Complexity Medicine: The Basis for a Functional Standard of Care

June 28, 2018

This podcast is episode 184 on the Evolution of Medicine Podcast

Daniel is a deep thinker and researcher on how human regulatory systems function, how they break down and how they can be supported to function with greater resilience.

In this thought-provoking half-hour, we take a deep dive into the future of personalized medicine, longevity and health, including:

  • How Daniel reversed his autoimmune diagnosis by using complexity science theory and functional medicine
  • The importance of non-linear thinking and investigation in pinpointing, stopping and reversing the causal factors of complex illness
  • Definitions of the 3 tiers of disease within the homeodynamic axis
  • The three fundamental tier 1 root causes of disease based on evolutionary code
  • How functional medicine practitioners can help attract biotech companies and entrepreneurs into our space
  • Insightful tips for practitioners to gain clarity in uncovering root cause(s) in an era of complex clinical cases
  • And much more

This was a fantastically dense half-hour of clinical insights, theory and tips…so grab your notebooks (hang onto your hats), listen and subscribe to the podcast today.

Full Episode Transcript:

Announcer:        Welcome to the evolution of medicine podcast. The place health professionals come to hear from innovators and agitators leading the charge. We cover the latest clinical breakthroughs in health technology, as well as practical tools to help transform your practice and the health of your community. Now here’s your host, James Maskell.

James:                 Hello and welcome to the podcast. This week, we feature Daniel Schmachtenberger, he is a deep-thinker in the field of complexity science, and has a number of businesses that are spawn from that. In this incredibly interesting half an hour we talked about different ways of defining health, aging and disease that will apply to you and interest you no matter what kind of practitioner you call yourself, or if you’re just interested in the evolution of medicine.

And we took a really deep dive on the future of personalized medicine as well as some great tips for any clinicians, it was a really, really interesting half an hour, I think you’ll agree and enjoy.

So a warm welcome for your debut on the podcast, it’s Daniel Schmachtenberger. Welcome, Daniel.

Daniel:                 I’m happy to be here, thanks, James.

James:                 So, in our first conversation you struck me as someone who spends a lot of time thinking about the future of medicine and obviously our audience made up of functional, integrative providers, and people on the cutting edge of the evolution of medicine.

I think they’d love to hear a little bit about some of your thoughts. So maybe we could just start with some of the journey to get here and what took you on a path to be operating on this sort of, the edge of evolution of medicine.

Daniel:                 Yeah, so first, thank you for having me here and thank you for all the work over the years building what you’ve built here, I think this is the group of doctors, they really are at the edge of the future of medicine and advancing it. It’s a honor to be here and chairman of one.

I’ve spent my life thinking about how we go about solving hard problems we’re not good at solving yet, and particularly complexity science and other types of epistemologies for understanding complex systems that was largely applied in think-tank work to how we solve economics issues, environmental issues, government’s issues.

Where the kind of symptomatic approach that we take to governance and humanitarian, environmental work, very much an allopathic approach doesn’t work, also studied the body largely as a metaphor first, how self-organizing systems self-organize and work.

How self-organization breaks down and how we can understand and seek to support increased organization capacity. I ended up getting diagnosed with mystery and then incurable autoimmune neurodegen illness and there in the allopathic world, or the integrative world, that weren’t particularly good success rates with these things. And so, I started applying these methodologies to trying to understand how to go about resolving them, was able to resolve the issues which was really fortunate and then help a lot of other people in the process.

And starting to apply formal methods, like information theory and cybernetics and complexity theory and different elements of evolutionary theory to take all the vertical slices of medicine. Neurology, gastro-neurology, oncology, et cetera, and all the horizontal slices, all the omics and being able to put it together, say, how does this self-organizing system actually self-organize and how do we define health in terms of its self-organization capacity. And its adaptive and meta-adaptive capacity across different adaptive landscapes.

And what causes the adaptive capacity to decrease, and then what causes it to actually leave adaptive capacity going to disease, and how can we understand we have a generalized framework for being able to synthesize all the information, various fields of medicine, the bio-sciences, to have a solid personalized medicine which is very much what functional medicine’s doing. Us just seeking to kind of think through it and a formal systems way.

