Cleveland Clinic Opens Center for Functional Medicine: An Interview with Patrick Hanaway,MD

The Cleveland Clinic has collaborated with the Institute for Functional Medicine to bring the functional medicine model to the masses. The Cleveland Clinic Center for Functional Medicine—the first of its kind in a large academic and clinical setting—endeavors to provide clinical services, research, and education to both patients and providers. In this profile, Patrick Hanaway, MD, medical director for the Center for Functional Medicine, shares the evolution and patient-centered approach of the Center. Dr. Hanaway is also the chief medical education officer for the Institute for Functional Medicine, in Federal Way, Washington.

Jane Hart: Dr. Hanaway, you have extensive experience in the field of functional medicine. How did your interest in this area of medicine evolve?

Patrick Hanaway: When I attended medical school, I thought I would learn about how to help people be healthy. I quickly realized, however, that the curriculum emphasized a pathophysiologic and pathologic focus in terms of what patients were experiencing. As a result, I began to learn about nutrition on my own and with other students, and we learned about what “food as medicine” really meant. I spent 3 months of my last year of medical school in the Nutrition Division at the Centers for Disease Control and Prevention (CDC) and worked for 2 months offering health-promotion services in a federally funded community health center. These experiences fueled my interest in how we begin to change health and health policy through nutrition, health promotion, and good clinical practice.

Applying a holistic systems approach in patient care and working with multiple therapeutic modalities to help people has been important to me since my residency training and during my work with the Yu'pik Native Alaskan people people on the Bering Sea. However, it was not until my wife and I started our own family practice in Asheville, North Carolina, in 1999, called “Family to Family: Your Home for Whole Family Health,” that we were able to design and offer a set of services to people that was truly taking a systems view and a holistic approach in medicine. This began the deepening of my understanding of what is now called functional medicine.

In 2002, I began teaching and working with Genova Diagnostics, in Asheville, and that was my entrée into the Institute for Functional Medicine. I began to teach for the Institute, as well, and now serve as its chief medical education officer. Through all of these experiences and over time, I have observed that functional medicine has gained traction in medicine because this approach has a unique operating system, and provides a way in which clinicians can apply their knowledge from integrative medicine and other fields and bring them into an organized framework. The functional medicine approach allows clinicians to be able to work with patients in a very specific way, focusing on levels of dysfunction to guide a person back to health and well-being. This approach has gained momentum to a tipping point at which the Cleveland Clinic has now created the Center for Functional Medicine.

Dr. Hart: How did the Center for Functional Medicine at the Cleveland Clinic evolve, and how have things been going since the opening in 2014?

Dr. Hanaway: About 2 years ago, Mark Hyman [MD], director of the Center for Functional Medicine at the Cleveland Clinic, had a meeting with the chief executive officer and president of the Cleveland Clinic, Delos “Toby” Cosgrove [MD]. Dr. Cosgrove wanted to know more about the functional medicine approach and began to inquire if this approach could help to shift the cost curve and provide truly “value-based” medical care. Dr. Hyman believed clearly that functional medicine provides a “value-based” solution, which could help a variety of people with complex, chronic diseases to achieve healthy outcomes. Dr. Cosgrove was interested in this concept and felt that this was an innovation for which the Cleveland Clinic could become a leader. As a result, we put together a business plan to provide a Center that would include three arms—clinical care, prospective research evaluating value-based care, and innovations in educating clinicians from medical school through residency training, as well as continuing medical education.

The Center for Functional Medicine opened in October 2014, with 1 full-time physician, and another half-time physician seeing patients, as well as 2 full-time nutritionists. At this point in time, we have had more than 1200 visits, and we are booked for the next 6 months. We are currently interviewing more doctors and nutritionists to meet the demand.

The model is such that we have a nutritionist for each doctor in our department. When the patients come in, they are seen by the medical assistant and then a physician who sees them for a 75-minute visit—to evaluate all aspects of their lives and understand their stories—and then makes recommendations for diagnostic testing, medications, nutritional supplementation, and nutritional and/or dietary recommendations. The dietitian then works for the same amount of time with new patients to develop specific nutritional plans and coaches the patients over time to help them continue with their goals. The patients are also seen by a nurse, and we have a full-time health coach who meets the patients and motivates and supports them in behavior change. This is a true team approach.

It's important to point out that the nutrition consultation and health coaching are not optional add-ons, but rather are integral parts of patient care. This is so critical, and this is true on the initial visit and also for the follow-up visits. Nutritional support is a key aspect in all of the therapeutic recommendations that we make.

Nutritional support is a key aspect in all of the therapeutic recommendations that we make.

Dr. Hart: What gaps does the Center for Functional Medicine fill in terms of patient care, and what has been the response of your colleagues?

Dr. Hanaway: As clinicians applying the functional medicine model, we look at complex chronic disease from a perspective that focuses less on the specific disease and more on discerning the root cause(s) underneath what is occurring. For example, people who come to our clinic may be experiencing symptoms related to migraines, asthma, diabetes, or autoimmune disease. The question is: “What are the drivers underneath these conditions?” This then leads to a series of additional questions such as: “Are there significant stressors in this person's life? Are there nutritional issues? Infections? Could toxins be mediating the underlying problems?

As functional medicine clinicians, we individualize care by identifying why an individual is manifesting symptoms in a specific manner. We listen to the patient's story to be able to understand what are the root causes, antecedents, triggers, and mediators of disease, and to learn how to use the tools that we have to treat those underlying causes.

