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Dr. Michael Smith (Host): Integrative medicine, functional medicine, holistic medicine. Have you heard of these terms or phrases about how to approach medical care? Is it confusing? Well it is to a lot of people and we’re going to try to clear the air today. Welcome to The GW Hospital HealthCast. I'm Dr. Mike Smith and today’s topic: the facts about integrative holistic and functional medicine. My guest is Dr. Mikhail Kogan. Dr. Kogan is medical director at the George Washington Center for Integrative Medicine and assistant professor of medicine at the George Washington University School of Medicine and Health sciences. Dr. Kogan, welcome to the show.

Mikhail Kogan, MD (Guest): Thank you. Happy to be here.

Host: So, I think it’s fair to say that the average person in the United States, and I know my listeners, are familiar with these terms. Like they’ve heard integrative medicine. They’ve heard the term holistic medicine, even functional medicine, but I'm not so sure if everybody truly understands how they are similar but yet how they are distinct in the way they approach patient care. So, I think this is an exciting topic. So why don’t we just kind of start overall. When you look at these three forms of practice, what’s the overall goal or philosophy about these approaches to patient care?

Dr. Kogan: Yeah so. Thanks Mike. It’s a great question. Let me back up for a second because I think actually what most of the people in the United States are familiar with is the older charms, or what’s called CAM or complementary alternative medicine. We don’t really use those terms much anymore. They're falling out of favor, so they really got substituted for what we call an integrative medicine.

Integrative medicine, I’ll describe a little bit first because that’s sort of what I do. That’s what I practice. Integrative medicine is basically based in principles of western approach where you diagnose condition and treat it. The difference is instead of trying to say look, I'm going to have an immediate treatment for a given condition, I'm going to try to understand a little bit more about the person’s body, about how they function, about their environment. I will try to figure out is there a causality that’s based in their lifestyle. For example, maybe their diet’s very off and they're consuming too much sugar or too much salt that’s causing increase in blood pressure. So, it’s really a root cause that we’re trying to identify and then address it first with a [inaudible]. Then we start adding first left interventional modalities, maybe massage or acupuncture, before we start engaging in utilization of medications or surgery.

So, you have the tool box is then includes a variety of different, what used to be called complementary modalities. Things like acupuncture and massage and maybe some even energy healing, which is a lot harder for western system to appreciate in things like reiki or healing touch. Yet what I think a lot of this field is trying to do is to really address the kind of epidemic of nervous system regulation and epidemic of trauma and epidemic of very poor lifestyle. I think that unfortunately in the traditional medical field, we go too quickly to the medical tools. They're really not appropriate for most of the chronic conditions that are stemming from poor lifestyle choices and toxic environments. By toxic environments, I don’t just mean literally toxins. I also mean stressors and traumas and societal settings where people are constantly struggling. So, I hope that maybe 100 years from today instead of calling this integrative medicine, we’ll just call it medicine because we’ll find out what things should we be using first instead of putting on the drugs and surgeries. In that sense, I really can’t quite separate what is integrative medicine, what is just good medicine. That’s kind of out there.

The next is let’s talk about functional medicine. That’s an interesting system in itself. A lot of people I think confuse them. They think that integrative and functional medicine are the same thing. Not quite. I think that functional medicine’s different is very similar to allopathic model in the way the diagnosis is approached. So, you're finding out the diagnosis, but then your treatment in functional medicine would be much more biochemical. So, you would first apply maybe a supplement or very specific diet to modify whatever the issue is.

Let me give you an example. So, let’s take some mild inflammatory conditions. Not necessarily mild, just inflammatory conditions. So maybe inflammatory bowel disease. In inflammatory bowel disease, this could be quite severe and usually quickly treated with medications. In functional medicine, if it’s not dire circumstances, we may try to apply a method that would be trying to address possible root cause, but much more specifically utilizing a diet or supplement. So, we may give high dose probiotics. Or we could try taking gluten out of the diet. You could arguably say that there’s not a whole of evidence for those things, and that’s a whole separate conversation. But that’s kind of a core principle in functional medicine is that we try to address the underlying driver of the condition by maybe giving more nutrients, maybe taking away allergens. The model here, we don’t necessarily use methods that are based in maybe energy principles or modalities such as acupuncture.

I know it’s kind of a vague answer, but frankly I think that’s actually the best I can do. Also, functional medicine has been popularized by a pretty specific educational entity, what’s called an institute of functional medicine. So, there is a little bit of, ISM has this proprietary teaching, and I think a lot of the terminology came out of what they teach in their program.

Host: Right.

Dr. Kogan: So, I don’t think I practice a lot of functional medicine. I really call what I do and what our center does integrative medicine.