James:                 Super interesting to all of our listeners, you know we’re all on this journey together and if you look at medicine from taking a step back, move from sort of a population, a system to sort of a more precision-based system. From my point of view, it seems like functional medicine is a good deal on the way in that journey. And perhaps the journey from allopathy to functional medicine is greater than the journey from functional to individual precision. N=1, and so what is this lead you to spend time thinking about in this particular world now that you’ve been sort of face-to-face with it?

Daniel:                 Yeah, so our allopathic medicine is really quite good at acute cause health issues. If someone has an acute injury, if they have an acute infection, if they have acute toxic exposure, we’re relatively good at that. And the kind of increase technology and the exponential medicine space there’s gonna have that keep getting better. What we suck at is the things where the causation isn’t obvious.

And in a very complex system, causation isn’t gonna be obvious for lots of things. So if we look at all complex illness, psychiatric, neurodegen, autoimmune, cancers, anything that has complex etiology, we don’t really have what we could call cures for any of them.

We have symptom treatment, we might be able to stop the patho etiology, obviously things like immuno-oncology are starting to get closer to what you could call partial-cures and some of the space. But when I think about what is it to be able to understand causation in a complex system, what are some of the kind of epistemological tools that we have to bring to there that are tricky, three things that are worth kind of saving up front.

When the cause is very time-dilated, so part of the causal cascade started 20 years ago, another part started 10 years ago, how to be able to assess what things were actually causal to what’s expressing, is much trickier when you’ve got significant time dilation, but that is actually how it works in body and health and complex illness.

Multi-factorial is tricky when there isn’t one cause, there’s a number of causes, and there’s not even the same number of causes in different people with the same disease diagnosis. So if I see 10 different MS cases, it’s 10 different patho-etiological cascades and then causal cascades that are complex, meaning that if I look at, okay so this tissue’s being damaged and I can see auto-immune antibodies that show up for that that start leading to it, I can see cytokine changes before that, maybe I can see endogenous changes and changes in endogenous opioid or transmitter or hormone levels before that.

I can’t say because inflammation precedes the MS that inflammation causes it, I can say it’s part of a complex causal cascade, and I wanna be able to trace that cascade all the way back to the tier 1 deviation from homeo dynamics. And then I’m interest in both stopping the cascade, which will stop disease progression, reversing it, and making sure that I got all the way to the tier 1 things being addressed across whatever number tier 1 things might be in place.

So one thing is to understand how to think about causation and complex illness. And I can go on to the next thing or we can touch deeper on that one.

James:                 Yeah, you know I think that’s an area where so many of our practitioners are interested. I mean, if there was one unifying principle around the functional forum and the shows as root cause resolution, and ultimately one of the reasons why this doesn’t fit very well into the current paradigm, it’s just because of exactly that.

It’s very difficult to trace the cause, and you have so many networks interacting with each other and so it’s not a linear process and ultimately dealing with that complexity is sort of the journey to the next stage in medicine.

Daniel:                 Right, so just to add clarity and formal language, if this is interesting or useful to anyone, I’ll go ahead an offer definitions of health, aging, and disease.

And what the tier 1 categories of causes of disease are, because this actually starts to help clarify things. Often times we’ll be at IFM or AFM conference and someone will say all disease comes down to, and they’ll say something like infection, inflammation, and oxidation, or whatever they pick, and they’re not even at the same taxonomical level. Right, it might be oxidation that then causes inflammation, or other things.

So when we wanna kind of apply some formal systems to say how do we think about it.

If we define health as the homeo dynamic capacity of all the homeo dynamic systems across all the axes, now when I to define the term homeo dynamic capacity. This is just evolving the way we think of homeostasis, so I got the word homeo dynamics from Andrew Hill from UCLA because he hates the word homeostasis because there’s no stasis in it, and then homeostatic capacity is a term Joon Yun from Palo Alto Longevity projects started popularizing where he said, rather than looking at homeostatic state, is someone fighting a D level or they’re whatever within a particular range. And if it’s high let’s do something to lower it and if it’s low let’s give them something to raise it. Let’s ask, is the capacity of the system to self-regulate under different types of pressure’s good. What is the resilience or the anti-fragility of the system across that axis.

So the resilience of this system to be able to keep its pH in the right range or it’s temperature in the right range or its HRV or its EEG, or its you know those are all different what we could call homeo dynamic axes.

