Incremental Medicine + Functional Medicine = Good Medicine
Atul Gawande, MD
Atul Gawande is a surgeon and well regarded writer on public health issues. He was awarded the Lewis Thomas Prize for Writing about Science from The Rockefeller University in 2014. This Prize honors “the rare individual who bridges the worlds of science and the humanities — whose voice and vision can tell us about science’s aesthetic and philosophical dimensions, providing not merely new information but cause for reflection, even revelation.” (The Rockefeller University, 2014)
Gawande practices General and Endocrine Surgery at Brigham and Women’s Hospital and is a Professor of Surgery at Harvard Medical School as well as a Professor in the Department of Health Policy and Management at the Harvard School of Public Health.
I’m writing about him today after reading his article Tell Me Where It Hurts: Our medical system rewards heroic intervention. When will we grasp the power of incremental care? In The New Yorker‘s January 23 2017 issue. (I’m usually at least a few weeks behind.)
Gawande eloquently makes the case for switching our health care system’s focus away from relying on heroic specialty care once we’ve develop medical conditions to ongoing, incremental care by primary-care docs to keep people healthier in the first place:
“We have a certain heroic expectation of how medicine works. Following the Second World War, penicillin and then a raft of other antibiotics cured the scourge of bacterial diseases that it had been thought only God could touch. New vaccines routed polio, diphtheria, rubella, and measles. Surgeons opened the heart, transplanted organs, and removed once inoperable tumors. Heart attacks could be stopped; cancers could be cured. A single generation experienced a transformation in the treatment of human illness as no generation had before. It was like discovering that water could put out fire. We built our health-care system, accordingly, to deploy firefighters. Doctors became saviors.
“But the model wasn’t quite right. If an illness is a fire, many of them require months or years to extinguish or can be reduced only to a low-level smolder. The treatments may have side effects and complications that require yet more attention. Chronic illness has become commonplace, and we have been poorly prepared to deal with it. Much of what ails us requires a more patient kind of skill.” (Gawande, 2017, p. 39)
Studies have demonstrated “that states with higher ratios of primary-care physicians have lower rates of general mortality, infant mortality, and mortality from specific conditions such as heart disease and stroke. Other studies found that people with a primary-care physician as their usual source of care had lower subsequent five-year mortality rates than others, regardless of their initial health. In the United Kingdom, where family physicians are paid to practice in deprived areas, a ten-per-cent increase in the primary-care supply was shown to improve people’s health so much that you could add ten years to everyone’s life and still not match the benefit. Another study examined health-care reforms in Spain that focussed on strengthening primary care in various regions—by, for instance, building more clinics, extending their hours, and paying for home visits. After ten years, mortality fell in the areas where the reforms were made, and it fell more in those areas which received the reforms earlier. Likewise, reforms in California that provided all Medicaid recipients with primary-care physicians resulted in lower hospitalization rates. By contrast, private Medicare plans that increased co-payments for primary-care visits—and thereby reduced such visits—saw increased hospitalization rates. Further, the more complex a person’s medical needs are the greater the benefit of primary care.” (Gawande, 2017, p. 40)
“In this era of advancing information, it will become evident that, for everyone, life is a preexisting condition waiting to happen. We will all turn out to have … a lurking heart condition or a tumor or a depression or some rare disease that needs to be managed. This is a problem for our health-care system. It doesn’t put great value on care that takes time to pay off. But this is also an opportunity. We have the chance to transform the course of our lives.
“Doing so will mean discovering the heroism of the incremental. That means not only continuing our work to make sure everyone has health insurance but also accelerating efforts begun under health reform to restructure the way we deliver and pay for health care. Much can be debated about how: there are, for example, many ways to reward clinicians when they work together and devise new methods for improving lives and averting costs. But the basic decision has the stark urgency of right and wrong. We can give up an antiquated set of priorities and shift our focus from rescue medicine to lifelong incremental care. Or we can leave millions of people to suffer and die from conditions that, increasingly, can be predicted and managed. This isn’t a bloodless policy choice; it’s a medical emergency.” (Gawande, 2017, p. 45)
I highly recommend reading the entire article.
If we were to take Gawande’s argument for incremental care over heroic rescue care one step further and add a shift to Functional Medicine instead of what has come to be called Conventional, Traditional, Allopathic or Western Medicine, then we’d really be on the right track to regain our health and save a bundle on health care.
Functional Medicine treats the patient, not the disease. It looks at the underlying causes of diseases and conditions in a particular person then works on rebalancing the body to return the person to full functioning.
