Why Treating Complex Illness is Like Rock Climbing: Special Series from The Cohen Center for Recovery from Complex Chronic Illnesses at Mount Sinai

Dr. Raven Baxter

Hello everyone. I'm Dr. Raven Baxter, your host of this episode of the Raise the Line podcast. I'm a molecular biologist and director of science communication at the Cohen Center for Recovery from Complex Chronic Illness at the Icahn School of Medicine at Mount Sinai Hospital. 

At the center, we work to advance treatment and knowledge of long COVID, tick-borne and vector-borne illnesses, myologic encephalomyelitis, chronic fatigue syndrome, and connective tissue disorders like hypermobile Ehlers-Danlos syndrome. Post-acute infection syndromes are characterized by persistent symptoms that last for months or even years after the initial infection has been treated. Many of these conditions are often misdiagnosed, leading to delayed treatment and prolonged suffering for these patients. And although we are making progress on our understanding of post-acute infection syndromes, there isn't a standardized treatment protocol for them. So, in today's episode, we have the privilege of hosting Dr. Leo Galland and Dr. Sunjya Schweig, who will join me in discussing their approaches in treating post-acute infection syndromes, and today we'll be deep diving into their methods. 

To introduce our guests, we have functional medicine physician Dr. Sunjya Schweig, who's dedicated his career to the pursuit of innovative and individualized treatment strategies that address the root causes of chronic illness as co-founder of the California Center for Functional Medicine. He has played a pivotal role in advancing the understanding of complex chronic diseases, including post-acute infection syndromes. Dr. Schweig's approach intertwines cutting edge scientific research with holistic health principles, striving to restore wellness by balancing the intricate systems within the human body. His work not only offers hope to those suffering from challenging conditions, but also pushes the boundaries of traditional medicine towards more comprehensive and personalized care. 

We also have Dr. Leo Galland, who is a New York-based internist and author who specializes in undiagnosed or difficult to treat illnesses. His practice combines conventional and alternative therapies. He's an award winning internist and his research includes nutrition, chronic allergies, leaky gut syndrome and Lyme disease. 

You are both very accomplished in your own right and extremely knowledgeable. I'm so excited to dive into the wealth of knowledge and learn about these innovative approaches to treating these complex diseases. So, to start off, this is episode eight of this series and so at this point, our medical student audience has heard about what post-acute infection syndromes are, what a diagnostic approach is to diagnosing what the patient is experiencing, and then also the various clinical manifestations of post-acute infection syndromes, ranging from cardiovascular to neuropsychiatric to, oh my gosh, joint pain and hypermobility. You name it, we've talked about it.

So at this point, we are now looking at treatment strategies. Being that there isn't a standardized protocol for treating such complex illnesses that really can prove as an interesting challenge to a treating physician. So, for the medical students listening, what does that look like for you? How do these present in the office and what is your first step? 

Dr. Leo Galland

Well, my first step is to really take a life history on the patient. The person is going to come in with a series of active complaints, and we want to know what that is. But especially if we're talking about a post-infectious condition, the infection usually represents a kind of boundary in time. Before they had this illness, they were one kind of person and since they've had this illness, they’ve become another kind of person, basically a patient. So, I want to know what was this person like before they had the infection? 

Now, often the patient just wants to talk about what's going on now. But I may go back to birth or before birth. I want to know what was this person like when this happened to them? That becomes really important to me. And I want to see how much of what they're experiencing now is rooted in problems they were manifesting or potentially manifesting before they got the acute infectious illness that they have. 

I also think that although we're talking about treatment, I think it's especially important for students to understand that all rational treatment starts with diagnosis. The problem is that the concept of diagnosis in which we're trained as physicians is very narrow. It's basically differential diagnosis, which is ‘what disease does this person have?’ That may work great in an emergency room or in a critical care situation. It does not work very well with a complex chronic disorder. 

I've been dealing with these kinds of problems for almost forty five years. In the early stages when I was doing this, I was in New Haven. Most of the patients that I saw had been going to specialists at Yale and I discovered that the more specialists at Yale a patient had seen without getting the help they needed, the more likely I would be able to help them. That didn't make any sense to me. It would seem as if the opposite should be true. And so I started thinking about that and I realized that they were really getting very good conventional evaluations with the specialists they were seeing but I was looking at all the things that hadn't been looked at and that I really was using the diagnostic process in a different way and I think that has to underlie the approach that we take to thinking about treatments. 

