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What I learned in my third year as an integrative medicine physician

I was scrolling through social media when a picture popped up from five years ago: it was taken after I practiced my last clinical shift in the ER—January, 2018:


Dr. Angelo Falcone and Dr. Noah Keller
Me and Dr. Noah Keller on my last day as a practicing emergency medicine physician

Seeing the photo led me to reflect on that life transition from a craft I honed for 25 years. As I have often said, I loved being an ER doc. The ability to walk into a patient’s room, quickly gain someone’s confidence, and communicate that I was here to care for them and would do what I could to ease their pain or anxiety was beyond gratifying. It was something in which I took great pride and was pretty good at doing.


Whether it was a newborn child in distress or someone at the end of their life, I had the knowledge and skill, along with a great team, and most importantly compassion, to deal with the myriad challenges that walked through the door.


When I decided to change course and practice integrative medicine it was not without a fair amount of thought and consideration. Now that I am approaching three years of having practiced holistic/functional/integrative medicine, I am struck by the very different kind of impact I can have on people.


This year I have been struck by a few realizations in particular: 

  • There is a dire need for a different approach in healthcare

  • Nutrition continues to be the most important pillar of the 4 pillars 

  • A defined set of baseline lab testing is enlightening

  • Functional genetic testing is changing how I structure plans


There is a need for a different approach in healthcare

Every time I see a new patient I am struck by the difference of what I did for 25 years and what I am doing today. Spending 2 hours speaking with a patient and hearing someone’s life story is both humbling and powerful. I have been privileged to hear about childhood traumas of abuse and how that impacted a person’s mental and physical health for years. How being dismissed by the traditional healthcare ‘system’ has impacted a woman’s (typically) search for the cause of her fatigue and joint pain led to finding Hashimoto’s disease worsened by multiple food sensitivities. How the challenge of managing chronic obesity led to yoyo diets and medications which temporarily helped but did not get to the root cause. 


These patients and many others have reinforced for me the ‘for every problem we have a pill’ approach to health care is not working despite the latest TV ad which aims to cure your psoriasis with the latest biologic. When I take a structured approach focused on the 4 pillars of 

  • Nutrition

  • Movement

  • Sleep

  • Mental Resiliency 


The results when taking an integrative medicine approach are often remarkable. It is not uncommon for patients who come to see me to have a combination of problems: gastrointestinal discomfort, headaches, anxiety, fatigue, joint pain.


This combination of symptoms, in our traditional health care system, might get you a referral to a gastroenterologist, neurologist and psychiatrist, each one addressing their area of expertise. I greatly respect the deep knowledge specialists have. But I’ve also been struck by the fact that being able to rebalance the microbiome, replace vitamin deficiencies, and add focused effort on movement and mindfulness activities can have a remarkable impact on multiple symptoms. 


A growing number of patients also are coming to see me to address Medicine 3.0. It is a term coined by Dr. Peter Attia regarding an aggressive, proactive approach to addressing issues that impact healthspan and longevity. Taking a deliberate approach to address issues today to assure you are in your best health in 20-30 years is an exciting area and one I am privileged to join as a practitioner.


Nutrition is the most important pillar

When I began my practice I knew nutrition would be a cornerstone of my practice. What I did not appreciate was the degree to which I would need to provide dedicated expertise to help patients achieve optimal health. It is one of the reasons I have partnered with Amanda Appelbaum to assist my patients on their journey. Having deep knowledge and training in nutrition is an invaluable asset. Nutritional modifications are a key component of many of the health plans I develop. 


Some are struggling with weight, metabolic syndrome, pre-diabetes, type 2 diabetes or chronic inflammation. These patients need someone to guide them in their journey and understand that the only sure path to success is ongoing support and long-term behavioral change. This happens over several months of intensive work to gradually change the dynamic between nutrition and health. 


Just as frequently, I see patients with chronic gastrointestinal issues and more seeking our services to assist with SIBO (small intestinal bacterial overgrowth). It is a frustrating condition that requires persistent efforts to rebalance and repair the microbiome and find the right food regimen for long term success. 


Finally, it is common to find patients with chronic inflammatory conditions like chronic joint pain, Hashimoto’s thyroiditis and others to have a strong nutritional component. It is a sad statement on the overall status of our food system when the foods we eat are often the source or contribution to some of those issues. 


A defined set of baseline lab testing is enlightening

It is very common to find significantly abnormal lab testing on my patients. I recently wrote a piece on some of the lab tests I perform, and why they are important (link here). While most people understand basic testing such as blood counts and electrolytes there are common abnormalities I find such as:


  • Vitamin D – important not only bone health but numerous other systems including immune system regulation. One of the most common supplements I prescribe. 


  • Vitamin B12 – It is common to have low B12 levels especially as we age. There is a known association between low B12 levels and fatigue as well as mood disorders such as depression. Simple supplementation often corrects this imbalance.  


  • Ferritin – A storage form of iron and important as a cofactor for many metabolic processes. It is more common than I expected for younger people (woman more than men) to have low ferritin levels which can contribute to fatigue or mildly low red blood cell size. 

  • CRP – C reactive protein is the ‘canary in the coal mine’ warning about high levels of inflammation in your body. While it is not specific to any particular organ it is often a reflection of an overactive immune system. The cause of which may be multi-factorial. 

  • Homocysteine – A marker for the effectiveness of how your body utilizes folate (vitamin B9) and a biochemical process called methylation. When elevated it can be a risk for blood vessel inflammation and is often a sign of a need for methylated folate and possibly B12. 


The ability to have a more comprehensive picture of your biochemical processes is an important component of optimal health. Following these levels over time ensures these imbalances are corrected through proper nutrition and supplementation. 


Functional genetic testing is changing how I structure plans

In the last few months I have started to do functional genetic testing on my patients called 3X4 Genetics. It is one of a new type of tests released over the last several years which deals with identifying various genetic variations and how they impact multiple body systems. These types of genetic tests used to be very difficult to run and certainly expensive but the technology continues to improve and the price is quite cost effective. We all carry genetic variations which impact mundane processes like how we metabolize caffeine to how we handle cholesterol synthesis or deposit adipose tissue in our body. 


The insight it provides is quite remarkable including overall genetic tendencies toward inflammation, oxidative stress, blood vessel clotting, specific nutritional needs and numerous others. It can even answer the question as to why someone is chronically hungry despite eating a normal number of calories or why someone responds better to resistance training vs endurance exercise. 


The evolution of these tests allows for more personalization of specific plans for overall health and longevity. The combination of standard lab testing, microbiome analysis, genetic profiling and personal biometrics through Apple watches, Garmins, Oura Rings, Whoops as well as advanced consumer biosensors like continuous glucose monitors are allowing a quantam leap in personalized medicine. It is an exciting time to be practicing in this space. It does mean absorbing a tremendous amount of learning on the clinician’s part. The next frontier of AI tools like ChatGPT and Bard will no doubt push this envelope of personalization even further. Exciting times indeed for clinicians and most importantly for patients. 


From the entire team at Dignity Integrative wishing you’re the best this holiday season to you and your families. Here’s to your optimal health in 2024.


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