And we know that we’ve got in a self-organizing system, we have a couple different ways the system can respond to different types of stress. Either because they’re fundamentally different types of stress or total magnitudes based on the load capacity. We have adaptive stress, eustress, that drives hormesis and increases the system’s capacity to handle that kind of stress. And we have distress, that actually causes strain or deformation to the system.

So we can say any kind of stress that is actually taking the system out of its homeostatic or homeo dynamic range is what we can start to think of as the things that cause illness. And so increased health is the capacity to have more different kinds of stress exposures without getting illness. Right, so if I can be exposed to pathogens and not actually get sick, if I can be exposed to certain toxins and have my body detox them well, that means increased resilience of those systems. If I’ve got strong metabolic flexibilities which means whether I’m taking in macronutrients from fat or carbs or protein, the cells can adapt very well. That’s a resilience of the homeo dynamic capacity.

So we define health that way. Then we say aging is not a disease, aging is increased susceptibility to all disease. Aging is decreased homeo dynamic capacity or resilience across one or more of the axes, where then it’s more fragile to smaller stressors being able to actually take it out of range.

Disease is where one or more of the axes actually goes out of the adaptive range, leading to a patho-etiological cascade.

And then when we give a disease a name, like MS or rheumatoid arthritis, or autism, or Alzheimer’s, it just means there’s some cluster of symptoms and biomarkers that we call that thing. But it doesn’t mean that it has one clear patho-etiology which is why when we’re looking for single ones to create single molecular mechanism treatments, we don’t give it because this person’s MS might have been a micro TBI from a car accident that didn’t show on an MRI and they didn’t do a spec-scan or a QEG and then 10 years later it was some mold exposure, and then a number of years later it was a divorce that lead to progressive deregulation of the regulatory capacity that lead to the types of things we call MS.

And in someone else’s case it was a GI parasite and some mercury and some other … right?

But what they all have in common is more load, more stress load, than this system’s capacity to handle could handle. Which then started leading to dysregulation which created increased susceptibility for more dysregulation with these stressors.

Now if we wanted to say what are the fundamental tier 1 causes, the tier 1 causes will always be one of three things, and it’s usually, or often, a combination of these. And then saying this in a very high level way to begin with.

If we think about the evolutionary code, that codes protein development and how to make a body, it evolved in a particular environment to be able to handle the types of behaviors and things in that environment. So that means the relationship of the organism with its environment which means the movement of energy and information across the boundary of the organism and its environment. What it takes in and what it excretes.

If the organism takes in too much of something for what its evolutionary code is developed to be able to process well, you’ll end up having a problem. It can be too much of something that it can process, like sugar, or something that it didn’t really evolve to process at all, like glyphosate. So even small amounts are problematic.

If it takes in too much of something like a pathogen that overwhelms part of the immune system, where the pathogen starts developing, so pathogenicity is a subclass of toxicity. Or if it takes in not enough of something, we call deficiency, and these can all be subclinical.

And then of course also if the system doesn’t get rid of, you can have deficiency from excreting too much of something, you can have toxicity from not excreting enough of something, so all of that is the relationship of concentrations and ratios of things that are all from what the evolutionary code handles optimally and of the relationship of the organism with its environment. That’s one category. Toxicity, deficiency, pathogenicy, main way of thinking of it.

Second category is if the overarching behavior of the organism is different than what its evolutionary code evolved to deal with. That means you’re not sleeping enough or you are not exercising or you’ve got shitty posture from being on the laptop or whatever it is, you’re basically behaving ways different than what the evolutionary code does well.

And then third thing, if there’s actually damage to the evolutionary code itself. Or it has made adaptions that are actually maladaptive to its current environment. When we recognize that our evolutionary code is not just a genome, it’s also the epigenome, the microbiome, the virome, the whole code set that does bottom up organization. If I take antibiotics, or if my mom took antibiotics before I was born and so I don’t have the microbiome that codes certain key capacities, that’s damage to the foundational code set for how to be human, we have to actually repair that code set.

Obviously there are other things that can create genetic transcription issues. That is a way of thinking about when I wanna come back to root cause, the root cause will always be either toxicity, pathogenicity, deficiency, that first set, too much, not enough of stuff in the organism and relationship with what it’s been exposed to. Behavior of the organism that’s off, or the evolutionary code itself has something maladaptive.

