insights

In this video interview, two experts in the Functional Medicine approach to gastrointestinal issues discuss how they are able to help patients. Interviewer Robert Rountree, MD, has decades of experience applying Functional Medicine to patients with a range of conditions and difficulties.

From Vincent Pedre, MD, IFMCP, you’ll hear the story of how his personal struggles with digestive health informed and inspired him to work with patients in new ways.

TRANSCRIPT:

Robert Rountree: Hi, I’m Dr. Bob Rountree, and I have the great pleasure today of interviewing my friend and colleague Dr. Vincent Pedre, who has been practicing in New York for a number of years—in New York City. He’s trained in internal medicine, and he’s also trained in Functional Medicine.

Vincent Pedre: Yes, I am.

RR: He wrote a book called The Happy Gut. So tell us about that. How have you come to focus on the gut, and why do you think the gut is so important for health?

VP: It’s funny, because I grew up with IBS [irritable bowel syndrome], and for a long time, I just felt that that was just my normal. I just thought I was the canary in the coal mine. I couldn’t eat like my older sister. I would joke with her and tell her, “You have the iron stomach, and I inherited the sensitive stomach.” But in the end, it’s turned into my greatest gift, because it got me interested in gut health.

When I was in my early days of practicing internal medicine, I felt that when I spoke to a patient about gut issues, I thought, “Oh my God, this is like some amorphous…” Like it might have been in the blob. I didn’t know, how do I approach a patient?

I didn’t have a systematic way to approach it.

And I was also suffering from my own sensitive stomach issues until I discovered Functional Medicine. And I learned then I had already discovered some things; I knew I was sensitive to dairy. I was lactose intolerant, but I didn’t realize that gluten was an issue until I started studying Functional Medicine. I treated myself as patient number one, fixed my gut issues, and realized that the normal—[what] I thought was my normal—was actually not normal.

When I started feeling better, I just turned around and started working with patients. I thought, well, this is a lot of fun.

RR: I could apply this stuff.

VP: I can apply it. And you can make the patients better. I thought, you know, this is a really fun place to start for me because I had chronic diabetics, other chronic diseases, and I thought, “Well, in our Western paradigm, does it ever get better?”

In Functional Medicine, we’re flipping it around. Western medicine is looking at it from, “Okay, how do we treat the symptoms?”

Functional Medicine is, “Let’s lift the hood up. Let’s look under the surface. Let’s find out what’s going on at the root of the matter. And then let’s fix that.” And then the entire system fixes itself.

I thought it was so much fun to finally understand how to work with gut patients that I started with one of my most challenging cases. She was my patient number one, and that became my multi-month project.

I just started expanding from there, and before I knew it, friends would refer friends would refer more friends. And one day I woke up, and I’m like, “Oh my gosh, like I’ve become a gut expert without planning it.” You know, an accidental gastroenterologist that doesn’t do procedures. But I understand how the gut works functionally, you know, something you can’t see in an imaging study, and it just built from there.

RR: It’s functional gastroenterology…

VP: That’s what you could call it.

RR: Now is it… for people that might not really understand what Functional Medicine is all about, can you elaborate on how you might approach a gut-related problem versus how a gastroenterologist might approach exactly the same problem?

VP: Well, first off, in Western medicine, the average patient visit is seven minutes. That’s pretty scary, because in seven minutes, there’s no way that you can dive deep into the underlying issues that are going on with a patient. A typical intake for me with a gut patient is [going to] be an hour long. I need that entire hour to cover everything that’s been going on with them.

Because to me, it’s about building the story, and that is a foundation of everything.

Within that story is a timeline of how their symptoms started:

• How old were they when the symptoms started?
• What were they eating at the time?
• How did their diet evolve over the years?
• How does food affect them?

Then it’s always really essential to understand:

• How many times have you been on antibiotics?

You have to go back to childhood and find out—and what types of antibiotics, if they know, because most people, they don’t know. But we know that Cipro [ciprofloxacin], for example, is going to wipe out the gut flora for 12 months.It’ll take it 12 months to recover.

And I was a victim of that, because I was on Cipro multiple times when I was a child, so I had completely wiped out my microbiome. I understand what that does.

Then a travel history is always really important. I think that’s one of those things, if you have limited time, you’re not gonna be able to get into “Oh, five years ago, I went to Africa…”

RR: …and things were never the same.

VP: After that trip, things were never the same. That’s what I’m looking for.

It’s that inflection point. You know, when is it that things shifted for people?

