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Chris Kresser: Hey, everybody, welcome to another episode of Revolution Health Radio. I’m Chris Kresser. Today we have a question from Kira. Let’s give it a listen.
Kira: Hi, Chris. My name is Kira and I’ve used your book and have been an avid follower of your blog and podcast for many years. Your insight and ideas have helped me resolve many health issues. In my sophomore year of college I was diagnosed with five parasites, PCOS, adrenal fatigue, and severe hormonal imbalances. Over the past five years I’ve worked with many practitioners including naturopaths, functional medicine practitioners, acupuncturists, nutritionists, and chiropractors. In this process, I’ve become a huge advocate for my own health and have developed a burning desire to help others. I have a degree in economics, but my passion is health and I want to pursue a career in the medical field. I specifically would love to work with women preconception, during pregnancy, and postpartum. I’m looking into training programs and am unsure about the best path. Ultimately, I want to do your clinician training, but I’m not sure what degree to pursue prior to it. I am most drawn to a master’s in nutrition but am concerned this may not be a sufficient credential for the work I want to do. I’m also considering a naturopathic or a nurse practitioner route. Any insights into programs and paths would be ever so appreciated. Thank you very much.
Chris Kresser: Thanks for sending in your question, Kira. This is by far the most common question I’m asked in support emails, at conferences, or speaking events that I attend. I would say probably a few times a week we get some form of this question. And it really makes me happy because we desperately need more practitioners that have both a functional medicine and ancestral perspective. I get at least three to five requests per week for referrals to other practitioners because my practice has been closed to new patients for the better part of the last four years. Although I just recently reopened my practice. And the other clinicians at California Center for Functional Medicine, we have five now, are also either full or on the way to being full. And I know many other functional medicine clinics are in the same situation.
The truth is that the demand just far outstrips the supply at this point. And unfortunately there just aren’t that many practitioners that I feel confident in referring patients to that are able to accept new patients at this point. This is of course why I launched the Kresser Institute last year, which is dedicated to training clinicians with a strong foundation in both functional medicine and ancestral or evolutionary perspective. And I’m really proud to say that we graduated our first class of nearly 200 clinicians last December. And we’ve got another 100 currently in training and we’re about to enroll another cohort in March of this year.
Is there a place for you in functional medicine?
So I’ll come back to Kresser Institute a little later because it’s relevant to your question, Kira. But I first want to back up and give you a frame that I use to advise people who ask me about building a career in this field. There are numerous directions that you could go, of course, such as getting a conventional license like an MD or a DO or becoming a nurse practitioner (which you mentioned) or a physician assistant, becoming a nutritionist or a coach or becoming a so-called “alternative” licensed practitioner like a naturopath (which you also mentioned) or a chiropractor or an acupuncturist. But I think the most helpful way of getting at this issue is to ask a series of questions.
And I think the first and most important question you need to ask is, “Does the work that you want to do with people require a license?” In order to answer that question, though, you need to know whether you’d be satisfied by focusing on diet and nutrition, lifestyle factors like physical activity, sleep, stress management, etc., and behavioral change. Or do you want to be able to order lab tests, diagnose disease, and then treat patients with nutraceutical protocols and even medications based on those lab test results? And as a sub-question, perhaps, “Do you need to do that kind of testing and diagnosis and treatment yourself? Or would it be enough to work in a collaborative settling with clinicians that are doing that, while you focus on diet and lifestyle and behavioral change?” I see a big shift in evolution happening in this area.
So, for example, at CCFM, we’re in the process of hiring coaches and deeply integrating them into our model of care. We have so many patients that are not sick enough for the hospital but they’re too sick for the typical episodic care model where you only see a practitioner once every two to three months for maybe a half an hour or an hour. Our coaches at CCFM are going to be a primary point of contact for patients in our practice, starting with the initial consult and then proceeding through regular check-ins with patients between appointments, answering questions about protocols they’re on, supporting them and making diet and lifestyle changes, etc. And I know we’re not the only ones doing this. Many other functional and integrative medicine clinics are hiring coaches to play this kind of primary role. And even conventional medicine organizations have jumped on the bandwagon.