James:                 That’s a really great way to put it together. Everyone’s always looking to sort of make it very easy for people to understand, communicate it to the patient’s way of thinking, so that they can participate in conversing the disease for themselves.

What you said there also made me think of when we had Dr. Dale Bredesen on the forum for instance, when he’s talking about the reversal of cognitive decline, he’s very sure that they will never be an Alzheimer’s drug because for all the different upstream factors that end up causing those symptoms that we call Alzheimer’s, it just doesn’t come from one thing.

There’s just a mismatch in the gall of, now that we understand enough about Alzheimer’s to know that it doesn’t come from a single cause, why would we ever think that there’ll be a single cure.

Daniel:                 Dale Bredesen did something really great in terms of being able to formalize that while we still need to do a personalized approach, that it clusters in one of several types. Being able to kind of get a sense of the typologic direction then informs which labs to go heavier into so you can kind of do a tier 1 lab, tier 2 so that you don’t have to run a million dollars in labs to somebody upfront, and you kind of have an easier sense where to take treatment.

But then it still does need personalize within those clusters and I think this is a good example of starting to formalize within one domain. The next step in personalized medicine, using models, using good modeling. And with regard to no drug, I’m gonna say something that is obviously preaching to the choir here, but if I look at the difference between a person when they were young and the same person when they’re older, the difference was not the absence of that synthetic molecule that wasn’t ever part of the evolutionary environment.

If I look at the person, they were healthy before the disease expression, and after, the difference was endogenous molecules that were in a different position and maybe things they were exposed to in the environment that shouldn’t be in the system that are now.

But it was not synthetic molecules, so the chance that the synthetic molecule is the answer to bringing their health back to where it was before, like it doesn’t even make sense. But given that if I study endogenous molecules and I see that there’s something that I could synthesize that’s really interesting. In pep tides we see this, we’ll take epitalon or thymaline or some interesting peptides probably a lot of doctors work with. Since we won’t be able to patent those, we’ll never be able to do, put the financial resources into going through phase 3 clinical trials for proper drug discovery.

The intersection of the regulatory landscape and the fiscal landscape and the IP landscape, independent of even the epistemology of looking for single reductionist things, makes it to where we can only study patentable stuff, and the patentable stuff doesn’t make sense that it would be … patentable also means synthetic.

That it would be studying how health works and be able to support complex health at all.

James:                 That makes total sense. It’s just a guiding principle for us all to think in those terms and I guess with what I said earlier about the distance between population medicine and precision medicine, I think that everyone’s in favor of more precision.

But are they, I think one of the things to see is that when you come in with a headache to one of our doctors and they’re able to determine which one of the six buckets of cause it falls into, is a far cry from population medicine. And is a lot closer to the future precision medicine that we’re sort of inching towards or maybe flying towards, as we start to understand the microbiome and the genome and all of the things that make us ordinary.

Daniel:                 The reason that everybody was so fricking excited about Theranos and why it was such a disappointment was the idea that we could get lots of biodata affordably and repeatedly on people was obviously very exciting.

And there are things that are happening in the space that are really promising, so if you look at like company gene radar, produced by Nanobiosym, they’re just doing PCR replacement right now. But can do PCR for any virus or any pathogen on a single drop of blood with higher than PCR accuracy.

I talked to chief scientist there at one point and said, will this be able to get beyond infection. They said, yeah, fundamentally we should be able to do the nano tech tap onto anything. So when you start thinking about not needing separate reagents for everything, and being able to do a drop of blood rather than fifty vials of blood, and being able to do it quickly and you start to think about, okay what if I could just run all the markers. Not even the ones that seem relevant, just all the markers for everybody pretty often. And then be able to actually do good data analytics on that.

It’s interesting how often, when I’m working with somebody with complex disease, the thing that I find that ends up when we address it really shifting it for them, is fairly exotic. It’s like it’s not one of the most common things, and of course, the stuff that is common in functional medicine now was exotic at one point.

I’m speaking here, not to the doctors, I’m speaking to the people at biotech of being able to get through metabolomics, through proteomics, through nanotech, et cetera, much better diagnostic and interpretation tech is gonna be very important.

James:            Absolutely, and finding ways to make it affordable and easy for people is not always easy, too. Where you’re working in right now you obviously got like a starting point of understanding these big problems and thinking into it. What have you seen from your world that has guided you to do the work that you’re doing now? As far as what you think the entry points and that sort of leverage points are for moving along the line a bit quicker?

