This is an excerpt of Dr. Thomas Sult’s book entitled Just Be Well.
THE TIMELINE AND THE MATRIX
Most physicians have been trained to practice “acute care”—in other words, they’re focused on diagnosing and treating short-term or urgent conditions. You go to the doctor with appendicitis; you get your appendix removed. You go in with a sinus infection; you get a prescription for an antibiotic. The physician sees a problem and prescribes a specific corresponding treatment, such as a medication or surgery. Once your immediate symptom is treated, that’s that.
But as we all know, Americans are suffering from an explosion not of acute conditions but chronic disease, from cancer to diabetes to mental illness. The acute-care approach doesn’t come close to addressing the complicated nature of these conditions. Functional medicine, on the other hand, takes a deeper, more nuanced look—not at the patient’s immediate com- plaint, but at the patients themselves, their complex backgrounds, lifestyles, and environments. Unlike traditional medicine, the functional approach strives to enhance wellness—and if wellness is optimized, disease cannot flourish. I’m convinced it’s what all physicians will be practicing fifty years from now—or sooner.
Before they even arrive for their first visit to my practice, our patients are asked to fill out a comprehensive online questionnaire. All the questions require a yes or a no answer—there are no maybes. If you say no, you move on, but if you give the computer a yes, you’re prompted to answer a new set of questions about your symptoms and medical history. The goal of the questionnaire is to find when wellness started to diminish, not the time when illness started (generally, there is a big gap between the two). Some patients complain about how long it takes to answer all the questions, but it’s crucial that I have a full portrait of what they’re experiencing. After all, I’m not just trying to mask a symptom with medication. I’m going to look for patterns and connections. It takes a little effort on the patient’s part, but that’s why I call what I do “audience participation medicine.” It’s as if you’ve come to a theater where the actors expect you to be part of the play.
This approach isn’t something patients are used to, as today’s traditional physician is far too busy to delve into the causes of a complex condition in a person. He’s not trained in the proper methodology or equipped with the necessary tools to treat long-lasting conditions that may be bound up with several simultaneous conditions. He doesn’t have the time to delve into the patient’s genetic makeup, environment, and exposure to different toxins, or the aspects of the patient’s lifestyle that are likely contributing to the condition. Though the physician can match disease to drug, he’s not trained to address the root of the problem or prescribe nutritional or exercise strategies—treatments that may, in some cases, be as effective or more so than drugs. Worse yet, his recommendations may be woefully out of date: there is a huge lag between medical research and integration into medical access—sometimes as long as fifty years. And the gap is particularly wide in the treatment of persistent, complex, chronic diseases.
A patient who makes an appointment with a functional medicine doctor—usually after several exhausting acute-care visits—finds a wholly different style of addressing the problem at hand. The practitioner is conversant in the latest research. He asks abundant questions and listens closely to the answers. He’s focused on the body as an integrated system, not as a collection of independent organs. He treats disease not as an anomalous quirk but as the body’s natural effort to normalize physiology in the face of a mismatched genetic makeup and environment. But let’s take a step back.
In my office, the very first difference patients notice is the atmosphere. We ditched the sterile, unwelcoming whites and grays of the traditional doctor’s office in favor of a large, open reception area painted in vibrant greens and yellows. Plants populate the corners of the room, and large photos of tulips hang on the walls. We stock a wide selection of vitamins and nutritional supplements—used to control inflammation, high cholesterol, high blood sugar, and many other conditions—on a large shelf, but there are no drug advertisements. We want people to be struck by the healing energy of the room. We want it to be a far cry from how they feel when they step into to the drab atmosphere that plagues most waiting rooms.
On top of that, we make sure our staff members treat patients with true empathy and leave their own problems at the door. Too often, distressed patients are subjected to grousing and gossiping at the front desk or the nurses’ station, which only increases the patients’ anxiety and frustration. For that reason, we insist that our employees focus only on the patient once they cross the threshold. If one of us is having a bad day, we take a deep breath, center ourselves, and do our best to move forward with a healing attitude. If that’s not possible, we go home.
It may seem extreme, but that’s what we’re here for—to help the patient heal. Because we practice functional medicine, we give patient-centered care. We don’t want to just rid people of disease. We want them to regain vitality and true health. And to do that, we have to get to know them quite deeply. That all starts in the first appointment, where functional medicine doctors deploy two key tools: the timeline and the matrix.
When I first met Jared, he was thirty-two years old and sickly looking, with dark circles collecting shadows beneath his eyes. At five eleven and one hundred and seventy-five pounds, he was perhaps a bit underweight for the average American, though the weight itself was healthy. He seemed preoccupied and distant; eye contact was infrequent.