I came up with an anatomy of illness that recognized -- and I mean, I thought I was coming up with it...it turned out loads of docs for centuries had discovered this, but it was new to me -- that doctors are trained to recognize and treat diseases, but what the patient experiences is an illness, which is not the same as the disease. And with the anatomy of that I could describe through phenomena that I would call mediators, triggers, antecedents, events, and effects. The effects are what the patient brings in, what you're experiencing, what we see, but they're created by these underlying factors, and triggers and mediators are especially important. 

Mediators are anything that acts as an intermediary in creating illness. It could be a biochemical mediator, it could be a cytokine, or some combination of cytokines and prostaglandins. But it may also be social feedback and the effects of social interactions. The triggers are things that basically activate mediators, and in this case, we're talking about infectious agents. But most people with complex chronic illness don't have only one trigger. They usually have multiple triggers. And so you get the best results if you can identify and remove all of the triggers. 

That's kind of the first level therapeutically, is to think about what are acting as triggers and how can we deal with those and then go to the level of mediators. What are likely to be the mediators that link the triggers to the effects and how can we modify those mediators? Mostly we're trained to do it with drugs, but there are a lot of lifestyle factors and nutritional and dietary factors and mind-body factors that can modulate mediators. 

Dr. Raven Baxter

Thank you, Leo.  

Dr. Galland

So, that's a long answer to a short question. 

Dr. Raven Baxter

No, that was very insightful. Thank you. And Sunjya, what would you say about how patients present with these illnesses and what your first steps are in the treatment room? 

Dr. Sunya Schweig

So first of all, thanks so much for having us and thanks for having this conversation. Thanks to Mount Sinai and the Cohen Foundation for putting this on. And also thanks to all the med students out there who are watching. I just really appreciate that you are engaged with this concept and you're digging into this very, very important area. I respect that it's going to sound pretty complicated and sound very different from what you're learning in med school, so just keep an open mind and think through these problems because what Dr. Galland just spoke about and what we're talking about today and through this whole series is really, really critical because you are gonna encounter patients that you don't know what to do with and their symptoms don't make sense and their condition doesn't make sense because it doesn't respect the sort of more reductionist model of Western medicine where one problem has one specialist and one drug, ideally, because these are complex network problems and they're systems problems. 

What we see are multi symptom, multi system patients who, you know, will leave you with your head scratching and kind of your head spinning a little bit because at first, you won't understand that this is possible. But really what we're talking about is the fact that the human organism is incredibly elegant and complex and most of the time things work quite well. 

However, when enough things stack or there's a more severe insult -- and a lot of the times this is driven by hidden infections and therefore the title of this series of post-acute infection syndromes -- where somebody gets sick with an infection, whether it's a virus or a bacteria or a fungal or protozoan, a good subset of those people are gonna recover back to their normal baseline. However, there's a small, but significant group of folks who do not recover and who then go on to be sick for months or years or even decades. And those are the folks who are seeing all the specialists and then come to the offices of myself or Dr. Galland who are functional medicine, integrative medicine providers who are using more of a complex systems based approach. We're trying to then tease apart this complex ball of yarn of where do things go wrong? What's the priority of stack of triggers and antecedents and mediators like Dr. Galland spoke about? 

And then, if you're asking the question of how do we treat these folks, really we're looking for any and all levers we can pull on to try to get that body or that system back into balance. Absolutely, sometimes that is of course identify the bug. Figure out is this viral? Is this Lyme disease? Is this Bartonella? Is this Babesia? Is this H. pylori? Is this Giardia? You know, what's the bug or multiple bugs? And frequently we wanna address those bugs, but unfortunately it's not always that simple, right? Because now this person, they might have downstream gut issues or microbiome issues, they might have immune imbalance or autoimmune activation. They might be exposed to other toxins in their environment, including mold. They might have sleep disruption or mood disruption or psychosocial overlay on that. You know, how are their genetics filtering those, those insults? Do they have metabolic issues, hormone imbalances, inflammation, et cetera? I apologize, because that sounds very complex but the work we do is complex. 