For example, Duke University now has a training program for integrative health coaches. There are organizations like Iora Health, which have teamed up with insurance companies to tackle chronic diseases like diabetes. So in the case of Iora, they basically made a deal with an insurance company where they said, “Hey, give us some money and give us your diabetic patients, and we will—if they have pre-diabetes, we’ll reverse that to the point where they’re no longer even in the pre-diabetes ranges for the various blood markers. If they have type 2 diabetes, we’ll take them a step backward to pre-diabetes or maybe even further to where they’re not diabetic anymore. And if we accomplish that goal, we’ll keep the money. If we don’t accomplish it, we’ll give you back the money. And if we go even further than the goals we’ve set up, you pay us more money.” And then they hired an army of coaches and basically these coaches work with people to change their diet and lifestyle, and they really hardly see the doctors at all, just a few times in the year to get the necessary testing and talk about the test results. But their primary relationship is with health coaches. And that program has been fantastically successful and they’ve made a far bigger impact in treating and addressing diabetes than the conventional approach of prescribing drugs like metformin and newer blood sugar drugs. And, of course, all of you listening to this podcast know why. Because diabetes is a disease, it’s a modern lifestyle disease, modern diet and lifestyle disease. That’s the root of the problem from a functional medicine perspective. So that’s what needs to be addressed in order to make headway.
So this is really exciting and we’re seeing this explosion of interest in health coaching as a profession both in the conventional world as well as in the functional and integrative medicine world. And this is happening simply because there will never be enough licensed health care providers to address the epidemic of chronic disease that we’re facing. The various licensing programs just can’t train enough clinicians each year. There just aren’t enough licensing programs, not enough people going into them and graduating from them. What’s more, we know that 90 percent of chronic disease is caused by environmental factors, and this means that focusing on nutrition, physical activity, sleep, stress, and toxins is by far the most important task when it comes to reducing chronic disease. And the highly trained health coach or nutritionist can do this arguably better than a licensed clinician can because that’s what they’re dedicated to. That’s what their focus is; they spend more time with patients in it, and we can create models like Iora that I just mentioned, where coaches are really exclusively focused on achieving these goals. And if we do this, coaches can probably address 70 to 80 percent of the problems that people have, while licensed clinicians would then be needed to handle the remaining 20 to 30 percent. This is why so many clinics and organizations and institutes and schools are so excited about training coaches, and Kresser Institute is no exception.
In fact, as I’ve come to realize this over the past year or so, I’ve made two big decisions regarding the future of Kresser Institute and the training that we plan to offer. First, starting in March, we’ll be opening up the ADAPT training to qualified allied health providers. This includes registered dieticians, clinical nutrition specialists or consultants, occupational and physical therapists, and certified health coaches who either work in a collaborative setting with licensed clinicians, have education in the medical or life sciences, and/or have extensive experience working with clients. This is big news, since so far ADAPT has only been open to licensed clinicians like MDs, DOs, naturopathic physicians, chiropractors, and acupuncturists. As I said, at CCFM we’re hiring allied providers to work side by side with the licensed clinicians, and many other clinics are doing the same.
These providers will need to understand the various lab tests we use and how to make nutritional and lifestyle recommendations based on them. This is what ADAPT would prepare the providers for, and there are currently no other programs that offer instruction in both functional medicine and an ancestral perspective. It’s important to point out here that functional and evolutionary medicine are not professions. They are approaches to healthcare. This means that practitioners from many different disciplines and backgrounds may take a program like ADAPT. And ADAPT does not qualify or license practitioners to do anything that they cannot already legally do prior to entering the training.
So if an allied provider such as a registered nurse or a clinical nutrition specialist or a certified coach qualifies for ADAPT and takes it, they will gain an understanding of how the lab tests and treatment protocols that I teach in ADAPT are used by clinicians. And they’ll be able to make nutrition, behavior, and lifestyle recommendations accordingly. But the ADAPT training won’t enable them to order labs or prescribe treatment if they are not already licensed or qualified to do so. And all of the graduates of the ADAPT program are expected to practice according to the dictates of their scope of practice as defined by the regulatory body that they’re subject to.
