Exposure to toxins

Exposure to toxins

Exposure to toxins

Chronic disease

Chronic disease




Food allergen

Food allergen

Food allergen

Predisposition to inflammation

Dietary History

Dietary insufficiencies…antioxidants,

magnesium, fiber, EFAs, etc.

Dietary excesses: saturated fat, simple

sugars, caffeine, alcohol, etc.

Nutrient insufficiencies—EFAs, etc.

Nutrient insufficiencies –

sulfur, amino acids, etc.

Nutrient insufficiencies

Nutrient insufficiencies – zinc,

glutamine –leaky gut


antioxidants


Nutrient excess—alcohol

Nutrient excess—caffeine

Nutrient excess –

simple sugars

Nutrient excess—saturated fat

Dietary toxins…mercury,

exogenous estrogens, etc.

Dietary toxin—mercury

Dietary toxin-mercury

Dietary toxin—mercury

Dietary toxins –

exogenous estrogens

Dietary toxin –

mercury







Immune Surveillance




Food allergen

Food allergen

Specifically, what was this 37 year old female’s story?

Headaches triggered

by diet







Immune Surveillance




Dysbiosis

Food allergen

Food allergen

Structural damage

Digestive enzyme/HCL

insufficiency

Inflammatory damage

Nutrient insufficiency –

low EFAs, high AA

Standard American DietNSAIDS for OA

Drug side effects

– leaky gut

What are the clues inher diet and medications?







Immune Surveillance




Dysbiosis

Food allergen

Food allergen

Structural damage


insufficiency

Inflammatory damage


low EFAs, high AA

Drug side effects

– leaky gut

What are the cluesin her family history?

Ulcerative Colitis

Eczema

Inflammatory genetic predisposition







Immune Surveillance




Dysbiosis

Food allergen

Food allergen

Structural damage


insufficiency

Inflammatory damage


low EFAs, high AA

Drug side effects

– leaky gut

Through critical thinkingand pattern recognition,

a therapeutic plancan be developed. In thiscase, the primary focuscenters on three areas







Immune Surveillance




Dysbiosis

Food allergen

Food allergen

Structural damage


insufficiency

Inflammatory damage


low EFAs, high AA

Drug side effects

– leaky gut

Laboratory

analysis can beused to helpconfirm the

prioritization

Hs-CRP

RBC fatty acids

IgG/IgE food allergy

Digestive stool analysis

Ova and parasite

Intestinal permeability

Dietary changes to lower arachidonic




Hormone and



StructuralIntegrity

Immune

Surveillance



Oxidative/Reductive

Homeodynamics

InflammatoryProcess

The prioritizationof certain key

clinical imbalancesthen leadsto potential

treatment options

Dietary changes to lower arachidonicacid and the inflammatory cascade

Omega-3 fatty acids todecrease inflammation

Botanicals such as bromelain andcurcumin to decrease inflammation

Phytonutrients such as rutinand quercitin to decrease IP

Pre and probiotics

Decrease alcoholto decrease

intestinal permeability

Hydrochloric acid/digestive enzyme

Foodelimination

diet



Exercise

Acupuncture

ManipulativeTherapies

Phytonutrients

Minerals

Vitamins

Diet

Yoga

Drugs

Surgery

Counseling Meditation

Psychologicaland Spiritual

Equilibrium



StructuralIntegrity

ImmuneSurveillance

Digestion,Absorption,and Barrier

Integrity

OxidativeReductive

Homeodynamics

InflammatoryProcess


Structural or

physical damage


Xenobiotics

Radiation

Emotionaltrauma

Spiritualangst

Nutrient excess

Food toxicants(allergens, stimulants

etc,)

Drug side effects

Adiposity

Toxic metals

Aging

Genetic pre-disposition

(SNPs)

Disrupted lightcycles – circadian

dysrhythmias

Hyperglycemia

Hypoglycemia

Excessiveexercise

Excessive noise

Situationalstress – fear,anxiety, worry

Dysbiosis

The functional medicinemodel recognizes andprioritizes the patient’s

full, unique story anduses fundamental clinical

imbalances as a keyto treating complex,

chronic illness



Functional Medicine andthe Healthcare System:

Additional Important Benefits

Functional Medicine creates a level playing fieldamong practitioners

The Functional Medicine model makes readilyapparent that there is a need for many differentapproaches to helping people become and stay well

Functional Medicine helps to create and disseminate

a shared set of concepts and a common language Ultimately, Functional Medicine can contribute

greatly to our ability to create an integratedhealthcare system



Cardiology Pulmonary

Endocrinology

Gastroenterology

Neurology

Organ System Diagnosis

Urology/Nephrology

Hepatology

AllergySigns and Symptoms

Fundamental Clinical ImbalancesHormonal and Neurotransmitter Imbalances

Redox Imbalance + Oxidative Stress + Mitochondropathy

Detox/Biotransformation/Excretory Imbalance

Immune Imbalance

Inflammatory Imbalance

Digestive/Absorptive and Microbiological Imbalance

Structural Integrity Imbalance

1. Communication

- Outside the cell

- Inside the cell

Mind and Spirit

Genetic PredispositionExperiences, Attitudes, Beliefs

Psycho social Physical Exercise Diet Nutrients

Xenobiotics

Micro organisms

2. Bioenergetics/Energy Transformation

3. Replication/Repair/Maintenance/Structural Integrity

4. Elimination of Waste

5. Protection/Defense

6. Transport/Circulation

Fundamental Physiological Processes

AFMCP Teaching Model 1

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