So, from a treatment perspective, your goal is to identify and understand all the interplay and the network and the systems effect of all these things together. Identify as many as you can and just systematically work on them one by one and really to boil it down and make it kind of more simple. You know, the core lifestyle interventions are impressively powerful, right? So if you get someone's diet cleaned up, you get their gut cleaned up, you get them eating anti-inflammatory foods and drop out the sugar and the processed foods and the alcohol for a period of time -- we ask people to do that for thirty days up front -- that's incredibly effective for lowering inflammation, quieting down cytokines, getting the gut and the brain working better. You get people sleeping better. You have all the sleep hygiene tricks that you can ever think of. You get people doing some kind of meditation, mindfulness, brain training, which can help the body reset. You get them moving and exercising. Get their blood sugar balanced. 

All those are really foundational and can be done with zero cost, right? Just telling people those recommendations. So that's a really important starting place. And then advanced diagnostics. Understanding what tests to run and then understanding how to intervene on those tests is a really important next step as well. 

Dr. Raven Baxter

Absolutely. And so for many students, they're focusing on treating the symptoms. What would be your advice to a student who may be taught, ‘hey, address the symptoms versus get to the root?’ What kind of mindset shift does that require? 

Dr. Schweig

Yeah, I think you have to do both things at once, because the patient’s there in front of you and they are suffering and their goal is to start to feel better. However, as med students in training, as you go up through your career, you're gonna see that Western medicine is largely focused on the symptoms and that just treating the symptoms is not gonna be enough to resolve these issues for folks. 

In functional medicine, we think of the model of a tree and up at the outer leaves and branches of that tree are where our medical system works most of the time. You have all your specialists, you have medications which control symptoms...you know, let's give you a medication to lower your blood pressure, to lower your cholesterol, to lower your blood sugar, to block pain, to turn off the immune system. We're not always asking why are these things happening. We're just trying to control those symptoms. 

But what we're trying to do from a functional medicine point of view, and Raven, you used the word the root cause, we're trying to go down to those root cause inputs and figure out what's the starting place of this. And then how is that filtered up to the trunk of the tree, which is your genetics and your psycho-spiritual outlook and your family history, you know, the nurture side of things...like what did you experience? Did you experience trauma as a young person, et cetera? And then those become imbalances, which then again becomes symptoms. 

So from the patient point of view, you wanna work on managing what's right in front of you but you also simultaneously want to be working on the root cause because a lot of times, the symptoms are a common pathway to many different illnesses. And if you can work farther down the cause chain you're not sort of playing whack-a-mole as much and you're not just chasing symptoms but you're getting to the root cause of, is this inflammation? Is this immune disruption? Is this autoimmune activation? Is this a hidden infection? 

If you're just managing symptoms and you're not going after the bugs that might be persistent and driving a lot of this, you're never going to get full effect. You're never going to get full resolution of that case. Right? So it's, it's a ‘yes, and.’ 

Dr. Galland

One of the questions that I find really important is most of the patients who we're talking about will have seen other physicians and they'll have received other treatments. So one of the important things to find out is what specialists or what doctors or health practitioners have you seen? What treatments have you tried either through them or on your own and what's been your response to it? Because one way to look at the patient is as a kind of a standing wave that's vibrating. And if you can understand the person's response patterns -- this helped, but this hurt -- you start understanding the person better. 

How sensitive is this person to treatment? How likely are they to have adverse reactions? I mean, a lot of the patients that I see, are more likely to have adverse reactions to any intervention, whatever it is, even if it's an appropriate intervention, then they are to have the kind of therapeutic response that you'd anticipate from a textbook, for example. So that's important. It also is really important, and I still think we're not trained as physicians to do this, to ask people about what they eat and how they live their life. You know, how does your daily schedule go? When do you get up in the morning? What do you eat for breakfast? Do you eat breakfast? Do you snack? What are the foods that you eat? How is your body impacted? Do you notice any effect of eating or not eating or specific foods on the way that you feel? When do you go to bed at night? And who are the people that you interact with? 

Also, what's your home or work environment like? Not just in terms of a social environment, but a physical environment. Have there been leaks or floods at home? If you go away from home, you go on vacation, how do you feel when you're away from home? And then when you return home, do you feel differently? If somebody comes home and they notice that they're worse when they're home, well, let's take a look at what is it about being home that makes this person worse? Is it the stress? Is it the people they live with? Is it mold in their basement or their air conditioning system? So it's really important to go into the details of what makes you feel better or worse and how do you feel during your day? 