Daniel:                 We’ve got this nutraceutical company and it was an interesting place to start. We actually started even in a very strange place for the nutraceuticals, starting in nootropics and which seems like almost the least reputable type of place one could want to start in. The reason we started there was when I was working people with complex illness I got to see that brain fog was so kind of ubiquitous in most types of complex illness as were issues with drive and motivation.

And there was a lot of … they had to do, like it was important that they exercised and saunaed and took a bunch of supplements. Starting to help dial in their cognitive psycho-emotional chemistry increased the compliance of them doing everything else.

We were doing that in a personalized fashion, getting really good results and I was curious, can we do this in a generalized fashion, because the personalization a big deal. We were able to find that there are some axes that are true pretty widely and so we went ahead and did that.

Now that is expanding, our company’s about to rebrand and a bunch of products and other spaces that involve life extension and foundational health stuff will be coming out.

But the reason that we went from the nutraceutical direction was because we didn’t have to do phase 3 clinical trials upfront that would force us to then only work with synthetics and have to have IP issues that were fundamentally against how medicine worked.

The nutraceutical space actually had less perverse incentive than the pharma’s base did. We could take research that had already been done, so like on each nutrient we do structure literature of view meta analysis of all of the research that’s ever been done so we get billions of dollars worth of research that has been done for not that much money. A few scientists getting to do structure literature review.

Make things that are novel, invaluable. And then, not be stuck with how do we, I don’t need to harp on the perverse incentive of the pharma model.

That was a place where we found that we could actually fund doing more research in a way that was where the funding was. Helping do positive things. I think people building clinics, one of the best things, and the hard part is if you really wanna do a good job of being at the cutting edge of medicine it becomes this concierge medicine that’s just stupid expensive and then it’s only for rich people.

While that’s a bummer, one of the things I really wanna see is, I wanna see really good functional medicine doctors, have clinics where they do really comprehensive assessments, they’re very well trained, they’re not like mold people, or Lyme people or parasite people or that kind of default, what their favorite thing is. But who really work quite comprehensively. And actually do a very good job of documenting the cases because even if it’s unscalably expensive and even if the initial patient eval takes 10 hours and that’s ridiculous. Curing things that we currently think of as incurable and being able to document it well changes the paradigm of the possibility space and then that brings biotech entrepreneurs and biotech companies to say, how do we make that economically viable at scale.

So better clinics is something that I really care about. There’s a number of places that people can enter to start making health better, but the thing is I want them to think about whatever the nature of the funding is, does it create perverse incentive or does it create the incentive to actually work on medicine well?

And then are we working on issues that are actually foundational?

James:                 Absolutely, and that’s kind of why, these kind of thoughts exactly and why people say we realize that with the first iteration of the evolution of medicine we just needed to get more doctors interested in functional medicine and recourse resolution. But ultimately, making sure that everyone was having a consistent experience with functional medicine and an accessible experience, and an affordable experience.

And then also making sure that we were tracking the data in a way that would allow us to understand things that we don’t understand. I just thought that there was almost none of that happening. There’s was almost no clinics where there was any proof that this worked in anything apart from on pieces of paper in a file somewhere in a building.

It is frustrating and so I think one of the reasons why we saw that new health was a priority was just to be able to formalize and organize that, and get the modern functional medicine doctor. Not just having to do a completely different operating system of medicine that is typically in private practice and has to get good at marketing and systems and organization and HR and all this stuff. Nevermind being a data scientist. We [crosstalk 00:25:47] to be that, too. And that’s really an impossible ask.

Daniel:                 You know there are cradle curves in everything and so there’s definitely a 2088 thing that people can do where they, if you don’t work with the hardest issues and you do like hormone replacement therapy and diet and PRP and help people’s guts, you can help 80% of people pretty easily, and pretty affordably.

So a lot of people in functional medicine are doing that, awesome, I think that’s great. I’m particularly interested in anyone who is actually reversing autoimmune antibodies regularly. Or cancer markers regularly, or things like that. But they’re just doing their thing and it’s like you said, just on pieces of paper in a client file. I want those people to get the support to be documenting those cases formally and publish.

