Cardiology and the Functional Medicine Approach in Academic Medicine with James Carter, MD

- Around the world, many dedicated clinicians are practicing functional medicine in all types of settings, from rural family medicine to emergency medicine at the largest institutions. Today's guest began his career as an interventional cardiologist, practicing in a large academic medical institution before finding functional medicine, and changing his entire approach to medicine and his relationships with his patients. But despite this shift, he continues to practice cardiology at a major academic institution, all while working inside the insurance model. - I could just walk into a space and be present and listen. And that's been transformative for me. And it turns out that it takes less time to listen than to talk. So people think that they can't do it because there's not enough time. And I find that not to be true. I can find out a lot about a patient in five minutes if I just stop interrupting them. - I am IFM Medical Director of Medical Education, Dr. Kelechi Uduhiri. And on this episode of "Pathways to Wellbeing," we welcome Dr. James Carter to discuss his experiences integrating functional medicine in an academic medical setting, his vision for transforming medical education and why he sees functional medicine as not just needed, but imperative for the future of medicine. Welcome to the show, Dr. Carter. - Thank you for inviting me. Did I say all that Dr. Uduhiri? That's pretty bold statements, I don't know. - Well, that's why we're having this conversation. We'll keep it going. So really, it's so great to see you And thank you for joining us today on this podcast. Maybe we can begin by talking a bit about how you got involved in practicing functional medicine. I believe you started your career as an interventional cardiologist, is that right? - Yeah, I mean, it depends on how far back you want to go as the start, you know, as a functional medicine- - We got time, we got time. - As a functional medicine doctor, we tend to think about things going way back and planting the seeds. So I probably would go back, you know, to my great-grandmother having the courage to move from South Carolina to go to Brooklyn, New York and find her way and then grab her brothers and sisters to join her. Perhaps to my mother who was obsessed with the power of words and my father who was a hardworking civil servant who spent 30 years in the New York City Police Department before retiring as a lieutenant. So I don't know how far back we should go, but I think I always understood context. And back when I was in undergraduate school, I was a sociology major interested in resistance to change and systems, believe it or not. I was too young and naive to really understand what that could mean in the future and how much it would eventually impact my medical career. But I actually started out in general cardiology at University of Chicago. And then I did an interventional fellowship at University of Maryland long ago enough that it was only a few years after the first angioplasty had ever been done in humans. And I actually was in community practice most of my career. So I was out in the real world trying to create change. Back then, my concept of change was, can't we change this yesterday? And so I was pretty pushy about trying to do things the best way to relieve suffering. And I just saw a lot of suffering. And a lot of it was truly heart and vascular. Patients who not only had heart attacks and strokes, but were suffering from limb loss. And I always felt disconnected from our terminology about that in medicine, having the nerve to call something a minor amputation, and somehow we're supposed to communicate that to patients. So I was really dedicated to try and prevent people from losing their limbs, ending up on dialysis, in addition to saving them from heart attacks that occurred suddenly. So I did that most of my career. And then back in 2017, I actually went back to academics. So I started practicing functional medicine and weaving that in, even before I went back to academics. - I love that. You know, what I heard was the word context because that is so fundamental in how we approach patients in functional medicine. But before we get into that, I'm sure our listeners want to know, based on context, why cardiology? What attracted you to cardiology, that specialty? - Truthfully, it was a guess. I wanted to have an impact. I liked the biology of it and that it affected so many different systems and organs. And I was not sure until my first day as a cardiology trainee, and then I was sure. - Oh, wow. - But up until that, and I had done some research back in the day, research that actually resonates now. It was early work on heart rate variability, believe it or not, back in 1989, 1990. And I was very interested in the parasympathetic nervous system and its impact on the heart way back then. - That's interesting. Yeah, because it's always interesting to see, because now as a functional medicine, you know, physician, everything begins there. The heart is so vital, like the impact of the gut to the heart, all that is so vital, right? It drives all the systems as well. So, and I know that your transition to practice in functional medicine was not exactly easy. Can you share about your experience attempting to integrate functional medicine into your practice in a major academic institution? I love that story. - You know, when I got to a major university, I actually had sent them a letter about who I was that I identified