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At the end of medical school, I had to choose one of forty-two specialties: one part of the body to devote my life to.
Separation defines modern medicine. Starting from my first year of medical education, I funneled from a broad perspective on the body to increasingly narrower and narrower ones. When I picked a premed major in college, I left the study of physics and chemistry behind to focus solely on biology. In med school, I memorized all the facts on human biology, no longer focusing on other biologic systems like plants and animals. As a resident, I was focused on performing surgeries on one specific area: the head and neck, and thought little about the rest of the body.
Had I completed five years of that training, I would have been eligible to zero in even further on a subspecialty within that specialty. I could have become a rhinologist (focused solely on the nose), a laryngologist (focused solely on the larynx), an otologist (focused solely on the three tiny bones of the inner ear, plus the cochlea and eardrum), or a specialist in head and neck cancer (among other options). The primary goal for my career would have been to become better and better at treating a smaller and smaller part of the body.
If I were really good at what I did, maybe the medical establishment would even name a disease of a body part after me, as they did for the dean of Stanford Medical School-a world-renowned otologist named Dr. Lloyd B. Minor, who focused his entire career on about three square inches of the body. In the condition named after him, Minor's syndrome, microscopic changes in the inner ear bones are thought to lead to various balance and otologic symptoms. Dean Minor represented a physician's ultimate model of success: stay focused on your specialty and climb the ladder. You also protect yourself that way: for the average clinician, staying in your lane ensures you don't incur liability for incorrectly treating something out of your scope of practice.
By my fifth year, I was the chief resident in otology, a subspecialty of head and neck surgery, focusing on those three square inches of the body around the ear that control hearing and balance. I frequently saw patients like Sarah, a thirty-six-year-old woman who visited the otology clinic gripped with intractable migraine, with attacks occurring more than ten times per month. Since dizziness and auditory symptoms can be a feature of this debilitating neurological condition, sufferers often find their way to this specialized department as they make their way through a labyrinth of providers. After a decade of bad migraine episodes, Sarah's world had shrunk dramatically in scope. As she was living on disability and largely housebound, her existence revolved around her condition. She was so light-sensitive that she always wore wraparound sunglasses and walked with a cane due to her inflammatory arthritis. A support dog always stood by her side.
Reviewing her hundred pages of faxed medical charts, I discovered she had seen eight medical specialists in the past year to address a larger cluster of persistent and painful symptoms. A neurologist had prescribed medications for her migraine attacks. A psychologist had prescribed a selective serotonin reuptake inhibitor (SSRI) for her depression. A cardiologist had prescribed hypertension medication. A palliative care specialist had prescribed additional remedies for the unremitting pain throughout her joints. Despite all these interventions and medications, Sarah was still suffering.
Carefully paging through the documents, I felt stunned. What could I possibly offer this woman that she had not already tried?
As part of my routine migraine intake questions, I asked if she had had any success with trying a migraine elimination diet. She had not heard of it. That surprised me. Printed handouts on that very subject were readily available in our clinics to give to patients like her. But nutritional intervention hadn't registered as important enough for my colleagues to mention. Instead, she had been sent for testing, undergone expensive CT scans, and was prescribed psychoactive and other medications-one on top of the other. She visibly balked when I described the hopeful possibilities of a diet that would eliminate migraine trigger foods. If such a mundane thing as food could have helped, her body language suggested, the medical professionals would have told her long ago. She wanted to try another medication.
Sarah's case was not the first time I had encountered such a scenario. Patients often came in with stubborn cases of chronic disease, toting stacks of paperwork. But Sarah was cruelly young for this amount of suffering, and she'd bounced between so many different specialists so quickly that her case made the system failure especially upsetting. She was sick and getting sicker, living with not just one chronic illness but multiple ones. Unbeknownst to her, but evident to me, her life span was almost certainly shortening. She was frustrated with the care she'd received, yet she was still reliant on it-clinging to it, even.