And be able to publish using the right epistemology and interpretation. That doesn’t say, hey the way we treated this person’s prostate cancer where it went away is gonna work for all prostate cancer. It isn’t, it’s gonna be different to each case. But the generalized approach that leads to personalization across all of them actually does work. And even if it doesn’t work 100% of the time, it works statistically significantly more than what we’re currently used to.

And that’s one of the things that like, if the functional forum community can attract philanthropists who want to pay for some good data documentation, publishing to help change that model, that’s one of the things I would love to see.

James:                 I think that it’s really about setting up structures where it can happen. If you look at something like past the health of the clinic, they actually had enough control of their own technology to be able to make sure that they prioritize the right data and I hope that we can play some small or significant role in helping to turn that around.

I know you speak to a lot of clinicians and you’re connected in the industry. If you had to share some advice for doctors who are trying to, and practitioners who are trying to be on the cutting edge of this shift and do effective care for others, like either specific or guiding principles that have helped you, how does deliver something that’s substantial and successful in, what is clearly a new era in complexity.

I mean, one of the things that I saw and why I felt compelled to work in this place is I just felt like the human body with all of its complexity gives us an opportunity to learn so many lessons about the complexity or around us in the world.

It all makes an environment and ultimately those lessons needed to be learned by humanity and he was like a mini operating system for being able to do that.

Daniel:                 So I’ll share some kind of high level insights at a practitioner level that might be useful. I don’t know how many people here are familiar with integral theory and the integral model, if you are not, you can just google it and specifically see these quadrants.

I’m gonna say the quadrants are a good thing to factor when you’re doing medicine. So if you look at kind of the interior, the psychological interior of the being and the exterior, their physiology, kind of the software and the hardware of the individual and then also realize that they, as an individual are also embedded in the context.

So they’re embedded within a subject of context, which is their relationships and an objective context which is their physical environment. You actually have to do diagnosis and assessment across all four of those, because they’re all inter involved in the well being of the person and even inter involved in their physiology. If I’m doing a, typically we just think in the physiology quadrant primarily, and even within physiology we have the sub-taxonomy if I have to look at their gut, I’ve gotta do their nasal swab, I’ve got to maybe run their genomics, I’ve gotta look at toxicology, parasitology, blah blah blah, right?

There’s all of those things to look at within the body, but then let’s not just stay there. Let’s say, if this person has some kind of psychological stress that they don’t tell you in the first session, but that is keeping them up at night or making them not sleep well. Or that is creating chronic sympathetic overtone, low grade chronic sympathetic overtone is gonna keep someone from being healthy and you can’t just say, yeah deal with your stress and meditate. Often times you’ve gotta ask the questions to see, oh wow there’s a very acute thing going on, what is either, I’m gonna bring the right psychotherapy into my practice or I’m gonna network with the right people who can help with that.

And then of course when we look at the environment, if the person’s environment, many functional medicine doctors do this but, if their environment has mold in it, if it has heavy BOC’s, if it has any number of things that are actually in the physical environment they’re in. They’re not going to get better in a toxic osmotic gradient and so you’ve gotta deal with that. And then the social dynamic. If they are trying to lose weight and they live with a bunch of heavy people, or they’re trying to stop drinking and they live with a bunch of people who drink regularly, or the social relationships not only cause psychological stress if they’re not healthy ones, they also statistically cause lifestyle patterns more than anything else does.

Being able to actually address the relationship, to be able to change people’s lifestyle and foundations is key. In the initial intake, you actually have to look at the whole thing. You better look at their whole life or you’re gonna miss really critical … The initial medical intake questionnaire is the most important piece of diagnosis you have. More than any of the other things, because one it tells you which labs to run but it also gives you just a huge amount of insight.

Next step is when you’re actually doing the physical part, I take a lot of time and do a really long medical history where the medical timeline that is actually something that’s super valuable to me because I wanna know when certain symptoms started and when certain events or exposures happened. And I want to make sure that the medical timeline, their past and current symptoms and what I see in the labs all fits together to give me a full causal explanation and if I don’t have a full causal explanation, I’ve not done the diagnosis yet. What I’m offering in terms of treatment might really be wrong, because order of operations matters.

When they hit their head, and the headache started afterwards or not, when they lived in the moldy house, when they lived on the golf course that sprayed pesticides heavily, when they went through the divorce where they had the psychic break, and didn’t recover all the way. All that kind of stuff, when they had their tonsils removed and had lots of antibiotics, so I really wanna do a very detailed medical history.