as a functional, an interventional cardiovascular doctor who practiced functional medicine. And they clearly forgot that I wrote that. Once they saw me practicing, they were concerned because I wanted to talk to the patients before I did procedures on them and examine them and get to know them a little bit. And I importantly focused on nutrition and inflammation. And I remember being told to stop doing that directly. And I actually hid it for about a year. I put a whiteboard up in my clinical exam rooms and I would draw out pathways and the explanations to patients, you know, first steps, what they could do with nutrition. And when they would come back, I'd write down victories and barriers and it was great. And then I would have them take out their smartphone and take a photo of it. So they would have documentation because I told them I'm not going to put it in the record. And I asked them not to tell anybody I had the conversation with them. - My goodness, my goodness. - But they told people anyway. So my practice grew because obviously, it's good care. - Great. - And so... But the real secret was I was practicing wound care. And I felt that if I could get a wound to heal because of the overlap in the biology, then I was lowering cardiovascular risk. And that was my secret. And so I was dedicated to healing wounds. Some people had been suffering for literally decades with open wounds, and we would just use the functional medicine approach. And eventually, I started to get consults for what they called that functional medicine thing he does. They would wave their hands like, this is Dr. Carter, he says this functional medicine thing. I don't know what he does, but the patients get better. - It must be working. - It must be working. So that was it. - Now, before we, there was a lot to unpack there, a lot. So, you know, this is gonna be fun. The first thing you said that they were concerned, right? Because you were talking to patients, you were bringing up nutrition, you were trying to consider how to prevent disease. And then the next thing that came up is you had to hide it for almost a year. You know, your patients knew, but you couldn't put that in the EMR. As all that was happening, what was going through your mind about the state of our healthcare system? - I don't know that I was thinking about that at that time. I was thinking about not getting fired again. - Fair. So my goal was to not get fired. So I had to figure out how to do good work without getting fired. And it turned out that the work would start to speak for itself. I didn't have to do anything. And then I did start to think about the impact, what it meant for healthcare, because I also needed care. And as I had my life-threatening challenges, I could see it from the other lens. I was always pretty sensitive to that anyway, but then really being thrown into it, you could see the inherent deficiencies. I had two open heart surgeries and never ate a hospital meal, not one time, not one bite during two hospitalizations. So I think that tells you how I felt about the state of healthcare in our institutions. - Absolutely. And as you were going through your own personal health challenges, how did that impact the the care even further that you gave to your patients? - By that time, I was pretty sensitive to considering what the patient's voice was like and making sure I understood their perspective and their context and their decision-making. And it gave me probably more impetus to lean more into that, I guess. And I felt pretty strongly that the functional medicine principles saved me, starting with nutrition. And nutrition is not about weight. People get confused. It's about cellular metabolism and warding off inflammation and trying to get that balance of antioxidant versus oxidation, that balance that we need that some people called homeostasis. And I started to just see it more in practice and understand that there were not, patients don't read the textbooks. So they present in their own unique ways, a lot of times based on their past and their present context of living. So I think I became a better doctor, I know I became a better doctor when I got trained in functional medicine. And as you're alluding to, I'm pretty sure I became a better doctor when I was fortunate enough to have survived. - And in your training, on your journey towards becoming a better doctor because of functional medicine, what was the one key thing from your functional medicine training that contributed to that, becoming a better doctor? What was it about that training? - Go to it. - Explain that for us, Dr. James. - I no longer felt like I had to drive the experience of the therapeutic encounter like I was trained to do. And the more I learned, the more I became comfortable with biological knowledge and societal knowledge, I could just walk into a space and be present and listen. And that's been transformative for me. And it turns out that it takes less time to listen than to talk. So people think that they can't do it because there's not enough time. And I find that not to be true. I can find out a lot about a patient in five minutes if I just stop interrupting them. - It heightened your bedside manner. Is that accurate to say? - Yes, I had good bedside manner before. At least that's what patients told me. And I think that was true, but it did make it a lot better. Now it's, you know, it's very good because of that skill that I've developed. It took a while though. You know, new trainees, people who are just experiencing this, I think they're afraid