As Senior Adviser to the CEO at IFM, Patrick Hanaway, MD, also leads the organization’s COVID-19 Task Force, which provides practitioners with the tools needed to help patients combat the pandemic and achieve optimal health.
Dr. Hanaway is a board-certified family physician trained at Washington University. Dr. Hanaway served on the executive committee for the American Board of Integrative Medicine and is past president of the American Board of Integrative Holistic Medicine. For the past 20 years, he has worked with his wife in clinical practice at Family to Family: Your Home for Whole Health Care in Asheville, NC.
After serving as chief medical officer at Genova Diagnostics, Dr. Hanaway became the chief medical education officer at IFM, where he oversaw the development and implementation of IFM’s programs worldwide. He has been a core faculty member with IFM since 2005, he leads the GI Advanced Practice Module, and he continues his support of IFM as co-chair of the Expert Advisory Board.
In 2014, Dr. Hanaway helped develop the collaboration between IFM and the Cleveland Clinic, where he was the founding medical director. He later became the research director and now serves as a research collaborator at the Cleveland Clinic Center for Functional Medicine. His research interests focus on evaluating outcomes of Functional Medicine models of care.
The focus of Dr. Hanaway’s work is to use his skills, knowledge and perspective to transform medical practice through education, research, and clinical care. In addition, Dr. Hanaway is an initiated Mara’akame [indigenous healer] by the Huichol people of the Sierra Madres in Mexico. He holds community fires, leads ceremonies, and offers traditional healing sessions.
Integrative Medicine: A Clinician’s Journal (IMCJ): To start with can you introduce the Functional Medicine model to treat COVID-19?
Dr Hanaway: Functional medicine takes a unique approach when treating patients. This approach allows us to look across the whole Continuum from wellness to illness and back. We help patients using a personalized approach. From a functional medicine perspective our objective is to:
- Support the immune system.
- Decrease viral replication
- Reduce symptoms
Certainly, the public health measures to reduce viral transmission are essential to ‘flatten the curve’.
Functional medicine practitioners are uniquely trained to help those people who are at the greatest risks including: people with poor diets, people who are obese, people who suffer from nutritional deficiencies and those who are faced with multiple complex chronic diseases. We know how to help these individuals.
IFM’s role is to help practitioners understand how to work with the SARS-CoV-2 virus in their patients, whether they’re at-risk and concerned, whether they’re exposed, whether they have symptoms, or whether they’re recovering from infection. We have worked to put together patient education materials to help clinicians work with their patients effectively. We also provide resources to help clinicians in their business practices. Since the beginning of the COVID-19 crisis, we’ve seen a 60% decline of patient volume in doctors’ offices in the United States; as well as, obviously, a 55% decrease in revenue. We’ve also seen incredible growth in the burgeoning arena of telehealth. It begs the question, how do we help clinicians provide for patients in a sustainable way through telehealth?
To summarize, the people who are most at-risk for COVID-19 are those who have multiple complex chronic diseases, including: obesity, diabetes, hypertension and cardiovascular disease. This is why we see it affecting the poor and people of color to a greater degree. Functional medicine provides the tools to help move individuals from illness to wellness. That is our goal. Functional medicine is particularly well-suited for this approach, in contrast with “other branches of medicine” that work to suppress the symptoms. With functional medicine, we focus on the root cause(s) that drive these imbalances that increase the risk of individuals developing COVID-19.
IMCJ: When you have those people who suffer from various chronic health issues, are you finding that maybe right now they’re avoiding maybe regular doctor’s appointments because they are afraid to go to a clinic, because they don’t want to become infected with COVID-19 and be exposed to other patients.
Dr Hanaway: Exactly. While we see that visits are down, overall disease burden is not down. Rather, overall engagement with the healthcare system is down. We know that many clinicians within the integrative medicine/ functional medicine arena do not use insurance. Many practitioners use a fee for service practice model, but peoples’ finances are getting tighter because they’re not working. So, there’s a monetary aspect and a fear aspect to this decline in engagement with practitioners. What this means to me is that we have to become better at meeting people where their concerns are, to help them, to guide them along the path of healing. For example, we see that diabetic patients, because they’ve been hearing on the news that they’re at higher risk for developing COVID-19, are more motivated to take care of themselves in order to prevent a serious COVID-19 infection.
How do we support our patients? We need to help people understand that their food choices, their sleep behaviors and the ways in which they deal with stress are important drivers of risk for developing COVID-19. We can help them, motivate them and engage them to change their lifestyle, so that it decreases their risk.
IMCJ: I understand tele-health working from an MD perspective, but how do you get the DCs involved and the NDs, who are typically are more hands-on type of practitioners?