So, although we're supposed to be talking about treatment, these are all diagnostic questions, because in order to treat, you have to really understand the nature of the problem. 

Dr. Raven Baxter

Those are such comprehensive questions and it makes me wonder...in your opinion, is it more of the patient's responsibility to know that they should be asked those deep kinds of questions or is it really the physician's responsibility to do that? 

Dr. Schweig

That's a tough question. And it kind of gets to the heart of how our medical system works. Because to back up a little bit -- and we've seen this with COVID and with long COVID, and that's brought so much attention to this world of myalgic encephalomyelitis or chronic Lyme disease or chronic viral infections or chronic gut issues -- these people are unfortunately not well met by the medical system and they're not well seen by the medical system. They don't fit the box of primary care, internal medicine, family practice, pediatrician up to specialists. And also the medical system is just very busy and very time pressured. 

So these questions don't get asked a lot and the kind of net effect of that is I think that a lot of people start out their health journeys thinking, “Gosh, there's something wrong. I'm gonna go to the doctor. The doctor's gonna figure it out. They're smart.” Science and medicine almost has a godlike status for a lot of people in our culture. But then pretty quickly they realize like, this person, this doctor doesn't know what's going on. They don't know how to help me. 

In the best case scenario, that doctor's honest about that or they're at least they're, supportive and they say, yeah, I don't know what's going on, but there's something going on so let's try to figure this out. But unfortunately, way too often, the patient is made to feel like it's their fault or that they're crazy or that there's nothing wrong with them. The tests are “normal” and, you know, maybe they should go talk to the psychiatrist.

So, do these questions get asked? Not often enough and so as a med student out there, come back to the basics. Think about that. That's a great list of questions that Dr. Galland gave us. And you want to dig in because everything and anything is a possible trigger to that body. We're physical bodies, and all of our internal systems are constantly communicating with each other. We live in constant relationship with our environment and our environment absolutely affects us on all levels. Whether that's pollution or mold or diet or what you're drinking or your stress levels, and then all the things you're taking, you know, et cetera, et cetera. 

So all those questions become really critical. And even if you don't know what to do to help that person, simply by being open minded and understanding that these conditions exist and that even if you don't understand why someone is having all these symptoms, that it could be something real will be an incredible therapeutic gain for that patient, right? Because you're open-minded, you're willing to look for answers, you're willing to support them. And it's because there's a lot of actual medical trauma that happens with these folks, so that's a big important part of the treatment course, you know, is to really understand that and engage with that and just work as a collaborative team to try to get these folks some help. 

Dr. Raven Baxter

I want to dig deeper into that because I think that any patient would be very fortunate to be your patient. But the reality is that you aren't necessarily at the step of every process. You may refer out to a specialist who may or may not subscribe to the exact same treatment philosophy that you do. So speaking of medical trauma, what does that process look like? Because I mean, I'm trying to put myself in your shoes. I want to be very protective of the patient and make sure that the people I'm sending them to are in alignment with what our plan is, you know, as a primary, so what does that look like? 

Dr. Galland

Well, you know, you're not necessarily going to be able to find specialists. You probably will not be able to find specialists that think the way that we do. Would you agree, Sunya?  

Dr. Schweig

Yeah. 

Dr. Galland

But it is very helpful if there are specialists that you know who respect you and that you can communicate with. And what you want to do with specialists is you basically decide this is what I want from this specialist. There's some feedback, there's some decision, there's something that the patient needs from this specialist, so I'm going to refer the patient for that. If it's a specialist that you have a relationship with, great -- it takes a long time to acquire a network of people that you can have that kind of relationship with -- then you can interpret for the patient what that specialist is adding to the evaluation and the treatment. 

The first therapeutic step is that a patient needs to feel that you are listening to them, and Sunjya, you had alluded to that. That is so important. I mean, especially if you're starting out as a student, you don't have the experience or the knowledge of complex illness. Listening carefully to what the patient has to say. Yeah, I think it's really therapeutic on its own. 

Dr. Schweig

Yeah, I think that's right. And for all of you out there, you're in med school, maybe you have decided what you're gonna do for residency, maybe you haven't. Some of you are going to become specialists or maybe many of you are going to become specialists. And so I think that message is just ultra important because we talk about, you know, Munchausen syndrome, we talk about people making stuff up, and that does happen sometimes, and there is sometimes a psych overlay, but that's very rare. Much, much, much more common is the situation where these people are suffering from something which our medical system just doesn't have the box to diagnose or understand. We lean on tests as if they're the final word, but the tests are incredibly imperfect and can miss stuff all the time. And there's a much deeper topic to dive into. 

