In this episode, I am speaking with Dr. Scott Antoine—a board-certified emergency physician, and a functional and integrative medicine doctor. We will talk about the biggest problem in modern healthcare today.
In this podcast, Dr. Antoine will cover:
- How stress affects your health (and how simple lifestyle changes can make a huge difference)
- Why the modern healthcare system misdiagnosed his daughter’s PANDAS syndrome condition
- How legislation forces doctors to rush their consultations (and the scary impact it has on their patients’ health)
- The simple lifestyle habits that affected his children’s health and behavior drastically
- Why medical costs are so high (you’ll be shocked!)
Listen outside of iTunes
Ari Whitten: Hey there, and welcome back to the Energy Blueprint Podcast. I am your host Ari Whitten and today I have with me Dr. Scott Antoine. He is a board certified Emergency Physician who has served for seven years on active duty with the United States Army as an Emergency Physician. And also, very unusual, a little biography here, he went from emergency medicine to functional medicine. So in addition to his board certification in Emergency Medicine, Dr. Antoine completed a fellowship in Metabolic, Nutritional and Functional Medicine through the Metabolic Medical Institute which is affiliated with George Washington University and the University of South Florida. And in 2016 he was one of only 121 physicians nationwide to achieve board certification in Integrative Medicine through the newly formed American Board of Integrative Medicine. And he also holds a certification in Functional Medicine through the Institute for Functional Medicine. So welcome to the show, Dr. Scott Antoine.
Dr. Scott Antoine: Thank you very much, Ari, it is great to be here.
Ari Whitten: Yeah. Pleasure to have you. So, I first want to start off with your very unusual biography that, you know, it is not very common for someone to go from emergency medicine to functional medicine. So what prompted that whole… It is quite a big shift, right? Like the skills you have as an emergency physician don’t necessarily translate into functional medicine and dealing with chronic, complex diseases. You know, to deal with like acute stabbings or gunshots or car accidents and stuff doesn’t necessarily translate into an ability to deal with heart disease or Lyme disease or chronic fatigue syndrome or something like that. So what prompted this huge shift in your area of focus and training?
Dr. Scott Antoine: Sure. Well, I really, I still work clinically in ER about four shifts a month. I really enjoy what I do and worked in several trauma centers, level I trauma centers as well as in the military and really enjoy the work I did. And, you know, like a lot of physicians, it gets to be sort of cookbook after a period of time. In the ER we do great work but the approach is really the same to pretty much anything you are seeing in the acute care setting. I think we do a really good job. If you come into the hospital and you are having a heart attack or you are stabbed in the chest, I don’t really care what you have been eating. I don’t really care if you have been meditating. It is my job to keep you alive and get you moving on to definitive care. But I would see people in, you would see people come in with autoimmune disease or terrible pain or undiagnosed gastrointestinal disorders.
And there really wasn’t a lot to do for those folks. You could relieve their pain, you could check and make sure they didn’t have an infection or other problem. But beyond that they were relegated to chronic outpatient care. And unfortunately, outpatient care doesn’t do a great job with a lot of the folks you just mentioned. Patients with odd infectious diseases that don’t behave like they should, like Lyme disease and other common infections, Epstein Barr, also things like fibromyalgia and other autoimmune diseases. They just end up being difficult for physicians to manage. There is a component of pain with a lot of them. And now with the opioid crisis, that has made things even more difficult. So what ended up happening was I would see these patients in the emergency department and it always impacted me because I am kind of a people person. But never really got to me until my own, we experienced some illness with my own family and that is really where my search started. And I just came up with this idea that there has to be a better way. And then ended up, actually my wife is a physician as well and developed some joint pain, ended up having a positive double stranded DNA, which is the blood test that confers the diagnosis of lupus. And she saw someone, like anyone would do in our position, she saw one of our colleagues in rheumatology and they said, “We can put you on medications now, immunosuppressive medications to keep this at bay.” And she said, “I am not sure I am interested in that.” And we had other issues with our kids. Some issues with behavior and attention, and language and speech delays in our twins. We have five kids and had various issues and we were kind of the unhealthiest healthy family we knew.
