FOCUS ON: Bringing Functional Medicine to Residency Training—Tallahassee Memorial’s Family Medicine Residency Program















Dr. David Jones, President and Director of Medical Education for IFM; Laurie Hofmann, MPH, Executive Director IFM; Ruth DeBusk, PhD, RD, IFM Faculty; Cathy Snapp, PhD gather at the Tallahassee Memorial’s Family Medicine Residency Program

The Institute for Functional Medicine regularly receives inquiries from leaders in academic medicine who are interested in integrating functional medicine into their programs. With 17 residency programs offering some level of training in functional medicine, we wanted to highlight one that we find particularly exciting—a major program in functional nutrition that delivers innovative, effective care directly to medically underserved patients.

Using grant funding initially from HRSA and now from the State of Florida, Cathy Snapp, PhD and Ruth DeBusk, PhD, RD designed and implemented the program at Tallahassee Memorial Family Medicine Residency Program, integrating the basic principles of functional nutrition with mind/body/spirit approaches to prevention and self-care as the basis of treatment. Part of the grant is a diversion program for repeat emergency room users with serious chronic diseases (e.g., asthma, diabetes, heart failure); the immediate goals for that aspect of the grant are to connect patients with primary care providers and a medical home, and to ensure they take their medications. The other portion of the grant, however, has a longer-term focus—to train medical doctors in chronic disease prevention using all the basic areas of the functional medicine matrix. In effect, Snapp, DeBusk and the rest of their team had to develop a “laboratory” to show physicians how modifiable lifestyle factors could be addressed using a mindfulness-based approach with functional medicine AND to demonstrate the kind of patient response that such a program can produce.

The Tallahassee program offers patients all their necessary medical care, plus a 2-hour weekly session for 6 months, each month focusing on one of the modifiable lifestyle factors from the functional medicine matrix. Each of those modules is followed also by a cooking class. (DeBusk and Snapp are currently investigating whether it will be possible to reduce the time to as little as 8 weeks, because part of their mandate is to codify an exportable program.) Thus far, residents have observed the clinical care team as they discuss each patient’s antecedents, triggers, and mediators, and prepare a matrix and timeline. They are welcome to observe the patient sessions as well. However, beginning in 2013, there will be a whole curriculum for the residents, involving hundreds of hours and including functional medicine approaches to psychiatry and psychology.

We asked Snapp and DeBusk to identify 2 or 3 of the most important elements being taught in their program. First, they integrate the mindfulness approach into every aspect of the program, focusing on teaching conscious awareness, breathing, and movement. Second, they teach patients that they are really in control of their own health—a concept completely unfamiliar to most of them.  Third, they surround them with support and personal attention while they are making these difficult changes. And fourth, they have a written contract that patients must sign to enter the program.

DeBusk and Snapp are excited and delighted not only by the improvements in patient health and health-promoting behaviors but also by the astonishment of residents who observe the dramatic changes that occur over the course of the program. Some of their patients really qualify as miracle responders; CNN has been onsite to film one of those individuals—a person with 50+ years of inflammation–related complaints who is now completely pain-free!

Many readers may already be wondering, “How did they DO that?!”
We know it can be really difficult to capture space in the crowded residency curriculum, and it can be even more difficult to persuade department chairs and program directors of the value of a dramatically different approach. So, when we interviewed DeBusk and Snapp, we asked them to help us understand how they were able to accomplish these challenging tasks.

No one will be surprised to learn that the program was many years in the making. Many individuals were involved along the way, and many different possibilities were considered. The early ideas emerged from Snapp’s postdoctoral work 8 years ago, when she focused on the value of bringing mind/body/spirit into medicine. She subsequently got a HRSA grant to advance this goal, enabling her to stay on at
Tallahassee. (It is interesting to note that this program came through the behavioral sciences department, rather than medicine or nutrition, showing that there are many paths to the same goal.) Snapp learned about IFM and functional medicine through one of her mentors, an IFM faculty member, Rich Panico, MD, and then IFM offered one of the Tallahassee residents a scholarship for Applying Functional Medicine in Clinical Practice (AFMCP), IFM’s foundational program. Connections were made with Laurie Hofmann, IFM’s Executive Director, who then brought DeBusk (a long-time IFM collaborator and adjunct faculty member) into the picture. Subsequently, several of their residents were also given scholarships for AFMCP. In 2010, they got a large grant from the Florida Agency for Healthcare Administration to put all the pieces together to affect chronic disease. Michael Stone, MD, another IFM faculty member and a leader in the development of functional nutrition, is now part of the regular training program.