to do it, and I was. And you just have to, you know, put that toe in the water, put that foot in the water, and just go for it. And eventually it become pretty easy. - That's interesting. There's two parts to that that I'm hearing, you know, that go to it acronym, the T is for tell, one of the T's in this for tell, tell the story. How do you use that in your practice? What does that mean to you? How do you show up in that telling part of the patient's story? - You know, you wouldn't think that that question would be so important, but it really is because I don't just repeat the story back. I analyze the story as it's being told to me. That's why I remember it. Because as it's coming through, I'm watching them, I'm listening, I'm listening for what they don't say. I'm watching how they interact with whoever they're with. And I tell the story back to them and I add a little bit of creativity, sometimes drama to it. You know, and I'll say, I will ask first, I've learned to ask for permission. I didn't know to do that early in my career. So I will ask, is it okay if I tell you what I've heard? And they say, yes. Sometimes they keep talking. They say, no, let me keep going, which is interesting. And then I'll tell them, you know, I hear that this has been your experience. And what I gained from that is that it's affected you this way. And that's what led you to have this other experience, and so I layer it and it becomes richer and it's easier for me to remember. And the patients mostly seem to benefit from that. - And what did they say to you? What did they say? How did they respond to all, to that retelling of their story? - Sometimes they cry, not uncommonly, they cry. Sometimes they bawl. It's a little hard, you know, sometimes for even me to see that. And they just said, "You heard me." That's the most common thing they say is, "You heard me." And they were stunned. "You really heard me." - That is so beautiful. And let's tie that back to something you said earlier, which is fear. Your trainees, they're afraid to do that, you know, they're afraid to have that kind of experience. Where's that fear coming from, Dr. Carter? - I can only say what a few have shared with me. Mostly, it seems like it's a fear of standing out as different from peers. Some of it is a fear of having to learn it because it's not easy at first. So it's just one more thing on people who are, you know, I do that with a resident or a fellow, they're trying to learn all these facts and then I add that piece. I think that is a little difficult. I think it's mostly fear of being different though. - Being seen as an empathetic doctor? Why are we afraid of that? - No, no, not that. I think being seen as someone who didn't ask the 10 questions they're supposed to ask in the sequence they're trained to ask it. And so when they have to go in front of someone and or someone's observing them, what are they going to do? They can't say, well, Dr. Carter does it this way. It's not gonna work. - It's not gonna work when they leave Dr. Carter's presence, okay. - But I think there's a little bit of a fear of failure because it looks hard. It looks harder than it is. But I have had many trainees say that, what I just saw is why I went to medical school. I wish I knew how to do that. - That is so beautiful. Absolutely, you know, I think we believe that we were actually gonna help people get better. And of course, we do a lot of times, but there is still some barriers there to doing it the way we think it really should be done well. So thank you for what you do and how you embody that and how you're teaching that next generation of doctors to also embrace that process, the approach of really listening to the patient and learning how to tell that story back. I think that is so powerful. What does your current practice model look like? And how are you navigating the insurance model while practicing functional medicine? Because a lot of times I hear that it is hard to do that in a 15-minute, 20-minute appointment, but you've given us some insight that it's possible. How do you make it happen? - Navigating the time or which piece are you talking about? - All of it, you know, well, just share how the model looks right now, how your practice model looks like. - I'm still a cardiologist. I have a staff appointment with the Heart and Vascular Institute here, and I see that practice is growing as the word is getting out that I take this approach. I still see general functional medicine type patients, so patients who have all sorts of concerns. We have an hour for a new patient and 30 minutes for an established patient. I'm told that's not enough time, but usually that is plenty of time. It is not enough time if we have the agenda to be as frank as I can be. So, if our agenda is, I want to make sure I touch on every aspect of the functional medicine matrix today, even the ones that you're not concerned about and aren't bothering you. And there's enough time in my experience to see most patients within that time frame. And we bill based on my training. I'm board certified in internal medicine, cardiology, and vascular medicine. So I bill as that. And I do think that functional medicine should be for everyone. So I resisted the urge. I'm not criticizing anybody who has, you know, cash pay practice, but I wanted to see how we could do this for everyone. And so we have Medicaid patients, Medicare patients, private payers, cash payers, we get a mix. Yeah, that's how we do it. We do have a collaborative team approach. So we have registered dietitians, we