I have a patient recently that I diagnosed with SIBO (small intestinal bacterial overgrowth), and his story was, “I was fine until I went to the gastroenterologist because I had acid reflux, and he put me on a PPI, and he left me on it for six months. It was six months in,” he’s like, “I started not feeling so well.”

But you have to make the connections between things that you might not have learned yet. Or maybe your mind isn’t making those pattern connections. That’s why you need the time to be able to ask all the questions and get every single detail, even if it doesn’t seem like a detail that is important at the moment, it might be a detail that you’re [going to] need to understand the whole picture.

RR: The first step is to take a really extensive history. I mean, we were taught that in medical school, right? But as soon as you get out of medical school, the exigencies of your practice take over, and it’s five minutes.

VP: Again, it’s the viewpoint. The patient that goes into the Western doctor, and I know because that’s how I trained. From the first minutes they open their mouth and they’re talking to you, you’re thinking, “Okay, what drug can I prescribe? What can I give them for their symptoms so that this visit can be over and I can go to my next patient because I have 30 patients to see.” It’s horrible to think that way, but that’s really how, over time, you get trained.

You have to turn it around and say, “Well, let me sit there with a person and hear their stories.”

So, yeah, you’re going back to what we learned in medical school. Like taking a thorough history that you knew when you were a third-year medical student. Somewhere along the way, you just went into all these short cuts, and then you forget. That’s the one thing that patients will tell me when they come in. I will have spent more time with them than a specialist.

RR: Did they seem surprised when you spent that kind of time with them?

VP: The patient that comes in from the regular model, you start asking them questions, and they rush through 10 years of history in two sentences. And I’m like, “Whoa, Whoa, Whoa, like you just skimmed over a huge amount of your own medical history and gave me very few details. Let’s go back. Let’s start here. Tell me about this. And then let’s go here and tell me more about this.”

That’s the difference.

But I feel like a lot of what we do in Functional Medicine is really digging through the history.

I think of it as looking for the stones that weren’t turned over, like I want to look under each stone and see, okay, what type of bugs are there? What did somebody else miss?

You know, part of the privilege of what I do as a functional gut specialist, even with my internal medicine background, is I see patients that saw other doctors. I have the benefit of learning from what was missed. Because I can ask the question, “Okay, this is what they did, the patient’s not better. How can I look at this differently?”

That’s also very basic medicine. There’s a book by a Harvard doctor talking about that very question, why diagnoses are missed. It’s because when you’re in the room with the patient, you’re not asking yourself as the health practitioner questioning them, “What else could be going on?”

RR: Is that [Jerome] Groopman’s book, How Doctors Think, or something like that? They jump to conclusions…

VP: You’re jumping to conclusions really fast, and you’re not asking the question, “Okay, maybe I’m going with my bias, but what else could be going on with this patient that maybe I’m missing?”

RR: Let’s take irritable bowel syndrome, for example. Let’s contrast how, say, a gastroenterologist might treat somebody with irritable bowel syndrome versus what you would do. You already mentioned that:

• You do an extensive history.
• You look at the timeline.
• You look at things like foreign travel, or whether they took antibiotics.

What kind of things may you do?

VP: This may shock you.

RR: I’m ready to be shocked. Yes.

VP: I ask them what their diet is.

And I can guarantee you that 99% of gastroenterologists are not. They’re not asking [about] their patient’s diet. I’ve had patients come from gastroenterologists that told them that diet has nothing to do with your symptoms.

Now, just think for a moment… when I was a medical student and a resident, I just always thought, you know, what is the commonsense approach? If you’re putting all this stuff through this really long intestinal tube with a surface area that is—the small intestine is the size of a tennis court, and then the large intestine, and that is your biggest exposure to the outside world—is through what you’re putting through your mouth—how could that not be significant? And what is going on there?

Diet is really key.

I go into the details of the diet. I learned early on… Taking a diet history is challenging because patients don’t always tell you…

RR: They don’t remember…

VP: Or they don’t tell you the truth because they don’t want you to know. I used to ask general, like, “So what do you eat?” And then I found, you know, they’ll answer, “I eat this and this.”

Then I realized, you know, it’s better for me to ask them, “Take me through a day in your life.”

• You wake up. What do you drink? What do you eat?
• What types of breakfasts that you eat?
• Okay, then do you have a snack after breakfast, between breakfast and lunch?
• What is your typical lunch?

I found that when I go into that level of detail, I get more information about what the patient is doing.