And in this moment of desperation, I would have have to give credit to my wife who was searching for natural cures for whatever, sort of tears streaming down her face one day at the issues our family was having and stumbled on functional medicine. And it really resonated. And I would have to say as a conventionally trained physician, when she first started talking about this and got really excited about that maybe there is a cure for autoimmunity, maybe some of these behavioral issues in our kids, I kind of said, “You know, this doesn’t quite sound right.” Being used to being in this model where you make a diagnosis and then you give people medication and it either works or it doesn’t. If it doesn’t, you try something else. But that is kind of the model that I was stuck in. And it was only after I saw some great strides in our kids that I kind of reluctantly agreed to try an elimination diet and some supplements and do some blood testing.
Within a month of starting an elimination diet, I lost 30 pounds, which as you know, that is inflammation, that is it, right, and began to feel much better. Didn’t realize that I felt bad until I could suddenly get out of bed without back pain and I didn’t have insomnia and my brain was clear and I am a bass player. I play in church and I noticed that my dexterity was better. I could now [inaudible] music and just lots of special things. And then it became even more cemented a few years later when my daughter got really sick.
Ari Whitten: Now, I want to get to your daughter and the story of some of the family issues, but I am just curious. So, what kind of physician is your wife?
Dr. Scott Antoine: She was also trained as an emergency physician. So we both practiced emergency medicine, actually met in medical school.
Ari Whitten: Okay. Now, did either of you have any kind of background in studying nutrition or natural health or it was purely conventional medicine? Or tell me that kind of backstory.
Dr. Scott Antoine: Right. We both went to osteopathic medical school and so physicians in this country either go to osteopathic or allopathic medical schools. So we got a Doctor of Osteopathic Medicine degree, the other degree, a lot of physicians have is an MD, a Medical Doctorate. And so it is interesting because osteopathic medicine typically comprises a lot of primary care. And we were told when we went there that there was sort of a holistic mindset and to sort of pay attention to the whole patient. And we did that. But it is interesting because even after starting at medical school, it was very much similar to an allopathic education. So…
Ari Whitten: Yeah. My understanding is that osteopathic schools used to be more holistic, kind of natural health minded. And obviously there used to be more of a focus on manipulation, physical manipulation and osteopathic manipulation. And then now they have kind of deviated, moved more and more towards just the traditional allopathic curriculum. Is that accurate?
Dr. Scott Antoine: I think so. I can’t speak obviously for all institutions and we did learn manipulation. But as to your first question in terms of nutrition, I think we probably had about two weeks on nutrition and it was mainly focused on gross deficiency diseases. For example, people that are severely malnourished and get anemia from B12 and folate deficiency or people that have scurvy from vitamin C deficiency or rickets in children who don’t have enough vitamin D. And so it was really focused on deficiency diseases and not insufficiency diseases, which is what we see in our office and really can benefit from a keen eye and…
PANDAS and the modern medical approach to this condition
Ari Whitten: Yeah. I would definitely say two weeks of nutrition training is pretty far from a holistic training. Okay. So, yeah, I was just curious on that. So what kinds of issues were you dealing with with your daughter and with your kids that led to you developing an interest in, you know, nutrition and lifestyle and more natural health?
Dr. Scott Antoine: So initially our oldest, he is now almost 21, he had some issues in school. We weren’t really sure what was going on. He had some concentration issues and behavioral issues. And we had him seen here in Indianapolis at the Children’s Hospital. They did some testing and said, “We think he might be on the spectrum for autism or have Asperger’s.” And that diagnosis didn’t really seem quite right knowing him. And then we took him to see another specialist who said they thought he might have ADHD, also didn’t quite fit due to my understanding conventionally of that diagnosis. Then we took them to a third person, a psychologist who actually examined him and he was I think eight at the time. And she said, “You know, I think he may become psychotic one day.” And this is what they left us with with our eight year old, a diagnosis you really can’t make until children either are having hallucinations or they are in their teen years.
