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…
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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
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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
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Example #1Chief Complaint:
Wheezing
Diagnosis:Asthma Attack
bronchodilators corticosteroids
tightness inthe chest
suddenonset
asthmatichistory
shortness ofbreath
History of Present Illness
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Example #2Chief Complaint:
Chest Pain
Diagnosis:Heart Attack
angioplasty thrombolytics
sweating
armnumbness
shortness ofbreath
History of Present Illness
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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
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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.
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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.
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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
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Functional medicine should not be viewedas an alternative, but as a bridge to a more
effective chronic-care model.
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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:
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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
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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.
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Infectious micro-organisms
Structural or
physical damage
Nutrientinsufficiency
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…
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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
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Let’s apply the functional medicinemodel to an apparently simple case…
…a 37 year old female with a chiefcomplaint of chronic headaches.
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Diagnosis: Migraines
Treatment: Triptan
Chief Complaint:Headaches
History ofpresent illness
We’ve already seenhow she might be treatedusing the existing model.
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But her case maynot be as simpleas it appears…
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Psychologicaland SpiritualEquilibrium
Detoxification andBiotransformation
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
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Psychologicaland SpiritualEquilibrium
Hormone and
Neurotransmitter Regulation
Detoxification andBiotransformation
StructuralIntegrity
Immune
Surveillance
Digestion, Absorption,
and Barrier Integrity
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
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Psychological andSpiritual Equilibrium
Hormone and
Neurotransmitter Regulation
Detoxification andBiotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption,
and Barrier Integrity
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
Past or recurrent infections
Past or recurrent infections
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
Chronic antibiotic use
Chronic antibiotic use
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Psychological andSpiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification andBiotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption,and Barrier Integrity
Oxidative/ReductiveHomeodynamics
Inflammatory Process
Estrogen dominance
Circadian Rhythm
Circadian Rhythm
Situational Stress
Hypoglycemia
Exposure to toxins
Exposure to toxinsSurgeries
Surgeries
Past or recurrent infections
Past or recurrent infections
AdiposityAdiposity
Adiposity
Adiposity
Accidents, injuriesAccidents, injuries
Accidents, injuries
Emotional trauma
Emotional trauma
Emotional trauma
Exposure to toxins
Exposure to toxins
Exposure to toxins
Exposure to toxinsChronic disease
Chronic disease
Chronic antibiotic use—dysbiosis
Chronic antibiotic use
Chronic antibiotic use
Family history may indicategenetic predispositions:
Food allergen
Food allergen
Food allergen
Inflammatory conditions
such as RA, UC, etc.
Allergies
Predisposition to inflammation
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Psychological andSpiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification andBiotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption,and Barrier Integrity
Oxidative/ReductiveHomeodynamics
Inflammatory Process
Estrogen dominance
Circadian Rhythm
Circadian Rhythm
Situational Stress
Hypoglycemia
Exposure to toxins
Exposure to toxinsSurgeries
Surgeries
Past or recurrent infections
Past or recurrent infections
AdiposityAdiposity
Adiposity
Adiposity
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 antibiotic use—dysbiosis
Chronic antibiotic use
Chronic antibiotic use
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
Nutrient insufficiencies
antioxidants
Nutrient insufficiencies
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
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Psychological andSpiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification andBiotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption,and Barrier Integrity
Oxidative/ReductiveHomeodynamics
Inflammatory Process
Food allergen
Food allergen
Specifically, what was this 37 year old female’s story?
Headaches triggered
by diet
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Psychological andSpiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification andBiotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption,and Barrier Integrity
Oxidative/ReductiveHomeodynamics
Inflammatory Process
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?
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Psychological andSpiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification andBiotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption,and Barrier Integrity
Oxidative/ReductiveHomeodynamics
Inflammatory Process
Dysbiosis
Food allergen
Food allergen
Structural damage
Digestive enzyme/HCL
insufficiency
Inflammatory damage
Nutrient insufficiency –
low EFAs, high AA
Drug side effects
– leaky gut
What are the cluesin her family history?
Ulcerative Colitis
Eczema
Inflammatory genetic predisposition
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Psychological andSpiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification andBiotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption,and Barrier Integrity
Oxidative/ReductiveHomeodynamics
Inflammatory Process
Dysbiosis
Food allergen
Food allergen
Structural damage
Digestive enzyme/HCL
insufficiency
Inflammatory damage
Nutrient insufficiency –
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
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Psychological andSpiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification andBiotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption,and Barrier Integrity
Oxidative/ReductiveHomeodynamics
Inflammatory Process
Dysbiosis
Food allergen
Food allergen
Structural damage
Digestive enzyme/HCL
insufficiency
Inflammatory damage
Nutrient insufficiency –
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
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Psychologicaland SpiritualEquilibrium
Hormone and
Neurotransmitter Regulation
Detoxification andBiotransformation
StructuralIntegrity
Immune
Surveillance
Digestion, Absorption,
and Barrier Integrity
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
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Exercise
Acupuncture
ManipulativeTherapies
Phytonutrients
Minerals
Vitamins
Diet
Yoga
Drugs
Surgery
Counseling Meditation
Psychologicaland Spiritual
Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification andBiotransformation
StructuralIntegrity
ImmuneSurveillance
Digestion,Absorption,and Barrier
Integrity
OxidativeReductive
Homeodynamics
InflammatoryProcess
Infectious micro-organisms
Structural or
physical damage
Nutrientinsufficiency
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
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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
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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