The seven basic principles of Functional Medicine are:
Science-based medicine that connects the emerging research base to clinical practice
Biochemical individuality based on genetic and environmental uniqueness
Patient-centered care rather than disease-focused treatment
Dynamic balance of internal and external factors that affect total functioning
Web-like interconnections among the body’s physiological processes also affect every aspect of functionality.
Health as a positive vitality, not merely the absence of disease.
Promotion of organ reserve.
– (American Academy of Anti-Aging Medicine, 2017)
“Here lies the clear distinction and definition of Functional Medicine. Instead of asking, ‘What drug matches up with this disease?’ Functional Medicine asks the vital questions that very few conventional doctors ask: ‘Why do you have this problem in the first place?’ and ‘Why has function been lost?’ and ‘What can we do to restore function?’ In other words, Functional Medicine looks to find the root cause or mechanism involved with any loss of function, which ultimately reveals why a set of symptoms is there in the first place, or why the patient has a particular disease label.” (Cole, 2012)
Another description of Functional Medicine – with an example of how he uses it – from one of my favorite practitioners, Frank Lipman, MD:
“Functional Medicine is a true combination of Chinese Medicine, Western Medicine, and scientific research. It combines the philosophy of balance and how to restore function from Chinese Medicine and the knowledge of biochemistry and physiology of Western Medicine with the latest scientific research about how our genetics, environment, and lifestyle all interact with each other. Functional medicine focuses on assessment and intervention at the root levels of metabolic imbalance and is an evolution in the practice of medicine that addresses the healthcare needs of the 21st century by focusing on prevention and uncovering the underlying causes of serious chronic disease. Instead of just suppressing symptoms, it deals with the root causes of disease and is less concerned with making a diagnosis and more concerned with the underlying imbalances, which are the mechanisms of the disease process. “For instance, in the last 2 weeks, 3 people came to see me complaining of reflux and all had been given Nexium by their Doctor. But for one of them, the cause was his diet, and eliminating the foods that caused the problem did the trick. For the second person, giving her probiotics and nutrients to heal the lining of the gastro-intestinal system helped, and for the third person, giving him HCL, yes you read correctly, giving him Hydrochloric Acid tablets to help digestion helped. All 3 had different causes and needed to be treated accordingly.
“As opposed to Western Medicine, Functional medicine treats the patient and not the disease. In addition, it provides a framework for the practice of medicine that uses all the tools of healing, both conventional and alternative, to address the whole person rather than an isolated set of symptoms. I have studied Acupuncture and Chinese Medicine which taught me to see the body from a holistic perspective. Now Functional Medicine gives me a framework to combine this with a Western understanding of the body.” (Lipman, 2009)
American Academy of Anti-Aging Medicine. (2017). What Is Functional Medicine? See: http://www.a4m.com/fellowship-anti-aging-overview-what-is-functional-medicine.html
Cole, W. (2012). The 5 Principles of Functional Medicine. See: http://www.mindbodygreen.com/0-6014/The-5-Principles-of-Functional-Medicine.html
Gawande, A. (1/23/2017). Tell Me Where It Hurts: Our medical system rewards heroic intervention. When will we grasp the power of incremental care? The New Yorker. See: http://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care
Lipman, F. (2009). WHAT IS FUNCTIONAL MEDICINE? See: https://www.bewell.com/blog/what-is-functional-medicine/
The Rockefeller University. (4/1/2014). Surgeon and writer Atul Gawande awarded Lewis Thomas Prize. Newswire. See: http://newswire.rockefeller.edu/2014/04/01/surgeon-and-writer-atul-gawande-awarded-lewis-thomas-prize/
© Copyright 2017. Joan Rothchild Hardin. All Rights Reserved.
DISCLAIMER: Nothing on this site or blog is intended to provide medical advice, diagnosis or treatment.
Comments submitted prior to 8/25/2021
This is a great piece. I have long enjoyed the medical writing of Atul Gawande. We just started up with an internal medicine practice here in SW Florida in the event we need healthcare during our 5 months here. He didn’t like like lung sounds on S and ordered a chest X-ray. Came back fine, just some old scar tissue that has been more than adequately
adjusted to. Probably aftereffects of years of smoking long ago. We felt he was being thorough and careful and we appreciated it, if anxious until getting the results. And this professional was the doctor’s PA. We were impressed.
In reply to Sonnische
Good to know that thorough internal medicine practitioners are alive & well in SW Florida!