Is the Patient Right for Your Functional Membership Model?

membership model membership practice Oct 19, 2023
 

This week we had a conversation about a patient who has worked with people in the past and has a number of complex presentations: alopecia, microcytic anemia, and lichen planus. She is really trying to figure out how to fit all of this together and is very specific that she wants to work with someone who can tell her what the cause is. We not only discussed the patient's specific health concerns, but also discussed an essential question that practitioner and patient both ask. 

“Is the Membership-Based Approach the Right Fit?”

So, this week’s conversation centered on the question, “Is she right for a membership-based approach?”  Initially, the physician who was working with her was thinking, “I'm not sure, because if she really wants to know ‘What is the root cause?’, is that something that I'm able to deliver on? And is that appropriate for a membership-based practice?” 

To me, it's an overwhelming, resounding, “Yes!” Membership is excellent for a patient like this. 

Patients with Multiple Presentations

This is exactly the kind of patients that we want to work with, patients that have these layers and presentations that wouldn't have been addressed already. So, when we look at this particular patient and think about what's going on in terms of lichen planus, we know that that can be associated with, for example, other autoimmune conditions. She also has autoimmune thyroiditis or Hashimoto’s.  As we began in our discussion to look at this in terms of autoimmune thyroiditis, we noted that autoimmune thyroiditis could be associated with alopecia and also lichen planus.

Lab Work

Then what are the next steps? We talked about how even though she's had some lab work done in the past, “What are the parameters for when we want to redo that?” If she's done lab work, outside of three months, really thinking about, “Okay, let's repeat that and still start with the basics.” This is one of the things that we talked about in our approach to the patient from a functional medicine perspective: “How do you work in treating everything, but keeping compliance where it needs to be and cost where it needs to be?” Even though she might have had an AMA in the past and she might have had thyroid antibodies in the past, we need to look at those. A couple of other basic markers we'd be interested in to start with the functional assessment. We would look at CRP, which can be elevated in lichen planus and also things like vitamin D. If that's low, of course, we know that our Treg cells won't function as much, and that can be indicative of autoimmunity as well.

Approaching the Patient

So how do we approach this patient? From there we discussed, “Yep, still start with the basics and see where she's at.” And then from there, when she's searching for that root cause, I feel that is very deliverable because when we look at what's going on there, it's likely that there's a pattern of gut-based inflammation. As we start in the gut, we're going to understand where what is driving her towards autoimmunity, probably starting with something like a stool test, and maybe also things that would measure lipopolysaccharides. So, why? Well, in a stool test, if we have low diversity, we're more likely to be on that autoimmune continuum. When we look at certain short-chain fatty acids, that make us more likely to have autoimmunity, when we think about panels that would have lipopolysaccharide—even adding on a Zonulin (Zonulin goes up before the onset of autoimmunity because there are tight junctions open)—and when you go to the literature, it's all associated with lichen planus. It's also associated with autoimmune thyroiditis. So, right off the bat, we're thinking of why leaky gut is a unifying theory for what's going on. Now the alopecia is associated with microcytic anemia. Well, if there's more inflammation, it's going to be harder to absorb iron.

Allow Things to Build on Themselves

All of these things build on themselves. But even though they're all there, we don't have to address them all at once.

Gut-Based Approach

We look at these gut-based studies, we look at a stool test, and we look at LPS that up-regulates toll-like receptors that just caused the immune system to ramp as an autoimmunity. There's LPS that downregulates Treg cells and shuts off autoimmunity, so we begin to pull the story together for the patient. Then we start there looking at things like LPS, Zonulin, and stool testing. From there we see how the patient responds. We decided, based on the history, if immediately we think we should add a food sensitivity as well. We do our gut-based approach.

Hormone Profile or Detox

We see where the patient gets, and then we think about other pieces that might be a part of our story. “Is there a stress component that needs to be addressed?” “Did any of this get worse post-menopause?” These are the kind of questions that lead us to decide, “Okay, yes, then we're going to add on more hormone pressure profile, or were these things that got worse after a certain exposure? Do we know that she's around anything?” because toxic burst can cause the immune system to be overly excited as well. We'll prioritize those and then either work on hormones next and then detox, or vice versa, based on the patient's history. So, we see if we're thinking about a five-visit membership model, actually how perfectly this person slots in.

Two Main Objectives

Now when we get to that last part of “How do we get to what she wants?” (understanding what the root cause is), we have two objectives:

  1. To help her understand that gut is a likely part of that and explain that piece of it so that she understands the “root cause” is being addressed.
  2. And getting her to understand that most conditions are multifactorial. So when a patient is looking for a “one bullet, one solution kind of piece,” this is where we need to step in and explain to them “You know, what? You are not just one pathway; you are not just one infection; you are not just one organ.” And so that reductionist perspective that's looking for only one reason why this would be the case is exactly why you failed in the past.

 Conclusion

That is why, in terms of the membership, we're able to spend the time working on that gut-based inflammation that contributes and working on that toxicity that likely contributes while thinking about hormones that might lead to creating more inflammation as well, being able to pull the whole thing together, so that ultimately, the patient understands, has realistic expectations, and is served well by exactly what's being offered.

 

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