Dr Hanaway: Well, it’s a great question. I see that many of my naturopathic and chiropractic colleagues have embraced the importance of nutrition and modifiable lifestyle factors. Working with patients to help them use these specific tools, that is where the opportunity is right now. From a naturopathic perspective, there doesn’t have to be a physical exam in order to use the different kinds of lifestyle tools, as well as the nutraceutical and botanical tools to help the individual to be able to optimize lifestyle, and minimize the risk of SARS-CoV-2 infection.
Chiropractors are more hands-on in the nature of what they do, but many chiropractors have an important part of their practice to use nutrition and lifestyle to support their patients. They can do that virtually as well.
I’m finding it interesting to do virtual physical exams, to assess physical status and work with home stretches. I think that we’re going to learn (while not a substitute for one-on-one in-person care), to meet with each other and connect with each other virtually. I feel that telehealth will be an important adjunct for all healthcare in the future. We need to learn how to do it effectively. We must engage patients where they’re at and also determine what other resources will help support them. We can team-up with nutritionists and coaches to help our patients, to be in their kitchens virtually and help them cook. We can go to the grocery store with them, virtually. We see the emergence of opportunities, not just problems.
IMCJ: How would you describe an in-clinic appointment versus a tele-health appointment?
Dr Hanaway: In my clinical practice, we arrange our appointments based on what we need during that engagement time. We sit face-to-face and talk to each other through a HIPAA-compliant Google MEET video app. I find it really fascinating to see someone’s home. For example, the patient I just “saw” this morning was in his kitchen—I can see his kitchen, and I ask him to “Show me your refrigerator.” He initially balked, and then he said, “Okay.” While he had told me what he’s eating, I can now see what’s in his refrigerator and I comment, “There are many things you didn’t tell me about in your refrigerator. Tell me about that.” It was an interesting moment during which he was a little bit defensive, but it also helped me to see that his partner wasn’t supportive of what he was trying to do nutritionally. I got a lot more insight by being in his home and to be able to see what the challenges that he is working with. I recommended a coach to help him with those challenges. I find that there are incredible opportunities to support my patients virtually.
One of the opportunities for functional medicine is to let practitioners and healthcare systems know and understand what functional medicine can offer to our people. As we looked at Chris Cuomo on TV saying, “There’s nothing I can do,” while having a ‘compassion visit’ virtually with Dr. Sanjay Gupta. In fact, there are things that you can do to be able to optimize your diet (minimizing sugar), deal with the stressors pressing on you and to have some movement every day.
And there are nutraceutical and botanical agents that have a good level of evidence and a very small risk of harm that are worth trying, both for prevention and treatment. We want our colleagues and practitioners in other branches of medicine to recognize that there IS something we can do to mitigate risk and to decrease the severity of illness from COVID-19. In fact, functional medicine is uniquely positioned to help patients work with foundational lifestyle factors to improve complex, chronic disease and improve their overall health and well-being.
IMCJ: Do you think that there’s maybe a positive that’s going to come out of this, because people are being forced to as they’re isolated, eat at home and maybe eat a little healthier?
Dr Hanaway: That’s true. People now have to eat at home and to cook on their own. My friend Mark Hyman tells me that (at least up until this point in time) people spend more time watching cooking shows than they do actually cooking. But now, we need to spend time cooking. Again, we can spend time in their kitchens to help them with cooking and determining good foods to eat. That can be a great opportunity, but we have to capture those opportunities. We can’t just assume that they’re going to happen. We need to educate and walk with our patients in their learning and understanding so they can apply these nutritional tools.
IMCJ: So, shifting gears a little bit, IFM did a webinar on testing for COVID-19 and maybe just give me some highlights of what your approach is on the testing side.
Dr Hanaway: Again, the Institute for Functional Medicine is a non-profit educational organization, so our goal is to educate practitioners to help them to understand what tools are available, what tests are available, what the results mean, and what kinds of testing we should do for each patient. We describe the time course of disease activity and immunologic response. People can be asymptomatic for up to three weeks period of time. Some people will develop symptoms within two, three days of exposure. Some people, it may take up to three weeks after exposure before they develop symptoms. 90% of people who develop symptoms will do so are going to have symptoms within the first two weeks.
During that period of time, if there are no symptoms, whom should we test? Depending upon how long it takes for their immune system to ramp up, so the people who are at-risk and have been exposed, we can do viral RNA testing on them. PCR testing is done from a nasal swab, oral swab, sputum or saliva. But there’s a significant false negative rate, where sampling error occurs, and they just didn’t capture the virus. Of the people who develop symptoms, only about 50% will show the presence of the viral RNA within the first five (5) days.
The sensitivity rate goes up as symptoms continue. In three to five days after they start having symptoms, that’s when that viral load maximizes, and we can do viral RNA testing. There’s a difference between the intact virus (that causes infection) versus the viral RNA. Those are not the same thing. Thus, we test the viral RNA. We want clinicians to understand the difference between these two things. Additionally, when we do antibody testing, it shows exposure and immune response, not immunity. In order to have people be able to return to work, we need antibodies demonstrating exposure and immune response, and we also need to see that there is no more viral RNA being shed through their respiratory tract. That will give us confidence, because we do not yet have a true test of immunity. The idea that people will walk around with certificates of immunity is a false perspective. We don’t have any testing for immunity.