“So, what brings you here today?” I asked.
“Well,” he said, gaze fixed on the floor, “I have asthma. I’ve had it for about five years. I’ve tried several approaches, but nothing’s really helped.”
This one- to two-sentence answer, followed by silence, is something I see often, and it’s a direct effect of the traditional approach to medicine. Patients have been trained to encapsulate their medical history and describe their symptoms briefly for an overbooked doctor, who then prescribes something and is on his way. But those two sentences tell me almost nothing. To learn about the patient’s condition, you have to dig deeper.
The next question I asked is one that all functional medicine doctors use in the first visit: “When was the last time you felt truly well?”
“Hmm.” Jared chewed his lip. “About five years ago is when the asthma really started giving me big problems.”
“So, before five years ago, you were doing pretty well?”
“Actually, I guess not,” said Jared. “I’ve had irritable bowel syndrome since I was a kid.”
“So, taking the IBS into account, when was the last time you felt truly well?”
Jared thought for a moment before meeting my eyes. “If you’re being that detailed,” he said, “probably not since the sixth grade.”
Now I had the answer to what I call the “not well since” question. I use that as the jumping-off point. “Tell me about fifth grade,” I said.
Jared shook his head, almost laughing. “That was almost two decades ago,” he said. “I don’t know. It was fine.”
He was obviously reluctant—not because he was hiding anything but because he felt as though he would be wasting my time with his childhood memories. I smiled back at him. “Humor me.”
“Well,” he said, eyebrows knitting together, “I could do whatever I wanted, eat whatever I wanted. I was an active kid. It wasn’t until sixth grade, about halfway through the year, that I got sick.”
I now had the starting point for Jared’s timeline (see figure 1). I took out a blank sheet of paper and snapped it to my clipboard. The timeline sheet shows a long line labeled “Triggers or Triggering Events,” with a short section at the far left marked “Antecedents.” The Antecedents section is for genetic factors and family history; it would hold the predispositions with which Jared was born. The beginning of the long Triggers section represented Jared’s life and would hold the occurrences that triggered his various conditions. I added a point in the childhood area near approximately sixth grade and wrote “IBS.”
The conversation moved forward as I teased more information out of Jared. He was actually a physician himself, though in Physician Land, a thirty-two-year-old is barely out of school. When he was diagnosed with adult-onset asthma five years earlier, he’d been given several inhalers, which somewhat improved his condition. A year later, he got a stool test—he was still living with IBS—and was found to have the parasite Blastocystis hominis and an overgrowth of yeast. He was treated with an antifungal and Metronidazole to kill off the Blastocystis, and after that, he noticed significant improvement in his IBS symptoms. All those events became data points—triggers—on the timeline I was filling out.
Unfortunately, Jared’s reprieve from IBS was short-lived. A year later, his symptoms slowly returned, worsening until they reached a low point about six months before he came to see me. But Jared came to me not to address his IBS but to address his asthma—he’d lived with the IBS since sixth grade and had come to view the condition as normal. Jared also told me that he’d been suffering from recurrent depression. It was becoming apparent to me that his conditions—primarily the asthma, IBS, and depression—were probably linked.
I now had the basics down on the timeline, but Jared’s resistance to sharing details with me wasn’t going away. He seemed to want to give me a neat little summary of his condition, get a prescription, and leave, even though I knew he’d come to me because he’d heard I was different. I sensed he didn’t quite think I was legit. I was asking him a ton of questions, but he’d give me one little tidbit of information and then clam up. Most patients have the oppo- site reaction—they’re delighted to find that I’m actually hearing their story and asking questions. They say things like “Wow! You’re the first doctor who’s really listened to me. I always thought these things were connected, but no- body took me seriously!” But Jared, as a physician himself, was initially resistant to the functional medicine approach.
After getting a particularly abbreviated answer, I stopped. “Jared,” I said, “I’m trying to get the big picture of what’s going on with you. All this stuff is potentially highly interrelated. We’ve got forty-five minutes, not five. I want more than a snapshot. Asthma is an inflammatory disease—don’t you think your gut is inflamed when you’re having an attack of IBS?”
Jared’s eyes flicked to the corner where wall met ceiling. “Yeah,” he said. “Probably.”
“Definitely,” I said. “And there’s some evidence that depression is an inflammatory disease of the brain, so I think that could be related, too.”
“Okay . . .”
