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‘Why’ Not ‘What’: Applying Functional Medicine to Perioperative Care

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I just returned from an extended trip — almost four months! Much longer than any usual journey I go on. At various times it was exciting, challenging, difficult, even hard to understand at some points…but by the time I returned, I was glad I had taken it.

I am referring to my initial foray into obtaining Certification in Functional Medicine.

Functional Medicine: Understanding ‘Why’ in Addition to ‘What’

As physicians, we are trained to delve into the ‘what’ a patient has. We look at their signs and symptoms, physical exam (sometimes!), labs, imaging studies and come up with the ‘what’. For all intents and purposes, most of our work is then done. Once we have the diagnosis, we apply ‘evidence-based’ treatment plans that are expected to have some degree of ‘success,’ with success being defined as partial or complete mitigation of symptoms.

Functional Medicine approaches the patient from a very different perspective. It is a ‘systems biology’ approach that involves looking at a patient’s medical timelines from prenatal history to current age, understanding a matrix of discrete biologic systems (Assimilation, Biotransformation and Elimination, Defense and Repair, Structural Integrity, to name a few), testing for nutritional as well as conventional biomarkers, determining the impact of stressors in a patient’s life — all to come to an understanding of the ‘why’ of a patient’s current state of ill health.

Determining the ‘why’ then allows the practitioner to remove, replace, repair, and rebalance the biological systems found to be dysfunctional through nutritional management, supplements, appropriate medications, lifestyle modifications, and other strategies to remove stressors. The FM framework for evaluating a patient is built around the mnemonic GOTOIT:

  • Gather

  • Organize

  • Tell (as in re-telling the patients story back to the patient)

  • Order and prioritize

  • Initiate (your intervention)

  • Track (the patients’ outcomes over a period of time).

As I became more deeply involved in online FM courses, I often wondered how a Functional Medicine philosophy could translate to the practice of this new paradigm of care within the specialty of anesthesiology: the Perioperative Surgical Home (PSH) or Enhanced Recovery After Surgery (ERAS).

The PSH/ERAS model is one of managing a patients’ surgical episode of care as a continuum of processes that is multidisciplinary in nature, collaborative between specialties, patient-centered, and connected between the preoperative, intraoperative, postoperative and post-discharge care plans. A cornerstone of the PSH ‘philosophy’ is preoperative optimization. Currently, by convention, preoperative optimization should include pre-habilitation ( the trimodal concept of nutrition assessment, exercise and psychosocial support), anemia management, frailty assessment, smoking cessation, advanced care planning and general comorbidity management.

Interestingly, FM’s basic tenets, goals, and interventions are similar to those espoused by the PSH model: psychosocial support, nutritional evaluation and optimization, exercise as a foundation for improving health, and many others.

Clearly, the ‘Venn diagrams’ of these two care models overlap somewhat. However, there are significant differences. One in particular is the typical time spent with a patient during a therapeutic evaluation — in the FM model this typically lasts 60–90 minutes, clearly not a reasonable expectation in a busy perioperative clinic. Also, the goal of FM evaluation and management is to mitigate, if not totally treat, chronic diseases such as diabetes, hypertension, and obesity — not really within the purview or directive of a preoperative clinic. Our goal is not to ‘cure the world’ but to ensure a patient is as reasonably optimized as possible prior to their procedural intervention.

Bringing ‘Gather’ From Functional Medicine to Anesthesiology

Nonetheless, there are lessons I believe we can learn and adapt from the Functional Medicine world to our world in perioperative medicine and even the practice of anesthesiology. The first is related to the first word of the FM heuristic: ‘Gather’. Intuitively, many of us would assume this refers to ‘gathering’ the patient’s current complaint, past medical history, medication, list, etc. upon our first encounter. To a certain extent, this is correct. However, within the FM universe, ‘Gather’ refers to the clinician ‘gathering’ of him or herself in a focused way prior to meeting the patient, such that a patient is the only consideration in that moment, and the clinician-patient relationship can be established collaboratively within the first minutes of the encounter.

We as anesthesiologists, whether in the preoperative clinic or upon meeting our patient for the first time minutes before wheeling them back to the OR, would be well-served to embrace this concept of ‘Gather’ just before meeting our patients: to take a deep breath, focus on the current patient without worrying about the patient we just left in the recovery room, and really give an direct focus and intensity to the patient at hand.

And then, in those few minutes we have for our pre-op visit before heading to the O.R., we can answer questions, re-engage the patient about their smoking history, ask about their nutrition — is it SAD (Standard American Diet)? if so, explaining that a more wholesome diet of fresh fruit, vegetables, sustainable meats, etc. could jump start their recovery process — it only takes seconds to do this.

A brief discussion of other stressors a patient is currently facing in addition to surgery — a recent divorce, a child leaving for college, financial strains — with an offering of support through social services may make a huge difference in their emotional stress, which will translate to decreasing physiologic stress factors and generalized inflammation — and once again, the message of improved recovery.

Functional Medicine approaches the patient as a whole, complex, interrelated individual in which modification of lifestyle factors can impact the patient at every level. There are no ‘Cardiac’, ‘Gastrointestinal’, ‘Neurologic’, ‘Rheumatologic’ etc. silos of care. In fact, these labels are artificial constructs that make little sense. Our internal interrelatedness is obvious from our understanding of molecular and systems biology, the neurohormonal gastric axis, the study of epigenetics and how environmental factors can influence our genes and their ultimate translation of proteins.

What other specialty of medicine, aside from perhaps Family Practice, looks at the patient as a whole, and not one particular organ system, other than Anesthesiology?

We manage the entire patient intraoperatively, and now, with the PSH initiative, perioperatively — managing their cardiac status, pulmonary function, renal function, and indirectly, their neuro status. We take care of the ‘whole patient’.

So, for anesthesia providers, embracing the precepts of Functional Medicine is a very natural fit, and one that could only improve our interactions with our patients, in addition to our long-term outcomes.

The Functional Medicine journey: it was at times arduous, but, without question, well worth it.

Les Garson, MD, is an associate clinical professor of anesthesiology at the University of California at Irvine School of Medicine.

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