The second big change that’s coming is that I’m planning to launch a training program for people who want to become functional and ancestral health coaches. Since I am now convinced that coaches will play an even bigger role in the future of medicine than licensed clinicians, I want to offer a cutting-edge training program to prepare these folks. I’ve studied the currently available coaching programs, and while there are some decent options, there aren’t any that specifically prepare health coaches to work in a functional medicine setting using ancestral nutrition and lifestyle practices. So the Kresser Institute coaching program would include comprehensive training on how to design customized ancestral diet and lifestyle protocols based on individual needs, how to properly assess a client and determine what they need, how to address particular health concerns like weight loss or fertility, autoimmunity, gut issues using the more advanced protocols like AIP, ketogenic diets, low FODMAP, low histamine, GAPS, etc. How to support clients in modifying their diet, telling them how to shop, where to find the right foods and snacks, how to do pantry clean-outs, food preparation, kitchen equipment, etc. How to be a change agent. So we would study cutting-edge research on behavioral change and how to apply that in a practical way with your clients using the latest hardware and software apps and techniques.
How to communicate effectively and establish rapport, which according to Iora Health is the single most important factor that determines the success of a coaching intervention is the relationship between the coach and the client. So that’s something we would focus on. Productivity and time management. So you’re able to get more done with less effort and less time. How to work in collaboration with licensed providers as part of a team and new models of care that coaches can be a part of, which can help you find a role or create a role in this new future of medicine. This coaching program would then be one step you could take toward qualifying for the ADAPT training if you wanted to go the distance, so to speak. The coaching program provides the training in nutrition, lifestyle, and behavior modification, and then the ADAPT training covers lab testing, diagnosis, treatment, and the ins and outs of working in a practice with licensed clinicians.
So getting back to your specific situation. Kira, you mentioned that you want to work with women during preconception, pregnancy, and postpartum, which makes me really happy because as many of you know, I’ve been passionate about that area for a very long time. In fact, the first educational program that I created many years ago was called the “Healthy Baby Code,” which educates women on how to eat, women and men actually, on how to eat and take care of themselves in order to ensure a healthy conception, pregnancy, and postpartum period. And I think this working with this population, which really is the single most important thing we can do to ensure healthy future generations. So I think that’s a fantastic area to enter. But the question is how do you want to work with that population?
For example, would you be happy working in a clinic like CCFM, California Center for Functional Medicine, as a women’s health coach alongside licensed clinicians? Maybe you would work one on one with patients designing their preconception routine, their pregnancy nutrition routine, and their postpartum nutrition and lifestyle regimens creating. Maybe you would also create in person and online support groups or classes for women in different stages of this journey. So, for example, a class covering all of the things that you’d want to teach women that are trying to conceive or maybe a support group for postpartum women, helping them to address issues that are common during that stage. Maybe you’d also review lab tests and work with the licensed provider to individualize each woman’s protocol based on those results, or would you really want to be the clinician that is actually ordering those tests, interpreting them, and prescribing specific treatment protocols based on the results? Would you want to be the clinician that handles those 20 to 30 percent of cases that can’t be resolved by nutrition, lifestyle, or behavioral change alone? That’s really the fundamental question that you need to answer.
So if you’re certain that you want to be licensed, the next step is to determine what license you need, and then there are several questions that you have to answer around that. So one is how much time, money, and energy are you willing to invest in formal training? Are you willing to spend six to eight years pursuing a medical degree, which is the amount of time it would likely take for someone with no medical prerequisites to acquire an MD, for example, or perhaps even longer? Or would you prefer to spend less time or money and maybe get started working with people more quickly? There is always a trade-off between scope of practice and the length of time and cost of training. In general, the broader your scope of practice, in other words, the more things you can do like ordering tests, prescribing medications, performing procedures, the longer and more expensive your training will be. That said, there are some newer licenses that provide relatively accelerated training and still give you a broad scope.