So I would go with the basic assumption that these people are suffering and they're not making it up and they need help and whether or not you know what to do to help them, as long as you're just willing to listen and talk to them and think about it open-mindedly, that’s key. Going back to your question, Raven, like, what do I look for in a specialist? I'm firmly of the belief that almost everyone who goes into this field of medicine is very smart; very, very dedicated; very service oriented; really coming from a good place. But things kind of get sideways a little bit because we have a very hierarchical system and it's very top down, you know, the knowledge dissemination from specialists down to the internal medicine, to family medicine, to pediatrics, to primary care, et cetera. So there does get to be a bit of ego involved. 

It's also a very stressful system. Doctors are under a lot of time pressure and just they're very overworked and they're burned out. And so it's just like, let's just deal with this quickly. Let's lock it down, let's start the treatment and let's, you know...onto the next patient. And so I think on the doctor side, when the patients don't feel heard, what the patient is not getting is that this person is just very busy and very stressed and maybe doesn't understand this, right? That's fine if you don't understand it, if it's not your specialty, if you don't end up getting into this work. 

But as long as you're willing to be open-minded and listen to someone and just use your brains and be smart and think, and don't just adhere to the algorithms that we're taught, that is the specialist that I'm looking for. And yeah, best case scenario is someone who understands this network systems effect. They understand a little bit about integrative and functional medicine and has a mutual respect, right? Because it goes both ways for the doctor and the patient. 

Dr. Raven Baxter

Thank you for that. I want to get into what you talked about of like going along with the algorithm. So, both of your approaches utilize alternative, non-conventional ways of approaching these treatment pathways for the patient. So one, how do students access that body of knowledge, you know, to go against the grain or think outside of the box? And then two, what challenges might they face in doing so from the medical community or just, I guess, in general? 

Dr. Galland

That's a hard question to answer. That is the acquisition of knowledge and experience. There are courses. I don't think there's any perfect setting in which to acquire the knowledge and experience and a lot of it, you're going to wind up acquiring on your own. 

I think that thinking for yourself is really important. Thinking critically. Not accepting what you're told as fact is important. I remember when I was in medical school, we were given an assignment to look at a textbook and then go to all the references that were cited in that section of the textbook and read the references. And I was blown away because what was in the primary research literature did not necessarily support the paragraphs that were written about that in the textbook. So at that point, I realized I'm not going to be able to really do the kind of work that I want to do if I rely on textbooks and I found the same thing with the abstracts of articles. 

You have to really get into the weeds. You have to really want to know the data to really understand what you're dealing with, with patients. And you have to embrace the complexity and the individuality of illness and if that's not for you, then this kind of work isn't for you. I mean, there are a lot of useful and great things that you can do if that's not for you, but your personality has to really suit the needs of dealing with complex chronic illness. 

Yeah, a certain amount of perfectionism and really wanting to understand what's going on here.  This is a lifelong commitment. I mean, this is a calling.

Dr. Schweig

Yeah, you have to be a “why” person. 

Dr. Galland

Right. A why and a how, you know?  

Dr. Schweig

Why and how? Why is this happening? 

Dr. Galland

Yeah. And questioning. Always questioning. You know, like a real pain in the butt kind of person is what you've got to be. 

I want to just second one of the things that you said, Sunjya, which is about accepting that these patients are not crazy. When I first started working with patients with complex chronic illness, I had taught for a few years. I had gone into a rural medicine practice for a few years because I thought that was something that I needed to reorient myself to. And then I joined a place in New Haven called the Gazelle Institute of Human Development and I had done a year's fellowship in behavioral medicine and so my expectation was that I was going to really deal with the behavioral and mind-body aspects of chronic illness in these patients.

What really surprised me was so many of the people that I saw who were chronically ill had great family lives. They had a really supportive social structure. They were very proactive. They had really taken measures to try and get control of their health and they still were sick. They were still stuck. And I realized this is not about psychology. Yeah, psychology is really important. In fact a cognitive psychologist once said to me, “What you do is psychotherapy without ever mentioning psychotherapy. It's psychotherapeutic to have someone try to help you problem solve in a proactive way.” But I was really impressed with how what I was seeing in chronic illness was not the result of psychopathology. It might create a lot of stress, but there were just so many layers that we needed to deal with. 