have health coaches, we have holistic psychotherapists, and we lean on their expertise a lot. So I tend to give it to them more than I used to where I was before because I didn't have that. Before I would do all the nutrition work, I would do all the health coaching. And most of my practice was really coaching back then. But now, I can give that to experts who have health coaching abilities and are experts in nutritional science. and I can keep seeing new patients that way and seeing the ones who have other concerns as well. So I like that model for us. - That's great. And so, it's not just cardiology for some here and functional medicine for others. Are you able to blend the two at the same time? - Everyone who sees me knows I'm a functional medicine doctor. - All right. - So we also have shared medical appointments. So we have people in groups and we try to care for them that way. But no, I don't have the separation that I used to before where, this bucket was only conventional cardiology. Now it's who I am. Everyone knows it. I don't shy away from it. - That is so beautiful. I'm so happy to hear that. And are you getting inquiries from your colleagues, other, you know, clinicians to teach us how you do this thing together? - Of course, tomorrow I'm giving a mini symposium on lifestyle modification for cardiovascular risk for trainees. You know, I was asked to do that, they know who I am. And you know, it's good medicine. - Yes, yes, so you no longer have to ride it behind the door and clean up real quick and have the patient take a picture with a cell phone. - No, I don't do that anymore. - That is a wonderful, wonderful. Wow, I love this because, you know, a lot of the times we hear that it is hard to practice functional medicine in a conventional type model. But from what you're sharing with us today, it seems that that is absolutely possible. - Well, the American Medical Association believes that systems-based medical practice is the way to practice. Health system science is a thing. We're training medical students in health system science. In fact, it's a mandatory part of undergraduate medical education now and a mandatory part of graduate medical education. So I think there's some misconceptions about what we do in functional medicine. There are, you know, conceptions that it's just a bunch of testing that no one knows how to interpret and a bunch of supplements that people have to pay for. But I don't think that's what it is. And I think it's understanding the intersection between social context and biological vulnerability and promise. - Yes, absolutely. So define that again for us, because the way you practice it should be the way that we do this, right? It shouldn't be for some and not for others. So in your mind, what is functional medicine? - Functional medicine is an analytical framework to explore what the body is trying to do for resilience, for function, for recovery, and for optimal performance. And to identify what has shifted that and to come up with a collaborative plan to shift it back with the patient. - I think that's the best definition I've heard ever. - That's good 'cause I just made it up that same day. - I'm sure my team- - You are recording this, right? - Yes, you'll get a transcript of your own words. That was beautiful. And then, you know, something you said just now was about the social drivers. You know, you put a lot of focus on the social drivers of health and how that impacts patient's health and their ability to heal. How do you meet patients where they are and help them succeed with their health goals, either you or your team? - So, I don't meet patients where they are. - Hmm, all right, tell us more. - So I am told I should, but I don't. I meet patients where they have expressed they want to be. - Big difference. - I'm not telling you it's right. I'm just telling you what I do. I don't believe in when a patient's suffering to say it's okay for them to take a year to make a change. I believe in telling them the truth that if they want to get better, these are the necessary steps. And then I do ask them if they'd like to get better, if they want to participate. And I don't judge if they are not able to, but I'd still tell them the truth, that it's the only path. I don't make believe there's another path from that. if someone's only eating ultra processed foods three times a day and they have an open wound, they're not going to heal. If they miraculously do heal, it'll come back. So I just don't believe in that. I believe in telling people the truth. With kindness, you know? - Yes, yes. Which of great bedside manners. Yes. All right, so you don't meet them where they are because you meet them where they have expressed they wanna be. And then you challenge them from there. - No, I just tell them the truth. - Tell them the truth, okay. - Sorry to interrupt. I'm sorry- - No, no, no, no, no. I'm processing it myself. Because a lot of the time- - It's a subtle difference. - Yes, it is. - Maybe it is meeting them where they are, but sometimes, I'll tell you what I mean by it. Sometimes in a visit, I won't go past why they are here to see me. Sometimes they can't tell me and I won't go past that. And I don't go past assessing readiness for change and what they're willing to do. In fact, I tell this funny story with this one patient and his wife. I asked him, "What are you willing to do to get better?" And he couldn't answer me. And finally said, "You know what? I'm leaving. I'll be back in five minutes." So I set the timer on my watch. I said, "You guys