Host: Interesting. Before--

Dr. Kogan: Then holistically they're kind of--

Host: I was just going to say before we go on to the holistic definition, you said something interesting there in your description of functional medicine that there may not be a lot of evidence for the use, and that is a topic for another time. I agree with that, but I just wanted to clarify something. Using your inflammatory bowel story or example, I want my audience to know maybe there’s not conclusive evidence and not enough clinical evidence, but in that one example using high probiotics there is some evidence in the literature that this could have some efficacy. So, it’s not like you're trying something that doesn’t have something in the research that supports that. That’s correct?

Dr. Kogan: Oh absolutely. I think it’s also not just that, but it’s also how do we use the evidence that we have? In the standard allopathic medicine, I think a lot of evidence gets put out by these large studies, but which really there’s not enough money in the system to study say a probiotic or a supplement the same way when it’s not supported by a drug company that’s interested in tapping something. So, we’re looking at very different comparison level of research and you're absolutely correct. I think functional medicine practices quite evident medicine. It’s just are you comfortable with the level of evidence. You can take three different clinicians and get three totally different answers no matter what field of medicine they are looking at the same study.

There’s also no guidelines, for example, which by the way we at GW are trying to address. We’re trying to create a set of guidelines for practice with integrative medicines because there’s a lot of needs to try to say well let’s look at this study. Can we have some agreement on what is the meaning of this result. It’s not so simple. It’s actually a daunting task. Not just in integrative medicine, I would say, in any field.

Host: Yeah. That’s fascinating. So, let’s go to then the holistic definition and how that distinguishes itself from functional and integrative.

Dr. Kogan: Right. Well you put my on the spot. That’s the hard one to answer. That’s kind of the big basket out there. Frankly, what concerns me a little bit here is that anybody, any practitioner out there who does something non-traditional can say oh I'm practicing holistic medicine. Unfortunately, it’s really hard to sort of define that. Are you going to call a lifestyle method that advocates for [inaudible] diet holistic? Are you going to call reiki holistic? Are you going to call anything that sort of looks at the person as a whole holistic? I mean I don’t know. If you're a very good primary care doctor and you're seeing your patient every visit, not just the disease in the room, you're a holistic provider, right? So where is the kind of…

So, I think the definition is simple. You're seeing the forest behind the trees all the time. So, you see the whole person and you address the whole person’s needs and functional status and whatever the really goal oriented treatment plan where the patient goals are prioritized. So, I'm kind of having a hard time to be very clear here honestly.

Host: Yeah, I get it. I get it.

Dr. Kogan: I’m also careful because I don’t want to leave anybody out there. Like no Dr. Kogan does not believe in holistic medicine. He’s thinks it’s standard medicine. No. Of course it’s not. If you look at who’s calling themselves holistic providers, those are usually providers that are practicing some form of integrated modality or formally called complimentary modality.

Host: It’s a tough one.

Dr. Kogan: So, a definition is to simply summarize it as just when you look at the person as a whole and you're not afraid of taking modalities that are typically not, would not be considered a standard of care and you utilize those tools to address the whole health, not just the disease.

Host: Okay. I think that works. I think that’s about the best definition we’re going to be able to come up with. So, again, fascinating topic. Let’s end this way Dr. Kogan. Speaking to the listening audience, what would you like them to know about integrative medicine?

Dr. Kogan: I think what I would say is probably most important is two things. So, one, don’t immediately jump to the utilization of the potentially side effect prone modality as tools. Think carefully. Is there some kind of a much less medical approach that I can safely engage to try to address whatever is going on? If I'm having a cold, do I need to take these antibiotics or am I better take vitamin C which is most likely a placebo, but it will take time and I’ll get better anyways, and I won't take antibiotics. So, kind of slow you're thinking down and think in terms of holistic way of addressing the problem which will help you generally speaking, I think, to stay healthier. Simply because you're going to have less utilization of possibly side effects prone treatments for simple conditions.

I think second is find a provider that you can trust. Quite often your own primary care provider will have a good network of people who they can tap onto on the need that will call themselves holistic or integrative or whatever the term would be. I think because there’s such a sea of providers and it’s really hard to figure out who is who and quite often this field is pretty much out of pocket. So, it may not be very expensive, but for a lot of patients it’s a lot of money.

Host: Yeah, that’s true.

Dr. Kogan: So, find a good referral, create a network, and have a team that you can use on a regular basis or as needed or in combination with your primary care doctor.

Host: Right. Well Dr. Kogan I think that was a great summary of it all and I want to thank you for the work that you're doing and thank you for coming on the show today. You're listening to The GW Hospital HealthCast. For more information, go to gwdocs.com. That’s gwdocs.com. I'm Dr. Mike Smith. Thanks for listening.