Now, in terms of like, how do you start out when you're talking to patients? I think some of the questions that I wanna answer is I do want to know what is the family structure like and how much support are they getting from the people they care about? Are there people who love them and whom they love? How isolated are they? How connected are they? And that's very important prognostically, if not diagnostically, because the people who have the best outcomes are generally the people who have the best social support and who are the most proactive in their outlook and who get the best reinforcement, the most positive reinforcement from the people that they interact with. So that is an important aspect of the person. It does not really explain the diagnosis. It explains the prognosis of the illness. Would you agree with that, Sunjya? Is that what you see? 

Dr. Schweig

I would, yeah. Yeah. It goes deep. I mentioned trauma. If you haven't heard about what's called adverse childhood events or the ACE score, I would encourage all the students out there to just type that in and you can find a symptom questionnaire and you can get a score, there’s a website on this, there's just tons and tons of research on this. Looking at early life trauma and how that then affects a variety of different immune and cortisol pathways and risk of autoimmune illnesses or chronic infections or complex chronic illness. So that's really important. And then I would encourage you to give it to all your patients too and start to understand, you know, historical trauma versus current life support and how that affects illness and all the social determinants of health are incredibly important. 

I'm just going to run through a little bit of a list that I jotted down, Raven, to your question of how do you learn more about this? I think that Dr. Galland’s points are great. However, you don't have to say, “Okay, I'm just going to go full bore and do this as my career.” Even if you're just willing to read something here and there, even if you're willing just to look at an article here and there, if you're willing to listen to a podcast or if you're willing to maybe pick up a book that someone has written, that will so deeply inform all aspects of how you practice medicine that it will be invaluable even if you are a neurosurgeon or you are an OB-GYN. 

So some resources: Chris Kresser has a great website, tons of blog posts, tons and tons of podcasts on great topics. Dr. Galland has books. Mark Hyman also has a ton of resources on his webpage whether blogs or also great podcasts. We have a lot of resources on our webpage. The Institute for Functional Medicine, IFM is a great resource. They've been in this for 30 years. I will give the caveat that people talk about it being like trying to take a sip from a fire hose. You're basically being blasted with information when you go to one of these conferences. It’s very informative, but it's frequently more in the theoretical side, so how do you translate that to Monday morning when you come back to practice, et cetera? But they do have virtual modules now where you can get that dripped out and, you know, work on that over time. 

I’d also point out the American Academy for Advancement of Medicine also has a ton of great content. There's another functional medicine training program called the adapt practitioner training program that was originally started by Chris Kresser. You can just go to PubMed and type in, you know, insert name of condition here and type in vitamins or nutrients or type in autoimmune with intestinal permeability and conditions and you'll start to really understand how all these things are linked together. So do a little bit at a time and just as you have time, as you have curiosity. I think one of the main challenges is time. You know, you're busy, you are working hard. There's an incredible demand on you for what you have to get through. 

How I did it when I was in my undergrad at UC Berkeley -- I was in med school also in California, at UC Irvine, and then residency at the UCSF Santa Rosa family practice program -- is basically anytime I had an elective or I had a project or I had some discretion on my time, I would choose to do it with an integrated medicine provider or functional medicine provider or research, i.e. how are vitamins and nutrients associated with this condition and then present on that. 

So, there's a lot of ways to do this. I would just encourage you to don't be overwhelmed. Understand the importance of these issues and understand all the things we've been talking about today and just try to jump into it little by little because the value to you and your patients will be immense. 

Dr. Galland

You know, there's something that I learned from sports psychology, which is that if you're a novice at a sport, you learn best from positive reinforcement. That is, what did I just do that was right? And you build on that. So you build on positive experiences. Once you get to be experienced and seasoned, you actually learn better from negative reinforcement. What did I just do that was wrong? What could I have done better? But to begin with, when you're starting out, what are those things that feel positive to you, that are satisfying? 

Dr. Raven Baxter

Gosh, well, you all make me want to hang up my career as a molecular scientist and go and be an MD! Very inspiring. Thank you! 

Dr. Galland

Molecular science is really the basis for what we're doing, though. Molecular science is really important. 