talk, I'll be back." So I got up and left the room. And I came back and sat down. I said, "So, have you thought about it?" He says, "Yes, I've thought about it. I'm willing to do whatever it takes that's necessary for me to get better." I said, "Okay, let's talk." - Yeah, absolutely. - And it turned out he had major nutrient deficiencies. I mean, unreal, scurvy. He's a grown man, a businessman. - Yeah, that's the power of this approach, right? Is you're processing what they're saying and you're understanding what needs to happen and then you're sharing the truth and all of it with them and they need to make a decision. - Yes, and I understand some people are not ready to, that's fine. I will say, "Well, that's okay. This is this is the things we discussed. Next visit, we'll discuss more." Okay, so I can come back in three weeks, you know? You need to talk to your friends and your family and everyone needs to decide. You need to figure this out and then come back and talk to me, and we'll see. And then they will. I gave them that grace to, it's not fair to dump that on them, right? So it's okay, if they're not ready. I'm not saying it's not okay. It's okay, if they want to wait. But I'm not going to pretend that I have a pill or supplement that's going to change their trajectory when they're not ready to do the basic fundamental things that are at the bottom of the matrix. We still need to know what our patients are eating, how they're sleeping, how they get to work, who they interact with, how they resolve conflict, what their spirit is, who or what they're grieving. You know, we still have to figure that out. - And that's lifestyle, right? The foundations of functional medicine is lifestyle medicine. - I think so. - And so, that being said, and just hearing you talk, it sounds like functional medicine is just the right medicine. And so, two part question, well, here's the first part. What needs to change in our educational system to make this the way we train doctors? - We need to focus on the teachers. - Tell us more about that. - I don't think functional medicines is separate from conventional medicine. I think it's just part of good medicine. Someone still needed to give me a heart valve, okay? - Right. - So, you know, we still need emergency room doctors, we still need them. - Absolutely, yes. - So I don't wanna overstate it. So I was replaying in my head, I felt like I might have. But I think the teachers who are teaching the students should be exposed to what this is. And right now, they don't know what it is. They just know what they hear, you know, on social media, they hear, they see in newspaper articles, they see, you know, on all different types of formats and they don't know what it is actually. - Right, yeah. - I have a doc who's going to come to shadow me tomorrow because she's curious as to what this is that we do. - That's beautiful and that is what is needed, right? That education piece, getting it out there, getting it more into the learners who will become the teachers, right? The learners like yourself, you were a student once, and now you're a teacher. And I'm sure you're still learning. - I learn every day. For example, I learned that I don't know how to turn my alerts off on my Outlook. I learned that. - Yeah, yeah, yeah. No, this is powerful. And I love what you said that you don't separate it from conventional medicine. For you, they're married. It's not one for someone, it's not functional for some and conventional for the other. You know, you marry them to make it one medicine, the right medicine. - Yes, I have patients who are on conventional pharmaceuticals. And I explain the truth to them. And I even tell them the truth, you know, this will help you a little. You've done all these lifestyle things, now there might be a little bit of benefit you get from this drug, and they say, "Okay, I'll take the drug." You know, but I've told them the truth. I don't tell them the drug is horrible, I don't do that. I tell them some people have side effects, some people have toxicities. The studies show this, I show them the graphs, and they say, "Okay, I think I'll take that." - So you let them make their own call, but you give them the information. - Yes. - Because it is hard sometimes I think to make one the bad guy, right? And you're saying that we shouldn't do that because they're both needed. They both have to work together, not in silo. - That's what I believe. I think the evidence for that is overwhelming. - Absolutely. Now I know that there've been some barriers and what have you found, 'cause what have you found to be the biggest barrier integrating functional medicine in an academic institution, both as a practitioner and as an educator? - It's the same barrier, they don't know what we do. - That sounds like a song. - It's a song, it's a mantra, it's something. - It's a mantra, they don't know what we do. Yeah, yeah. - So I try to share with as many people as possible. The last person who shadowed me after two hours, she said, "No amount of words could have explained what you do." Like I know we've been trying to tell everybody, but I had to sit here and watch it. And I said, "I'm blown away. No amount of words could explain this." - Yeah, yeah. 