I tried to hide my discomfort. How could I dole out another prescription without encouraging Sarah to try some simple strategies with significant data to back them up? My stomach churned at the knowledge that another prescription drug would not be the magic bullet that would radically change her life. She and I could go through the charade of engendering hope in a new medication, scheduling a follow-up six weeks out to see how it worked, and leaving our meeting feeling satisfied that we'd done the best we could. But at some level, we both knew a "medication deficiency" was not why Sarah had illness expressed throughout her entire body.
I could do what the other doctors entrusted with her care had done-and what I was explicitly expected to do: name the condition according to symptom-based criteria, rule out serious life-threatening issues, attach a prescription, input billing codes, and move on. That would be practicing respectable medicine. But Sarah, and the other complex cases like hers, made me want to work differently, to look upstream, and question why those symptoms might be there.
Peeling Back the Layers: What Causes Disease?
Invisible Inflammation: Everywhere, All at Once
When in doubt, always start by asking questions. And the obvious one in Sarah's case was the following: Were her different conditions so separate after all, or did something connect them that my colleagues and I couldn't see?
Looking through her labs, I noticed one of her inflammatory markers was high. I vaguely recalled learning in med school that this marker was high in conditions like diabetes and obesity. I noted that Sarah also had inflammatory arthritis. Chronic inflammation was at play here. So I asked another question: Could inflammation have a role in causing migraine? Surprisingly, a quick PubMed search offered over a thousand scientific papers connecting the two.
I knew well that inflammation refers to the swelling, heat, redness, pus, or pain created when immune cells rush to a site of injury or infection. All these symptoms are helpful: they indicate that a robust and coordinated defense is occurring to contain, resolve, and heal damaged or endangered tissue. The immune system is always looking for anything foreign, unwanted, or injurious and will jump to respond this way within seconds of detecting something wrong. After the problem is resolved, the immune system turns off the inflammation, and everything returns to normal. The heat, redness, swelling, and pain go away.
But Sarah's physical checkup and other lab markers were confounding. She had no injury, no overt infection I could see. Nothing was temporary about the phenomenon in this case. Her inflammatory response was switched on-and left on-to the point that it was causing collateral damage to her body. Why would the immune system stay so activated and remain in such a persistent state of alarm and defense-chronically inflamed-outside of acute situations, even to the extent of causing collateral damage to the body's tissues?
When I reflected on what I was treating as an ENT surgeon, something struck me: it was almost all inflammation. In medicine, the suffix -itis means inflammation, and our practice was made up of sinusitis, tonsillitis, pharyngitis, laryngitis, otitis, chondritis, thyroiditis, tracheitis, adenoiditis, rhinitis, epiglottitis, sialadenitis, parotitis, cellulitis, mastoiditis, osteomyelitis, vestibular neuritis, labyrinthitis, glossitis, and more. I was an inflammation physician, and I didn't even realize it! As an ENT, my job revolved around putting out inflammation wherever it appeared in the ear, nose, or throat. Often the process included using oral, nasal, intravenous, inhaled, and topical anti-inflammatory medications: Flonase spray, compounded steroid nasal irrigations, prednisone creams, IV Solu-Medrol, and inhaled nebulizers of steroids-all kinds of things to address the immune system getting so revved up in these bodies.
Suppose the medications failed, as was the case with my sinusitis patient Sophia. In that case, we might go to the next level in surgery: creating holes in a patient's body to reduce obstruction caused by inflammation and let inflammatory fluid drain. Sometimes we would intervene mechanically to force the anatomy out of the way of swelling. We might insert tubes through the eardrum to let fluid drain, drill through the skull bones to release trapped pus, or insert a balloon to enlarge an airway narrowed by chronic inflammation.
The medications and surgery would temporarily turn the inflammation off or minimize its effects-like subduing the invader with a tactical jujitsu move to the floor-but the tissues would often swell again or the pus would collect once more in whatever area was blocked. It wasn't in our job description as medical professionals to look for why inflammation kept returning.