So we were sort of discouraged by that. And our twins were I guess two and had some speech therapy, language and learning delay. And our fourth was like a classic ADHD kid bouncing off the walls, kind of driving his teachers’ crazy. Our fifth child didn’t seem to have any issues. So this was the backdrop. And then at that same time my wife got sick. And so I still wasn’t practicing functional medicine although I kind of reluctantly agreed, went on an elimination diet, felt a lot better with supplements. But my wife was sort of doing things and did some blood testing and found some issues with methylation with our kids and enhanced detoxification. And they all got dramatically better. In fact, so much so that people at their school were, their teachers were asking us what medication they were on because I think they wanted to recommend it to other parents.
And so we got over this little hump and my wife’s double stranded DNA test became negative. It is not known to be reversible, her pain went away.
Ari Whitten: Wow.
Dr. Scott Antoine: And so I still wasn’t practicing. I was still working full time in the emergency department until my daughter was about 12 and she got really sick. And that turned the key for me because she had a crisis in conventional medicine and I love conventional medicine. I am a huge fan of medications. We have saved many people. I still work in the ER and we use some very expensive medications to help patients. And when you do, when you treat a stroke patient with a thrombolytic and they regain their ability to walk, that is pretty amazing in the ER. But it really failed in the case of my daughter and really it took us to a dark place and then I experienced a change. And that is kind of what I am passionate about now is helping other physicians see that there is a different way, a better way.
Ari Whitten: So this experience with your daughter led, this was sort of the big catalyst along with your wife and sort of the backdrop of some of your other kids’ issues led to you actually going and doing a fellowship in functional medicine, getting board certified in Metabolic and Nutritional Medicine and really going deep with your education on an understanding of natural health of nutrition and lifestyle and of functional medicine and integrative medicine. Is that accurate?
Dr. Scott Antoine: That is right. So we both went to school and did residency in Philadelphia and it is a super formal place to study medicine. And by that I mean they are very rigorous, academically rigorous. And I knew that if this was something I was going to dedicate time to and possibly open a practice, I was going to need to know what I was doing and satisfy myself that there was science behind what I was speaking about that I could sort of defend myself if I had questions from colleagues about what I might be recommending for patients. And so I really, and to be honest, I didn’t want to hurt anybody. So I wanted to know what I was doing so that I could really help people and not feel like I was putting them at risk or myself at risk, just to kind of know. So that is why we ended up training.
Ari Whitten: Got you. Now, what specifically were your daughter’s health issues?
Dr. Scott Antoine: So my daughter, I have a daughter, her name is Emma and she is 17. And when she was 12 she used to love to go to the store with me. And one particular day we were at the store and she started lining everything up on the conveyor belt. And I said, you know, “Stop it, just fooling around.” And I would move things around and she would line them up and at some point we kind of annoyed the cashier and he said, “There’s people behind you, you know?” And so I, this kind of happened a few times and I had forgotten about it until a little while later when my daughter came to my wife and I one night and said, “God doesn’t like me. I think I am a bad person.” And she started washing her hands until they bled.
She developed urinary incontinence. She was losing control of her bladder at times. She had severe insomnia and became very defiant, this girl who had a heart of service for everyone became super defiant and so developed some facial tics as well. And we didn’t know what was going on. We were physicians and we hit the books and my wife came to me and said, “I know what is wrong with Emma. She has PANDAS.” And I said, “I am not sure what that is.” And she said, “It is pediatric autoimmune neuropsychiatric disorder associated with strep.” And these kids get a common infection with strep or it can happen with other infections or toxins. And their body makes an antibody that crosses their blood brain barrier. And when it gets into the brain, it attacks their brain and causes all of these characteristic symptoms. So I said, “Okay, we have a direction.”
And I said, “That sounds like an infectious disease issue.” Called a colleague of mine and said, “Hey, my daughter,” and this was not a physician I knew but a physician at the Children’s Hospital here and said, “My daughter has PANDAS and I would like you to see her.” And he said, “Eh, doesn’t exist.” And it was everything to just kind of keep my composure. I said, “Thank you,” and hung up the phone. And we kind of kept looking and we remembered that there was a guy in New York, a physician in New York, Dr. Kenny Bock who is awesome. We had heard him speak about treating kids with autism and ADHD and getting really good outcomes naturally, a functional medicine doc. And so my wife said, “You know, I think I heard him talk about PANDAS once.” And so I sent them off on a plane.