And I really wanna take the time to have that both inform what labs I run but then when the labs come back, and the medical history, and their symptomology, I wanna say, does the whole picture actually make sense? And if the whole picture really makes sense, what are all the things we’re gonna treat? And then what is the right order of operations of how we’re gonna treat those?

And order of operations really matters, and there are rules of thumb, but the rules of thumb are always just general, to say hey we’re gonna address stuff in the gut before we address stuff in the blood, and the blood before in the cells, from an infection point of view.

It’s a nice rule of thumb, or large infections to small infections first, or detoxing heavy metals before parasites, they’re good rules of thumb but they’re often times wrong. I might not be able to get rid of a really recalcitrant GI infection before doing something in their blood, because I might have heavy metal dynamics that are actually turning off their secretory immunoglobulin production. And until I deal with that I’m actually not going to be able to deal with their gut properly and I’ll just give them a huge amount of meds and not deal with it. So it’s important to have general rules of thumb of order of operations. But then to actually look at the specific things that are going on for them. And have a sense of does the whole thing map together? Do I have what looks like complete causation? Then what is the right order of operations and then with this next phase of treatment we’re gonna do, what do I expect is gonna happen?

I actually make the predictions ahead of time and then get the feedback to then change your model accordingly. So that’s one thing. Next thing I would say is that that takes a ton of time. And if you’re seeing lots of patients you just forget the nuance that you are holding and so either don’t work with really hard cases, and work with lots of cases. Or if you work with really hard cases, figure out a way to subsidize your income.

Get paid to speak, sell a book, sell some supplements, something else, or just do some really expensive PRP in your clinic that banks money because I’ve seen some of the best doctors in the world but who then everyone started flooding, so they started spending no time, and they just make mistakes left and right.

Even though they knew better because they weren’t spending enough time. If you’re gonna work in complex illness, it’s time consuming. If you’re gonna do a good job with it. Those are a couple off the top things.

James:                 That’s a huge piece and we’ve seen all the way through, with doctors, first of all outsource all of the stuff that’s basically health coaching. You don’t need to be doing that with your time, it’s super valuable. And even some of the intaking, one of the reasons why I was drawn to functional medicine as opposed to integrative or naturopathic, not because I don’t think there’s value to it, it’s just that everyone is kind of doing it the same.

When there’s a standard language, and a standard sort of intaking process that includes that timeline that you’re talking about, then someone could do the intake or someone could do it online or another person could do the intake and the doctor could be able to sit down with the whole breadth of the information and use the time that they’re really sitting with patients to get into some of this. And not have to sort of do the very basic intake that was turning up extremely valuable technician and clinician into sort of like a scribe.

Daniel:                 Obviously, since it does take a lot of time it’s their parts you don’t have to do. I’ll tell you something that when I would see people, I would do that was extraordinarily valuable. Is I would make a high level overview that had the most critical information extracted from everything else in one place.

If you have the patient fill out upfront the multi page intake that your medical clinic uses, there’s only a few things that are actually off in that multi page intake, in terms of which symptoms they have, which goals, what part of their bodies hurt, whatever. When we look at the labs, I might have a hundred pages of labs that come back from their previous doctors and current, but there’s only a few biomarkers that are actually, really off.

I take all the things that are off, and I put them in one overview doc. Now that doesn’t mean that I don’t wanna look at everything else, and see our ratios, sub ideal or how did they change within the ranges they’re in. I put it in one high level doc so I can see, what are all the immune markers that are off? What are all of the infectious markers? What are all the toxicologic markers? What are all the symptoms, et cetera? And I wanna be able to see it in one place so I can really get an overview effect, a big picture.

And make sure that I’m not forgetting any of the things that are off when I’m doing causal analysis, because it’s so easy to just forget that this one infection, dental infection, or this one whatever it is, and then overweight other things. So I really wanna get a big picture. Then I wanna put the key elements in one place. And I do wanna make sure that not only does it causal close, that the things that I’m seeing in their medical history and in their labs explain their symptoms and their patho-etiology, but that I don’t lose any of the parts of it, and just collapse into addressing just one part with overemphasis.

Actually writing an overview is super valuable. So I have a template that I put together for overview, where I can just also at a glance when they’re on the phone be able to see in one place the critical things, and then keeping that updated all the time.