Patients who we see in the clinic are both self-referred as well as being referred by clinicians whose patients' conditions are not responding to therapies. In addition, we are developing a series of prospective research trials including studies regarding patients with type 2 diabetes, migraine headaches, asthma, and inflammatory bowel disease. We are also developing a program for people who are in the employee health plan to help those with significant disease burdens improve their overall health status as well as decreasing their cost of care.

The majority of our current patients are from Cleveland and Northeastern Ohio, and the remaining patients are from the upper Midwest, including, the Cincinnati, Pittsburgh, Chicago, and Detroit metropolitan areas. We also have a few people coming from across the United States and even from other countries. This really is a milestone, in terms of having a designated Center for Functional Medicine in a large academic and clinical setting. It is the first of its kind.

Dr. Hart: How will the Center for Functional Medicine best serve as a resource for clinicians and patients, and which populations or conditions are most amenable to a functional medicine approach?

Dr. Hanaway: The clinical care that we are offering is of great value to the community both as a training ground for physicians who are developing skills in functional medicine, and for providing patients access to a functional medicine approach through an insurance-based model. In terms of populations and conditions that we see in our clinic, we are seeing some of the sickest patients. In the functional medicine approach, we think much less about disease and much more about the severity of illness that is going on in an individual. It does not matter what the disease is per se; rather, what matters is the patient's motivation to be able to work with us and make changes in his or her nutritional and other lifestyle behaviors.

Typically, we see patients who suffer from fatigue, and fibromyalgia, and who have autoimmune diseases of many different kinds. These are probably the biggest areas of focus. Then we also see a subset of people who want to lose weight or need help with managing diabetes or prediabetic conditions.

Dr. Hart: Please share some specific examples of how you might approach the treatment plan of a person who comes to the Center for Functional Medicine.

Dr. Hanaway: Each treatment approach is personalized based upon imbalances that are identified, and then the team determines the dietary, nutritional, and supplemental support that will best benefit each patient. We do not treat each person that comes in with asthma, for example, in the same way. The operating system—what we refer to as the functional medicine matrix model—begins by gathering information through an extensive intake, and then we plot the information we gather along a timeline. That timeline looks from the preconception to prenatal stage and throughout the entire course of the patient's life to find what are the antecedents and predecessors of that patient's disease? We ask: “What are the triggers?” “What are the specific precipitators and perpetuators of the disease?” Then we begin to organize all of the information in the setting of various types of clinical imbalance, whether they are in the gut or the immune system, or energy production, detoxification, hormone metabolism, transportation, or structural integrity. Each of these domains within functional medicine is then used as the means to be able to tell the story back to the patient. As mentioned previously, we are not focusing on the disease; we are focusing on the person and the person's story. By understanding that story, we can begin to determine the specific tools that are going to help that person get better.

To Contact Dr. Patrick Hanaway

Patrick Hanaway, MD

Chief Medical Education Officer

Institute for Functional Medicine

505 S. 336th Street, Suite 500

Federal Way, WA 98003

Phone: 828-713-1553

Fax: 253-661-8310

E-mail: patrickhanaway@fxmed.com

Website: www.functionalmedicine.org

Medical Director

Cleveland Clinic Center for Functional Medicine

Cleveland Clinic Main Campus

9500 Euclid Avenue

Cleveland, OH 44195

Phone: 216-445-6900

Fax: 216-636-3074

E-mail: functionalmedicine@ccf.org

Website: www.clevelandclinic.org/functionalmedicine

Then we begin to make recommendations based on the person's story. We utilize a particular order of treatments through which we work to be able to bring the person back toward balance, as we initiate therapies and track them. For example, a person with severe asthma may be helped significantly by identifying inflammatory triggers in the diet. We would work with that patient to identify some of those triggers and help him or her change the diet as well as offering nutraceutical support. Anti-inflammatories, such as fish oils and curcumin [Curcuma spp.], in a specific formulation may be helpful, as well as utilizing glutamine to help address mucosal-integrity issues.

However, therapies that we consider include not only medicines, nutraceuticals, supplement support, and dietary change, but also attention to other important lifestyle factors. We evaluate stress and resilience, sleep and relaxation, exercise and movement, social support, relationships, and purpose. We take a holistic perspective on integrating lifestyle change and want to ensure that our recommendations will continue to be maintained.

Dr. Hart: What do you hope for the future of the Center, and do you expect that the Center will serve as a model for other academic centers to follow suit?

Dr. Hanaway: Our approach in functional medicine is to take a personalized, systems-oriented approach. We want to empower patients to find an optimal expression of health and well-being. This is just good medicine. In working with some of the wonderful researchers and clinicians at the Cleveland Clinic in the Headache Institute or with the endocrinologists or gastroenterologists, we are all working toward the same thing; that is, healthy patients. Our greatest opportunity lies in demonstrating the efficacy of the functional medicine approach through continued research. In addition to that, we serve as a training ground for individuals, and we also serve as a model that can be reproduced in other Centers of Excellence around the country.

In fact, what we are doing is pretty “old-school”–spending time with our patients and listening to their stories, gathering their life histories, and determining genetic–environmental–lifestyle interactions that affect long-term health and/or the development of complex chronic disease. We work with diet, exercise, and lifestyle change, and we help patients to cope with their stressors in life and support these patients so they are able to overcome exposures to toxins, infections, and allergens. We are practicing medicine in a way that allows us to focus on those things that can have the biggest impact on the health of each individual. Functional medicine is providing value-based care…one healthier patient at a time.   ■