They went to New York and he said, “Yeah, that is right. She has got PANDAS. She needs antibiotics and she is going to probably need IV immune block,” It is a blood product that these children get. And it kind of turns off and regulates their immune system. So we brought her back and I called another pediatrician here in Indianapolis and pediatricians here are great, I swear, but I called him and said, “My daughter has PANDAS and I know you use IVIg as a neurologist for other children for other reasons and can you order some IVIg for her?” And he said, “From the symptoms you are describing she just sounds like she is psychotic and needs to be in a mental hospital. She just needs to be on medicine.” And we don’t give up, you know. It is what you would do. It is what any of us would do for our kids. And so we called and finally found a guy in Chicago who saw kids with PANDAS and gave IVIg.
And she got it. And within four days her symptoms were gone.
Ari Whitten: Wow.
Dr. Scott Antoine: Four days. And I just kept thinking to myself after that, “What if I just gave her the medicine and put her in a hospital? What if we didn’t keep pushing?” And it really struck me that the physicians I interacted with weren’t the enemy. It was medical mediocrity. This state that we have been forced in largely because of the insurance model where physicians are forced to see 40 patients a day. You have 20 minutes, most of the time you are spending documenting on a computer, very little time for patient interaction. In fact, there are some physicians now that are being made to wear tracking devices and one of the metrics they follow is if the physician is in the room too long with the patient. So I think a lot of this, and a lot of the fact that when in the outpatient setting we see patients with these chronic diseases and if you can’t get them better, I think that is what is leading to a lot of physician burnout and a lot of medical mediocrity.
So I don’t view either one of those physicians as the enemy. I think the enemy is medical mediocrity and it is brought on by this enormous system that has kind of forced things in that direction.
Ari Whitten: Yeah. I want to get into that and that is actually the focus that I want this Podcast to be about, but real quick on your daughter. So the symptoms went away in four days. You know, what is the trajectory since that time? And I am just curious about this because I myself, you know, just as you didn’t know what PANDAS was and had never heard of it, I heard of it for the first time within the last year. I had never heard of it before then and I now have a couple of friends who have sons with PANDAS. And so I have learned about it through them. And it sounds like a really messy, awful thing to deal with. And really, you know, having little kids myself, I mean, it really scared me to think of your kid getting strep throat and then all of a sudden developing this autoimmune attack on their brain that completely alters their trajectory in life. So I am just curious how this has played out with your daughter.
Dr. Scott Antoine: She is much better. She still gets IVIg from time to time, but her OCD went completely away. She is not quite the student she once was in school, but very popular. She just earned a soccer scholarship to Wright State University where she will be going next year.
Ari Whitten: Great.
Dr. Scott Antoine: Very social, very outgoing, and emotionally and behaviorally has come back. I now see, my wife and I both see PANDAS patients here in our office. And the common description, certainly true for our daughter, was that you feel like someone has abducted your child. It is as if there is an alien here. They have a vacant look in their eyes. They are just beyond. And it really can be a devastating diagnosis because parents don’t get great answers. They will go to see folks who honestly trying to do the right thing, but they want to medicate the children for behavior. Or, I even had one family come in whose son had a classic presentation and the parents were told that it was their marital strife that caused the child’s behavior.
Ari Whitten: Wow.
Dr. Scott Antoine: And you can imagine, and when I see these folks they have terrible guilt. They are all trying to figure out, “What did I do to make this happen to my child.” And when someone says something like that, it just takes them apart. So one of my first things I say to these moms and dads is just right off the bat, “It is not your fault, there is nothing. It is not because you missed a prenatal vitamin when you were pregnant. It is not, you know, it is none of these things. It just is part of the human condition.” So I can tell you from our practice here, from seeing a lot of these kids, we have had dramatic improvements. In fact, not all of them require IVIg. There is actually a significant proportion of these kids, I hesitate to say all, but we have begun testing probably in the last year and an awful lot of these kids have mold exposure, mycotoxin exposure in their homes. And my theory, not a scientific study, but my theory is that those mycotoxins disrupt the immune system. Then these kids end up having this crazy immune reaction. And we have actually seen PANDAS, the variety that occurs with strep, there is an overarching called PANS, pediatric acute neuropsychiatric syndrome. And that has actually been documented with mycoplasma infection, with influenza as well as Lyme disease. So those are some tests we would routinely run for these kids. And if you treat those infections and then take care of the mold and mycotoxins in their environment, a lot of them get better without ever needing IVIg. And that is super rewarding.