'Cause it's, again, you start with context, back to the first sentence you shared, or I think one of the first sentences you shared with us in the show, you start with context, you really listen. And it seems like sometimes that art is disappearing, but you bring it back and you make it front and center. - That's why it's hard to describe what we do. And this visitor said that. She was astounded by how important the patient voice was and how it just came through. And it was not prompted. Like I didn't tell the patient beforehand, please make sure you share your whole life story in five minutes. But this patient shared her life story, why she was there, what she was looking for, how she'd been impacted by other medical care. And it took about seven minutes. And I actually had all the information I needed for the visit in seven minutes. The rest was just me educating and fluffing, you know? But I already knew what was happening after that. - But you also have that awareness. You create an environment where she could safely do that. - I think I have. And I think the reputation now has grown because I'm noticing the patients are more relaxed when they come in than even a year ago, because I think they already know that I'm going to listen. The word has gotten out, I think somehow. - Great. - And they are thrilled to have someone listen. Isn't that something? So that does say a lot. I think back to your question, was it say, that says a lot right there. Someone would travel long distances just to be heard by a doctor. - Yeah, by a doctor. This is just so beautiful. I'm just so enamored by this conversation we're having today because I feel like there is an art and there's a science and you've mastered the art. - I'm trying to master the art. - Through your approach. Through your approach. So I was excited to hear that you are at IFM's Annual International Conference. And for those who may have missed it, can you share a little bit about what you covered there? - Sort of what we've been talking about, why it's just good medicine and where functional medicine principles are in conventional cardiovascular care. We talked about three major concepts. One is that not everyone who presents with a heart attack has standard, what we call standard modifiable risk factors. We call them SMURFs. Not everyone has those. And how finally, there's an emphasis on inflammation. There was a very major scientific statement last year from one of the major cardiology organizations journals about how important inflammation was. When I was called into the office at that major university, that was one of the things he told me to stop talking about inflammation. So I talked about that and I talked about a new paradigm and how we look at heart failure and understanding that a lot of it is adipose tissue being an active organ that secretes chemicals that influence risk and clinical symptoms and outcomes. - That is so important. And do you do a lot of research, Dr. Carter? - I do some. We have been doing food as medicine research. We won a few programs in the country to get awarded a pilot grant to study food as medicine using functional medicine type nutrition principles. And then we, from that, were awarded a planning grant opportunity to plan a bigger grant. And we submitted that a month or so ago. So, we haven't heard back yet. We have a new teaching kitchen that's opening up on our campus. So we'll be doing some research there. And we're part of a bigger department that has integrative and lifestyle medicine, and we have a research arm. So we work together for collaborative care and research and training. - That is so important in this work, right? Because again, how would they know what we do, right? So this research piece and, you know, the innovations that we need to do is so vital for folks to really understand the impact of this type of medicine. - Well, even our brilliant researchers need to understand what we do, and I don't think they do. - I'm gonna let us sit for a second. Why, again, maybe we had to sing that mantra. Why do you think it's taking this long for people to understand what functional medicine is? - I think they made assumptions about what it is. And it's hard to move people off of initial assumptions. It's a human quality. So I no longer take it personally, I used to, but I don't. And time will tell, eventually they'll come around. And it sounds like you have a lot of patience, Dr. Carter. - It's growing. - Yeah, it's growing. It has to, right, in this time and space that we work in. I have to ask this question. Has anyone ever come back to you and said, you know what, we now understand what you do from your past? - Oh, yeah. Oh, yeah. That same chief, three years later, he apologized to me. It turns out there are hundreds of papers written on what you were telling us about. It's okay. - Wow, okay. - I don't know what to tell you, but thanks. - Amazing, amazing. Well, that's a win right there. That's a win. You know, so, you know, just thank you for all that you do. Thank you for how you're empowering the students. Thank you for how you are educating peers and, you know, cross-pollinating, you know, to other departments and bring into light more of what functional medicine is and is not. So as we bring our conversation to a close, what one big thing would you like functional medicine clinicians to take away from this conversation? - The one thing is that functional medicine, in my opinion, should be a tool for everyone to utilize for their health goals. - I think that's a mic drop right there. Thank you so much, James, we appreciate you. - Thank you for welcoming me to your podcast. I appreciate it. It's an honor. - Have a great one. Take care. - You too. Bye-bye. - Bye-bye. Thank you for listening to "Pathways to Wellbeing." Discover the latest research and clinical insights at ifm.org. The future is functional.