So, for example, to become a physician assistant, or PA, the licensing program is typically only two years. You do need prerequisites like chemistry, physiology, and anatomy, which I’m guessing you may not have, Kira, as an economics major, but those can often be done at an accelerated pace in a post-bac premed program where you take these prerequisites in a one-year course. I mean, they’re very intense and challenging and also quite competitive, but you can do it. And then many PAs also have to have some kind of experience working in the medical field as a perhaps a medical assistant or something like that, in order to be accepted into a PA program because they’re quite competitive. Nevertheless, that’s probably the fastest route to getting the broadest scope. PAs have nearly the scope of practice as an MD or a DO but at a fraction of the time. However, they do require supervision by an MD or a DO and can’t work autonomously on their own. So you’d want to take that into consideration. Being a PA is ideal if you see yourself working in a collaborative environment in the future. Nurse practitioners have a similar scope of practice to PAs, but more autonomy. They can practice on their own without the supervision of an MD or a DO, but the training path is longer and more expensive. Then there are the other licensed professions like naturopathic doctor, ND; chiropractor, which is DC; or acupuncturists, like LAc.
The scope of practice of these licenses varies tremendously from state to state. For example, in California, acupuncturists are considered primary care providers in the Worker’s Comp system, which gives us the ability to order labs, make diagnoses, and prescribe treatments based on that. The training program is four years, and because of the scope of practice, includes a lot of Western biomedicine, pathophysiology, internal medicine, pharmacology, research methodology, etc., whereas in other states, acupuncturists aren’t even recognized as licensed providers and the training is far less comprehensive. And it’s a similar story with NDs, or naturopaths. In some states like California, Oregon, or Washington, they can prescribe medications, and their scope is similar to that of a doctor. But in others, naturopaths are not even recognized. So it really depends on where you live or plan to live if you’re going to choose one of these allied licensed professions. Because that will make all the difference in terms of what your ultimate scope of practice is. The other thing is that these license programs are for acupuncture or naturopathic medicine or chiropractic if they’re in a state that recognizes these licenses; licenses are usually four years and require prerequisites. So we’re back to like a minimum four-year, but probably more like a five- or six-year process, and they’re pretty intensive, so it’s going to be a full-time gig. They also include more training in nutrition and botanical medicine and nontraditional approaches than the conventional medical programs would provide.
So as you can see, there are many, many considerations, more than we can cover in a brief podcast. But I think the most important consideration from the start, as I said, is to determine whether you need a license for the kind of work that you want to do with people. If you don’t, you have a lot of options. You can do a training like the coaching program I plan to launch next year, or you can do a current coaching program like Nutritional Therapy Association or Bauman or IIN or ITN or FDN, which can provide the basic foundational skills and tools you need to work with people. Although few of them offer an ancestral evolutionary perspective and some of things that I think are crucial. And then you could do something like my ADAPT program or Institute for Functional Medicine training to give you a broader and deeper understanding of functional medicine, lab testing, and specific therapeutic protocols.
Now if you do decide that you need a license, then of course you have to decide which one, which we just discussed. Will you become an MD or a DO, or perhaps a nurse practitioner or a PA, physician assistant? Do you want to become a registered dietitian? Do you prefer a naturopathic medicine degree or chiropractic or acupuncture? Of course there are other licenses and training programs that I’m not touching on here. This is a very, very broad subject, and as I said, it’s really hard to cover in a brief podcast.
I’ve been thinking to that end of offering a webinar to answer people’s questions about this and maybe go into a little bit more detail since there are so many things to consider. And if you’d like to be informed when that happens, you can go to KresserInstitute.com and sign up for the email list there. You’ll also be notified then when the coaching program is released and when we do the first Kresser Institute in-person live events, which I’m looking forward to probably also in 2018. And then news about the upcoming ADAPT training program, especially now that it’s open to people who are already health coaches or nutritionists and have some training and want to go to that deeper level. You also, when you sign up at KresserInstitute.com, you get free access to one module of In Practice, which is a 10-part training course I developed on how to address the most common health conditions we see in practice using nutrition and lifestyle change.