I explained that from the perspective of functional medicine, medical specialties were outdated. The way we divide and classify these specialties, each addressing a different type of disease, is an antiquated holdover from the ancient Greeks. We now know that most diseases are “multi-system,” meaning they’re not isolated to a single specialized area of conventional medicine. This silo approach is at the heart of modern medicine’s failure to treat chronic disease. I explained to Jared that functional medicine organizes disease not by organ system but by fundamental physiological process—such as inflammation, biotransformation, communication, and so on. This is a better fit for the reality of disease: heart disease, gastrointestinal (GI) disease, and skin disease may all share a similar foundational cause, and three different people’s heart disease may have three different causes.
My explanation hit home. Jared was finally ready to talk more. It turned out he’d had several ear infections as a child, as well as a family history of chronic sinusitis and asthma. There was also a history of obesity on his mother’s side of the family. All this pointed to Jared having a strong genetic predisposition to inflammatory conditions.
We also delved into his lifestyle. Jared told me he was living on carbs and caffeine, a trend that had started in childhood. As an adult, he often picked up fast food at the drive-through, rarely exercised, never ate fish, and popped Tums frequently. He also told me he took aspirin several times a week for joint and muscle pain. At that point, it wasn’t lost on either of us that aspirin is anti-inflammatory.
I continued pushing Jared for details, asking things like “Did I get this right?” and “Do I understand that?” He doled out specifics reluctantly, but each time I got a new piece of information, I entered it into the timeline.
During the process, Jared also started opening up about what it was like to live with some of these conditions. “It’s not fun to go to a buddy’s house for a sleepover as a kid and worry the whole time about having an accident,” he said, explaining how the condition had made him feel marginalized, different from everyone else. It extended to his adult life, too—it was embarrassing to excuse himself to use the restroom and be gone for thirty minutes. Since the worsening of his asthma and IBS about six months before his visit with me, Jared had been on a strict diet, which made the social awkwardness even worse. He couldn’t even have lunch with colleagues—he’d have to tell them that, no thanks, he couldn’t go because he brought his own rice and water, the only foods he thought would improve his stomach condition.
Jared was on what I call the “fearful diet”—a diet in which you desperately try to figure out what’s causing your symptoms and are fearful that any food you eat may cause a flare-up. You know how it goes: “Well, last time I ate soy, my stomach was fine, but this time I got sick. I probably shouldn’t eat soy.” It’s like getting the flu after eating spaghetti and swearing off spaghetti for two years.
By this point, I’d fleshed out Jared’s timeline significantly. All of his various ailments were noted linearly across the page, allowing us to see a picture of his whole medical history at a glance. Soon, we made our first breakthrough.
Jared, like most patients and physicians—and he was both—had been trained to see everything in isolation. Though he’d come in because of his asthma, he hadn’t realized that it was inextricably linked to the IBS. As we looked at the timeline, I asked how his asthma had been in the year-long reprieve he’d had from IBS following the treatment of the Blastocystis parasite in his gut.
“You know what?” Jared mused. “It was entirely gone that year.”
There it was. Our first “aha” moment. The timeline had helped Jared make an important connection. “Did you ever think about getting retested for those parasites?” I asked.
“No . . . it never occurred to me,” said Jared. Then, almost instantly, he turned defensive: “But I’m not entirely convinced it’s possible that that’s the cause.”
It was going to take a little work to show him that the connection was real, but I knew he’d seen the connection between his asthma and his bowel problems for the first time. Insights like this one are why the timeline is so useful. So often, a patient will come in and say something like “I know Lipitor is what caused all my problems!” I’ll then ask them when the problem start- ed, and they’ll say it was January 4, 2001. But when I ask when they started Lipitor, they’ll say it was about the middle of 2003. When the patient sees the timeline, they see that this connection doesn’t make sense, but that’s just how the brain works; it doesn’t always view things rationally. I read this is a side effect of Lipitor, your brain tells you, so Lipitor must be the problem. No other facts are relevant until you see them on paper.
The process I went through with Jared is much like what functional medicine doctors do with every patient. I’m not so much interested in what’s bothering you right now as I am in who you are, what your history is, and what your environment and lifestyle are like. I’m interested in how you got to your current state of health because that will help us plot a path back to real health.
Once I have a sense of that, it’s time for the physical exam. This part of the visit is generally not long and drawn out, since my patients have seen multiple doctors and had many exams already, of which I have the records. However, I do a nutritionally centered physical exam and examine portions of the body that I feel are relevant based on the initial discussion. In Jared’s case, I looked at his nose and found that the nasal mucus membrane was boggy, swollen, and red. Inside his mouth, his pharynx—the part of the throat right below the mouth and nose—was inflamed and red. I also noticed that his skin was dry and that he had a cobblestone texture on the back of his arms and white spots on his fingernails. I then listened to five or six places on his chest, as I’d been taught by my mentors in Grenada. Jared’s heart rate and everything else I found in the remainder of the physical exam was normal.