James:                 Beautiful, well look I really appreciate you sharing this, I understand just like treating patients that are complex takes a long time, un-piling and unpacking all of the pieces of this medicine is a timely piece, too. Not just in the complexity of understanding how it works but also in communicating how to do it, and one of the things that I think we’re starting to see is more and more doctors looking for ways to be able to learn in sort of a mental ship capacity.

So that you can sort of ingest these things over time, but the best functional medicine doctors have been doing it for a while, and really understand that there’s a lot to learn and you have to do it. And I have so much respect for anyone who chooses to do this with their time, because it is, and I guess I just wanna throw one Charles Eisenstein concept to you is that the person whose doing all of this time, spending time with people, going into the root cause, if you look at a big enough time frame, is no less valuable than someone who has a million person book list. It amasses because of the complexity of causal theory that we now really understand.

Daniel:                 One of the things that I so want is that any doctor that figures out something really neat in the case, and they gain an insight, is sharing that in a way where everyone gets to benefit from the earnest clinical practice of everybody. Because when you’re doing n=1 stuff, and you’re not just doing population medicine, that’s actually the R&D center, like the clinics are part of the R&D center and that means that there has to be an information sharing layer.

One other thing I’ll share before we hop off just because it’s important and it’s obvious, I think we would all say that if people aren’t doing the foundational stuff, then if they’re not actually working on eating well and sleeping and doing some stress mitigation and movement, then the other things are gonna make really marginal difference.

The next step in that is to say root cause, we’re typically looking at something that’s wrong that we want to treat. The other side of that is what are the kind of core homeo dynamic capacities that we can just robust generally.

When we do NADID therapy with someone, we’re not treating a specific cause, we’re trying to increase the capacity of the system to do redox signally, and obviously redox signaling is just gonna be useful for a lot of — inside of cells.

If we put somebody on a hypoxia machine and do hypoxia, hyperoxia fluctuations, to increase mitochondrial biogenesis, that’s not going to specifically address their mercury toxicity or their mold or their whatever. But increase mitochondrial biogenesis will help their system do all of those things. So there is general work to increase health, and then there’s very specific work to reverse specific causes of disease.

You should be doing both simultaneously.

James:                 Yeah you have to be, that’s totally one of the things that we’ve learned along the way.

Well this has been great and I really appreciate the time to connect and if you wanna find out more about the Neurohacker collective and what Daniel’s up to, make sure to check out the website and we’re very interested in finding ways for practitioners to connect about these kind of things. Obviously we’ve built these meetups, but we can continue the conversation, I know there’s a lot of positions to get together for some sort of journal, book clubs, going over cases and learning from each other.

We need to find a way to share what we’re learning and I think those systems will appear as the demand.

Daniel:                 The other thing I wanna share on that is, when you ask like suggestions for physicians. Some physicians should just really be doing the work that they’re doing and figuring out how to share. But some people will realize that there is some kind of project based entrepreneurial thing that is actually a good fit for them.

And I wanna encourage people to think about starting projects in the space that are nonprofit too. Say you said, man there really should be a place that we can actually share what worked, and so someone can type in a specific disease and anyone who has had success with that disease we can put in their protocols and then start to be able to make sense as to why those protocols work. And you wanna make that website and you realize that there are people philanthropically who would fund it. You wanna take the project on.

The idea of just saying, if there’s something you really wanna see in medicine that’s missing, that you could just make it happen. And that you don’t have to get bound to doing it in a for profit way where then you have to say, well what is the profit output.

Sometimes you can do it in for profit way and that’s awesome, but there are times where doing it in a nonprofit way allows you to not serve two masters and it’s quite useful. I would just say anytime you have that question, man I wish such and such existed in medicine, just ask is that possibly yours to do.

James:                 I love that. Yeah and don’t ask for permission either, because no one’s gonna give it to you.

Daniel thank you so much for not asking for permission for all the work that you’re doing and just getting on with it, I think we’ll see what the implications of all your work end up being down the road but it’s great to have people on the path who are thinking in this way and then to connect with.

If this was a turn on to you and to your brain and the way that you think, get in touch with Neurohacker and see how you can connect, but in the meantime this has been the evolution of medicine podcast, and I’m your host, James Maskell.

Thanks so much for watching and listening and we’ll see you next time.

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