So I hope this was helpful for you, Kira, and for others that have this same question. As I said, it’s probably the most common question I’m asked, and I know I did a podcast on this topic a couple years back, over two years ago, I think now. But a lot has changed since I did that, in particular as I said, I’ve come to believe that health coaches and people in a similar profession are going to play an even more significant role in the transformation of healthcare than licensed providers. And I’m personally really excited about that. I’m excited about bringing more health coaches on board at CCFM and integrating them into our care model, which will, I think, provide a much needed extra layer of support to our patients. Especially between appointments with the clinicians and help them stick with the protocols and get the support that they need as things inevitably come up. And also just for coaches who are out there working on the front lines consulting with clients on an individual basis, helping them address their various concerns so that they may not ever need to end up in my clinic or any other functional medicine clinic.
This epidemic of chronic disease is really based on the mismatch between our modern lifestyle and our genes and our biology, as anyone who’s been following my work or people with a similar approach will know. So addressing that mismatch is really the most important thing we can do to address the chronic disease epidemic. And a really well-trained health coach can absolutely do the majority of that kind of work. So this is an exciting time to be in this field, and whatever decision you make, Kira I think you can have a big impact in the field, in the area that you have mentioned. And it really boils down to your personal feelings at this point or circumstances and needs about how far you want to take it and how much you’re willing to invest in terms of time and money in formal training. And hopefully what I’ve shared today gives you a little bit more perspective and a little bit more of a sense of what you could accomplish even as an unlicensed practitioner working in collaboration with licensed providers.
And a really well-trained allied provider like a dietician, nutritionist, or health coach can absolutely do the majority of that kind of work. So this is an exciting time to be in this field, and whatever decision you make, Kira, I think you can have a big impact in the area that you’ve mentioned.
So it really boils down to your personal feelings at this point or circumstances and needs about how far you want to take it and how much you’re willing to invest in terms of time and money and formal training. And hopefully what I’ve shared today gives you a little bit more perspective and a little bit more of a sense of what you could accomplish even as an allied provider working in a collaboration with licensed clinicians.
Now I know of several allied providers that have a lot of respect and authority in both conventional and functional medicine clinics, because they’ve just been given so much latitude and trust by the supervising physician and they have such a big impact that they are able to have a certain degree of autonomy within a clinical situation. So I think the lines between licensed clinicians and allied providers are blurring and they’re going to become increasingly blurry as we go forward, though some licensed clinicians may feel threatened by this transition, and I get that, but I think once my colleagues understand what a win-win situation it is to work closely with allied providers, they’ll be completely on board.
This kind of collaboration allows patients to receive better care and thus get better results. It allows clinicians to generate more revenue without working more or burning out, and it creates rewarding work and an exciting career path for allied providers. That’s not to say it’s not important to have adequate training or to follow the law when it comes to scope of practice issues and supervision. All of this is extremely important for protecting the safety and the well-being of the patient and preserving the quality and reputation of functional medicine. But it does mean that I don’t believe that it’s necessary for someone to have a medical license in order to make a big impact on a patient’s health, especially when working in a collaborative setting as part of a multi-disciplinary team.
And so having a license really becomes much more specifically about being able to order labs and diagnose disease and prescribe specific treatments based on those lab results. And so I think it makes it, it just expands the possibility for what you can accomplish as an unlicensed provider. And for those of us who are licensed or want to become licensed, it means that we are going to be able to provide a much deeper, broader support for our patients using really highly qualified health coaches, nutritionists, and allied providers. So it’s a win-win for everybody, for patients and clients, for coaches and nutritionists, and for licensed providers.
So I’m really excited about what the future holds, and I hope those of you who are considering a career in this field, this is been helpful and is inspiring for you. And if you’re interested in learning more about the training that’s available now and will be available at Kresser Institute, you can go to KresserInstitute.com. Okay, everybody, that’s it for now. Please keep sending your questions in to ChrisKresser.com/podcastquestion. Talk to you soon.
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