But once I began peeling back the onion, the whys wouldn't stop. Why were the immune systems of my patients like Sophia and Sarah so chronically revved up? Why were cells that should be healthy sending out "fear" signals to recruit helper immune cells to come to their aid? I couldn't see or detect an obvious threat like a cut or an infection, nor could my patients. So why were these cells so frightened on the microscopic level?
I reflected on Sarah's labs and the inflammatory marker that I knew was strongly associated with chronic diseases like diabetes, obesity, and autoimmune diseases. And suddenly it struck me. Could all her symptoms-not just those under my purview as an ENT-be driven by inflammation? Is one mechanism driving so many different disease states? Was every part of her body responding fearfully to the same invisible threats? From my point of view today, that truth seems utterly self-evident. Research has shown that chronic inflammation is a crucial instigator of all kinds of diseases and conditions outside of the ear, nose, and throat-from cancer and cardiovascular disease to autoimmune diseases to respiratory infections to gastrointestinal conditions to skin disorders to neurological disorders. Yet it was not part of the institutional medical culture to focus on those connections nor to go deeper to ask why all that inflammation is there.
Then I began to realize how much I knew. Ever since I had fulfilled my required histology coursework and gazed at hundreds of slides of human tissue and flesh under a microscope, I had been in awe of the nearly forty trillion cells that make up the human body. I felt awe at their complexity and tiny importance as life's very foundation and how all that we are is a collection of cells. They hold so much information inside. Each cell is a little universe of buzzing work and activity. And the result of all that activity, simply put, is our lives.
Our cells cannot talk or tell us what they fear. But incredibly, if we look from the perspective of the cell, the answers to the whys are there-complex, yes, but not nearly as baffling, complicated, or specialized as some might want us to believe.
After I left my position as a chief resident at OHSU, an opportunity for discovery opened before me. Free to fill the gaps my conventional education had left-and feeling infinitely healthier and more energized-I excitedly leaped into advanced training in nutritional biochemistry, cell biology, systems and network biology, and functional medicine, expanding and revolutionizing my understanding of health and disease. I got to know dozens of physicians who, like me, had exited prestigious institutions in pursuit of better medicine in the quest of learning to help patients actually heal rather than be managed. Reinspired and reinvigorated, I soon opened a small medical practice in the Pearl neighborhood of Portland, happily settling into a coworking space with sunny windows and many plants. I let a few friends and colleagues know I was doing something different: instead of offering sick care, I focused on generating health. Instead of managing diseases from the pinnacle of medicine as an esteemed surgeon, I would work to restore and maintain good health from the pyramid's base, via having deep conversations and creating personalized plans. Together, my patients and I would build the foundations of a solid and healthy body from the ground up. Word got out: my schedule was quickly full.
Many patients came to see me with clusters of chronic and intractable-seeming conditions like Sarah's and Sophia's. But this time, we started treating the problem from a different place: the foundational cellular level. I put the onus on giving the cells what they needed to do their jobs and removing what was blocking them, with a focus on nutritional changes, lifestyle changes, and overall cellular support. The results my patients achieved were different, too-often, transformative. Stubborn problems-weight gain, lousy sleep, unshakable pain, chronic conditions, high cholesterol, and even reproductive issues-began to resolve, sometimes in weeks, sometimes months. Inflammation began to disappear, never to return. Patients often reduced, and even eliminated, their medication regimen. Hope and optimism about what life could feel like returned in the dedicated people I was fortunate to help. Often, the results came from doing far less. They occurred from doing the opposite of what I had always learned, which was to add the next medication and add the next intervention.
I learned many things through practicing medicine in this new way. Not the least was that inflammation-which leads to disease, pain, and suffering-takes root because core dysfunctions occur inside our cells, impacting how they function, signal, and replicate themselves. Something became blatantly clear: if we truly want to restore general health in body and mind, we must look one layer deeper than the mechanism of inflammation alone and into the very center of the cells themselves.