How did they get their faculty interested in such a different approach?
First, they provided a direct experience of a mind-body approach by offering yoga classes to the faculty. They did HeartMath with some of the residents, providing another personal experience where the shift in autonomic regulation can be seen. They brought in evidence of the effects on health and disease of the modifiable lifestyle factors. They found resonance for the need to humanize medicine and to focus efforts on restoring health, and they built on that. Gradually, more colleagues become interested, then supportive, and ultimately involved. But they believe the breakthrough moments were those that provided a personal experience of the potential for lifestyle change to improve health.

How did they get time in the residency curriculum?
This has been a long road, beginning with preceptor time, then some clinical time, then time in the didactic teaching schedule, and finally integration into the clinical rotation. DeBusk and Snapp are really looking forward to introducing the full teaching program, which begins soon. That will bring the residency curriculum to a 50/50 balance between disease management and health promotion—quite an amazing achievement! We offer them our most heartfelt congratulations.

Insights from the Tallahassee experience
We asked DeBusk and Snapp to help us advise others looking to develop full-scale programs of their own, either in residency programs or for health professions students. They gave us some wonderful suggestions to pass along:

  • You always have to start where you are—if that means no one in your institution knows anything about functional medicine, functional nutrition, or mind/body/spirit approaches, then begin by offering experiential activities that can generate personal insight into the value of change. Snapp and DeBusk see mindfulness as the “bowl” that contains it all, so meditation, yoga, and HeartMath are all good choices.
  • You must have passionate, dedicated leaders who can dream big and offer to others a vision of what such a program can accomplish, regardless of which portal (medicine, nutrition, behavioral sciences) it derives from.
  • It’s vital to build a team that involves more than just a single discipline. No one pays for curriculum development, so you will need advocates and clinicians in several vital areas to advance the ideas, help write and administer grants, deliver care, and become teachers.
  • Understand your institution’s strengths and liabilities—is there something already in place that can be built upon? Where does opportunity lie within your institution? Who is already interested in this kind of change? Are there grants that can be funded? Scholarships or fellowships to be awarded?
  • Know the evidence and be prepared to educate others. Reducing costs and utilization are both important outcomes of teaching residents and students how to transition from the acute-care model to more effective approaches to chronic care that emphasize patient self-management skills and underlying causes.
  • No matter how small your initial program, be sure you collect data and report outcomes. Publicize your successes!
In the Tallahassee program, all the patient referrals are in-house, so it isn’t known how much the local medical or patient communities could drive demand or provide support if they were engaged. However, if there is interest in your community, don’t hesitate to get local leaders (elected officials, policymakers, hospital or clinic directors), functional medicine clinicians, energized patients, and philanthropic individuals and organizations involved. There is no single path, no one right way to bring functional medicine into medical education.

Whatever you choose to do, IFM would like to help. We can provide content, publicize ongoing efforts, and provide vital networking to all who are working to advance the common goal. Contact Laurie Hofmann at any stage of planning or implementation for more information.

Resources

  • Click on the following links to see the Poster Presentation and Abstract for “Newly Developed Functional Medicine Program in Diabetes: Impact on Clinical and Patient Reported Outcomes” which presents some early data that informed the development of the Tallahassee Memorial Family Medicine Residency Program
  • Click here to see an interview about the Tallahassee program with Dr. Ruth DeBusk
  • Clinicians interested in functional medicine approaches to one of the chronic diseases treated in the Tallahassee program—heart disease—should consider attending IFM's Cardiometabolic Advanced Practice Module which will be held in Tampa, FL this February
  • IFM's next 5-day foundational program, Applying Functional Medicine in Clinical Practice (AFMCP), will be held September 16-20, 2013 in Minneapolis, MD
  • About HeartMath