There is a ‘Wild West’ of testing out there right now. The Emergency Use Authorization (EUA) by the FDA allows tests to be on the market before they’ve actually been approved. There are, unfortunately, labs that are taking advantage of this and putting less than optimal tests into the marketplace. Thus, we see a significant number of false positives and false negatives. We are educating clinicians to ask the labs to ensure that they deliver high-quality, reliable, accurate results?
IMCJ: COVID-19 is something that’s not going to go away in the next three months, six months, probably going to be here for a couple of years- how can we participate in group activities and be assured we are not passing the virus but also not being exposed to it?
Dr Hanaway: There are some fascinating, new innovative tests that are being developed. My colleague, Dr. Helen Messier told me last night that there’s now a company in San Jose that’s developing a disposable PCR test; a one-time, do-it- yourself test in which the results are available in seven minutes. I know that there are certain airlines that are doing testing before they have people get on the plane. I know that there are projects being developed by the American Academy of Family Physicians and others that recommend the viral RNA test be done on patients before pre-op. This constitutes an admission ticket to the hospital, not that they are immune but rather a test to determine that they actually do not have the virus.
There is a difference between the sensitivity of a test and the positive predictive value. For example, if you live somewhere with a 1% prevalence of the SARS-CoV-2 virus, e.g. middle America, even a test with 95% good sensitivity and specificity will have significant false positives when we measure a population. If we were to measure people in line for a football game, we get five times as many false positives as true positives.
But, if the prevalence in a population is 25%, such as the recent data from New York CIty, and we do the same test in a similar group of people waiting in line for a football game, there will be five times as many people who have true positives than false positives. Here I’m talking about the public health perspective, not the clinical perspective. We have to understand the prevalence of the SARS-CoV-2 in the population because it will make a difference in how we apply testing to make clinical decisions.
In consideration of testing we break it down differently between the determination of risk for each person: the time course of exposure of symptoms, of resolving symptoms or in recovery. We see people in all three phases, and will make different recommendations to people whether they’re exposed, whether they have symptoms, or whether they’re showing symptoms after having the virus infection.
We find that recovery from COVID-19 can be complicated. There are issues that persist in a number of people that relate to the pulmonary system and difficulty breathing or the mitochondria and energy production or the vasculature and micro clotting, or even the brain with ‘brain fog’ and PTSD. There are many different factors that we’ll be dealing with on the recovery side as well. Again, functional medicine looks at the whole person and is working to understand the mechanism of action of the virus infection. We’re targeting treatments, low-risk treatments using food, using other lifestyle factors, using well-researched botanicals and nutraceuticals to be able to guide our treatment recommendations, in prevention, treatment and recovery.
IMCJ: To wrap up, do you think this is an opportunity to educate your conventional healthcare practitioners who really didn’t understand functional medicine? Because it seems that a functional medicine approach can be a much better long-term solution as opposed to just being able to create a pill or vaccine that’s going to cure the particular case of COVID, but next year, maybe it mutates and the pharmaceutical solution does not work?
Dr Hanaway: Well, we don’t know about the antigenic drift of the SARS coronavirus in terms of how it may shift and change. We don’t know if this will become endemic, like influenza. But like influenza, as with SARS-CoV-2, our focus is to be able to optimize the overall health of the individual, to decrease the severity of symptoms, and to decrease the long-term sequelae, the downstream effects of having been infected. All crises provide opportunities. What do we have to learn from this and how can we do this differently?
In a public health perspective, we’re learning what we need to do to prepare. From a clinical perspective, we recognize that people who have complex chronic disease are the ones who are at greatest risk for the morbidity and mortality of COVID-19. Knowing this, and using risk as a factor to help motivate individuals, we have an opportunity. Our colleagues in other branches of medicine may not feel that they have a lot of ‘tools in their toolkit’. With functional medicine we say, “Here are a number of tools to help these patients. Our patients are out there, concerned about getting infected. We have a significant opportunity to decrease their risk of illness, decrease their severity of illness, and to improve them in recovery. This is a great opportunity. We are currently reaching out to various healthcare systems and letting them know about the tools that we have available.
We encourage them to apply these tools first to the healthcare workers on the front lines. Help them to be able to mitigate the risk, and assess how it works? We don’t have real-world data yet. We don’t have randomized control trials. We need to look at real world medicine and ask, “What works and what doesn’t work?” Thus, we need to gather the evidence to be able to understand which of these components work the best. The Institute for Functional Medicine is excited to be a part of the journey toward health and healing,