Dr. Raven Baxter

That's how I got here. I just kept asking “why” until I got to the molecule and couldn't go any deeper than that, unless you want to be a quantum physicist.  

Dr. Schweig

Nice. I love that. 

Dr. Raven Baxter

So before we leave off, I do feel like our conversation was comprehensive, but I definitely want to ask you all, is there anything else that medical students should know about functional medicine and treatment approaches to post-acute infection syndromes that we haven't talked about yet. 

Dr. Schweig

Yeah, one of the big things I would say would be, again, I alluded to it, but the testing is helpful, but what I frequently tell patients is, you know, a positive test frequently means there is a problem, but a negative test doesn't rule it out. So ‘yes is a yes and a no is a maybe.’ So, just because you have a negative test result on a patient doesn't necessarily mean that that pathogen is not there and is not driving some issues.

The place that this is probably the most controversial in our medical world is with Lyme disease and tick-borne infections because the testing that we have is very imperfect and there's a lot of debate on whether or not these bacteria can persist and cause chronic infections -- which really in my world and for doctors like us, I don't think there actually is a debate. It's been proven and it's been proven at the animal model level with the work of Monica Embers at Tulane showing persistence of Borrelia infection in a rhesus macaque monkey model. But our current tests can't find those bugs very well.

So understand that the tests aren't perfect, but that the story in front of you, the person talking to you is really the source of truth. And then really the next source of truth is what happens when you try things, right? The art of medicine is understanding what's possible and what some of the possible differential diagnoses are or the pathophysiological mechanisms. Then, as you try different things and over the course of your career, you'll start to get your own pattern recognition because the data from the patient is one thing, the data from the test is another, and then treatment data is another. What happens to the patient? Do they get better? Do they get worse? What's the outcome? And if they're getting better, keep doing it. Keep trying those things and keep iterating on those and following that lead because when you're in this post-acute infection syndrome world, it's a little confusing and it's kind of complex and it's a little bit of smoke and mirrors and so you have to sort of put the clues together. You become like a detective, right? A medical detective. 

We talked about algorithms. Sometimes that's hard to do. There are some ways to learn some of these algorithms in this world, but a lot of the times we're learning as we go and COVID has been a huge learning curve for a lot of us, but some of the basic algorithms that we work on at our clinic is you know, get the patient in, do a very comprehensive set of tests, looking at all different biomarkers through regular labs -- whether nutrients and vitamins and CBC and inflammation markers and thyroid and hormones, et cetera -- and then also do infection testing, looking at viruses and looking for reactivation, looking for gut pathogens, and then do some functional medicine testing on the gut microbiome and the hormones, and then put that person through treatments based on those, like we talked about. 

But also intervene with their lifestyle and get them working with a nutritionist and a health coach and put it all together. We call it an onboarding deep dive. But really the goal with that algorithm, if you will, is to try to target, like we've talked about, as many different body systems as possible. 

Dr. Raven Baxter

Thank you. And Dr. Galland? 

Dr. Galland

Yeah, I think that's a great description. A couple of things...when you're dealing certainly with any kind of so-called post-infectious state, the number one question is, is there an ongoing persisting infection that needs to be eradicated? And the testing is, as Dr. Schweig said, really imperfect. 

Sometimes a person's history of how they've responded to different treatments is helpful. I mean, someone says, every time I take an antibiotic, I feel so much better or maybe they say, I feel so much worse. What does that tell us? What does that historical response of this person tell us about what's happening in their body? And if you try to repeat that, what happens? Is it consistent? Or was that something that may not be relevant right now?

One of the images that I use, and I sometimes will use this with very difficult patients, is this is a lot like rock climbing. That is, you're looking for toe holds and finger grips that you can move to get from where you are to the next level. And you often can't pull all the levers at once. You've got to work through in a systematic, rational, sequential fashion to get from where you are to where this patient wants to be. And it is really important to have a goal and to understand what the patient's goal is. 

Dr. Raven Baxter

Thank you so much. I learned so much. I'm very inspired and I know that the students watching also will be well-educated and inspired. Well, yes, it's very clear that your approach to treating post-acute infection syndromes is very essential and plays an important role in the patient experience and I'm hopeful that students listening will take away some strategies to try out in the treatment room. 

Thank you again for your time, Dr. Schweig and Dr. Galland. I will see everyone for the next episode of Raise the Line. Thank you.