The next step was filling out Jared’s matrix. I fill out a matrix (see figure 2) for each of my patients; it’s a helpful way for me to encapsulate the person’s condition in a holistic way. In the center of the circle is a space for listing antecedents (in Jared’s case, antibiotics and a propensity for inflammation) as well as triggers, of which Jared had an abundance, including the Blastocystis hominis parasite, the recurrent depression, and the aspirin and Tums he used to medicate his symptoms. There, I also listed the mediators—the intermediary factors that perpetuate the illness.
Eight points surrounded the circle at the center of the matrix, each sector representing a piece of Jared’s health. Using the timeline, I filled in the relevant sectors of the matrix; for Jared, my marks were mainly in the categories of Assimilation (Digestion, Absorption, and Barrier Integrity): the parasite, his IBS, his history of intestinal yeast, the antibiotics he’d been treated with, and the Tums he ate so often;
Defense and Repair (Inflammatory Processes): his asthma, his depression, the family history of obesity and sinusitis, the texture of his skin, the swollen nasal membrane, the inflamed pharynx, the white spots on his fingernails, his aspirin usage, his poor diet, and the food sensitivity I suspected; and Mental, Emotional, and Spiritual: Jared’s depression and slow social life.
Finally, I duplicated “depression” in the hormone and neurotransmitter regulation (Communication) section of the matrix.
Jared and I conversed as I filled out his matrix, and when I was done, I shared some of my speculations with him. I explained that because he’d been treated with antibiotics as a kid, his gut flora may have been altered, which may have led to his IBS. I also explained that, based on his family history, I thought he was predisposed to atopic disease—meaning he had a tendency to develop allergic reactions (including asthma). I told him that his mediators—factors that perpetuate his conditions—were the aspirin, his de- pression, and his poor diet.
Jared nodded, chewing his cheek, and said no when I asked if he had any questions.
Now I brought out a new blank matrix and filled it out not with his symptoms but with the underlying conditions I suspected had caused them. Under Digestion, Absorption, and Barrier Integrity, I explained that I thought he had a condition called dysbiosis, which was probably causing leaky gut. I told him that leaky gut can cause abnormal interactions between the immune system and the gut content.
“Think of it like this,” I said. “Put your hands in front of your eyes with the fingers close together.”
I demonstrated. Jared looked at me skeptically but raised his hands, blocking me from his line of sight.
“Now, your eyes are your immune system looking into your gut—it can’t see much. The bacteria in your gut is camouflaged as you. It looks to your immune system as if it belongs. That’s a healthy gut. Now open your fingers.”
Jared’s dark eyes peeked at me through the gaps between his fingers.
“Now that the ‘camouflaged’ stuff is easily seen, your immune system may start to make antibodies against it. The problem is because it looks like you, your immune system may make antibodies that react to the real you as well as the stuff that doesn’t belong. That’s autoimmunity, which brings us to the next section.”
Under the Defense and Repair sector of the second matrix, I wrote that he likely had food sensitivities and a zinc deficiency (one known sign of zinc deficiency is white spots on the fingernails). Next, we moved up to the Defense and Repair sector, where I noted that in addition to a likely predisposition to inflammation, he probably wasn’t getting enough fatty acids (since he never ate fish) or zinc.
Thanks to the matrix, we now had a basic picture of how all of Jared’s problems might interrelate. For the first time, he was seeing how deeply connected his asthma and IBS were—they’d likely both been kicked off by the childhood antibiotics and worsened by Blastocystis hominis and food sensitivities. Jared had found the matrix enlightening, but like all patients, he was eager to get to the next question—how do we start reversing this mess?
To find the answer, I took Jared for a third and final spin around his matrix. This time, at each sector, I told him what we might investigate. I told him we could run tests for gut permeability, gut digestive function, and food sensitivi- ty, and do a fatty acid analysis and test for the presence of parasites. It was a lot of testing, and Jared looked a bit overwhelmed when I was finished outlining the complete plan.
“Listen,” I told him, “don’t worry—we don’t have to do this all at once. My hunch is that this all hinges on the parasites. Let’s start there. If that doesn’t get you better, we’ll move on to the rest of it.”
Now that we had a path forward, it was time for the next step in the visit. It was time for me to tell Jared his story.