Then, if I feel that I’m not getting good enough information, I send them home with, imagine that, a food diary. I have them log their eating for 7-14 days, because usually, you know, they might want to tell you what they want you to hear. But as they’re doing a food diary, after the first two days, things start to break down, and they start going back to their natural eating habits, which is what we want to see. I don’t want to see the ideal. I want to see, ‘What are you doing?’ Because that’s why you’re here to see me. Then we need to analyze what is wrong with that. And how can we improve your diet so we can improve your IBS symptoms?

RR: You already mentioned gluten. Are there other foods that you say, with irritable bowel syndrome, are really typical? So when you’re doing these diet histories, what’s coming up for you? What are some things that are not so surprising, and what things really surprise you?

VP: We have gluten, dairy, corn, and soy.

We have to think about something that is not a food per se, but it is ubiquitous everywhere, and that’s sugar.

Sugar is really problematic.

Our understanding of sugar, and what I should say, patients’ understanding of what is sugar, is really varied. They think when you say sugar, “Oh, I don’t eat dessert, but I eat bread, pasta. I eat all sorts of packaged…” Or if they’re gluten free, maybe they’re eating gluten free bars that have 18 grams of sugar.

RR: Or high fructose corn syrup.

VP: High fructose corn syrup, yeah. Just recognizing where sugar is hidden. I call it the sugar impact foods, or foods that don’t obviously have sugar, at least from the patient’s perspective, but it’s causing a sugar impact, and that can cause yeast overgrowth. It causes an imbalance in the gut bacteria.

Then you have to think about things like legumes as well, because of lectins. Lectins are inflammatory. They can irritate the gut lining. And then food additives.

RR:

You know what strikes me is that you’re a detective.

You become a bit of a detective, like you’re turning over stones and you’re looking for things that people haven’t thought of before. Like not the obvious things.

VP: But with the understanding that there is something to find.

RR: Right, and it’s not just something to treat. It’s something to find.

VP: There’s something to find, and part of what we do in Functional Medicine is we remove the toxins. We remove the burden on the body, and the philosophy is if you remove this burden in the body, and give it the right nutrients, the body has a chance to heal itself.

You see a lot of associations with IBS, so typically, an IBS sufferer may suffer from migraines also. We know there’s a connection between migraines and food sensitivities. Not that it’s all clear because, you know, everything is multifactorial, and that’s the other part of the approach is that it’s a systems-based approach…

I tell patients that it’s a puzzle, or it’s a pie, and there’s all different pieces to that pie. We call it the matrix in Functional Medicine. But I find it’s easier to explain to the patient that there’s different pieces to the pie. Some pieces are bigger, so we need to address those.

But if we don’t address all the smaller pieces, then you’re not [going to] achieve the total result that you want. Those smaller pieces can be things like:

• How much are you sleeping?
• What are your stress levels?

Looking at mind-body connection, IBS patients tend to be anxious. They tend to be type A personalities like I was when I was a kid. I changed that through meditation. I go into, you know, what other lifestyle modifications can we work on? We want to increase parasympathetic activity in the body, relaxation.

RR: Rest and relax.

VP: Rest and relax, and that could mean meditation for one person. That could mean going on a hike out in nature for another person. We know that sitting out in nature lowers cortisol levels, [which] increases parasympathetic input. It changes your physiology by being out there and communing with nature.

So I try to help people find what speaks to them, because you want your patient to do what they’re [going to] be motivated to do. If someone’s not a meditator and they’re not open to that, you’re not [going to] get them to do that.

It depends on where the person is able to meet me. That was part of, you know, understanding the approach with an IBS patient. You want to start not where your ideal is. Because now that I’ve been doing Functional Medicine for a long time, I can think of this broad approach that I want to do with the patient. But I recognize that you have to start simple for people. Within that, you need to identify, ‘Where is the person at right now, and what can they do as a first step?’

RR: …to meet them.

VP: You meet them where they’re at. And you realize this is not a sprint, this is a marathon. And we’re running it together. If you can communicate that to the patient,

I think this is the most satisfying relationship that a doctor can have with a patient, is going on that journey with them.

Not that episodic type of care for symptom management that happens in Western medicine.

RR: Terrific. Well, I think that’s all we have time for today, but I really want to thank you for your insight. It sounds like you’re saying it’s a whole different ballgame.

VP: It is.

RR: Yes. Thank you.

References

1. Bhalodi AA, van Engelen TSR, Virk HS, Wiersinga WJ. Impact of antimicrobial therapy on the gut microbiome. J Antimicrob Chemother. 2019;74(Suppl 1):i6-i15. doi:10.1093/jac/dky530