Medical mediocrity and how it affects patient’s visits
Ari Whitten: Wow. Amazing. Okay. So I feel you are very uniquely positioned to comment on this issue that you termed “medical mediocrity” because you have, you know, conventional medical training. You have been in, I would argue, the conventional medical setting and specialty that is the best of conventional medicine and where they genuinely do absolutely amazing work, within emergency medicine. And I mean lifesaving amazing work, as you mentioned. You know, people with heart attacks and strokes and you know, gunshots and car accidents and losing a leg and shark attacks and all kinds of crazy stuff. And I mean, no shark attacks in Indiana, but some where I live in San Diego.
Dr. Scott Antoine: We are land locked.
Ari Whitten: So you have been in that setting. You also have experience, you went into this territory of natural health and nutrition and lifestyle and you have now got formal training in functional medicine and you also work in this setting where you are dealing with a lot of chronic, complex diseases with your functional medicine practice, which I would say, and I am sure that you would agree with me, but please disagree if you wish, that that setting is generally not very well done among conventional medical doctors. So the setting of chronic, complex disease or even simple problems like sleep problems or fatigue problems, energy problems and a lot of common complaints that have become epidemics. So, with that, I mean, first of all, do you agree with me? And then second of all, given that you are kind of uniquely positioned, given you have expertise in all these different areas, what do you think the crux of this issue of medical mediocrity really is about?
Dr. Scott Antoine: Well, I do agree with you first off. But what I have really seen… And I can tell you, so I went to medical school in the late ’80s and ’90s, early ’90s. And in the formal medical setting, the concentration really is on making the diagnosis, right? You wanted to be the guy that could walk in the morning report and say, “I diagnosed a pheochromocytoma or a Wilms tumor,” or something that people don’t see every day. And it almost, I hate to say it didn’t matter, but it almost didn’t matter if there was a therapy for that. You just wanted to be the person smart enough to figure that out. And I still like to figure things out both in the ER and in my office. But what then developed is, you know, we spend a lot of time in medical school and in residency, you spend a lot of time getting trained. And unfortunately what is really happened is people are really uncomfortable, now.
Physicians are uncomfortable saying, “I don’t know,” or, “I am not sure,” or, “I am not sure what this is,” or, “I have never seen this before.” And what happens typically? So if you would have a common thing, a migraine headache for example, a primary care physician might say, “Well, I will refer you to a neurologist.” But when folks start coming in complaining of chronic fatigue or of weird tingling pain that comes and goes away or odd hives after they eat, all things that we see in our office due to mast cells, etc., they are told one of two things. They are either told, “This sounds psychiatric,” or that “It is just not true. It is not there.” And so probably I would say more, well over 50% of my patients will come in and some physician has told them that it is all in their head or that they are just depressed.
And those, I mean, depression is a very real illness. But it is unfortunate because to not say that, you have to admit that you don’t know. And so I try and be a doctor that tells patients sometimes, “I don’t know.” So I will do my best to figure it out but there are sometimes we don’t. It is pretty rare with the tools that we don’t figure it out, the tools in functional medicine because I always tell people, “Almost everyone can be healed.” Not everyone can be cured, but almost 100% can be healed in some way or another. But what really I think developed was, as I said, you know, years ago people would go and pay their physician, you know, 15 or $20 for a visit and then the insurance industry became involved. And thank goodness for it because patients have catastrophic coverage.
So if you have an open heart surgery or something, you don’t have to go bankrupt if you have insurance. But what then developed was cost containment where they would say, you know, a doctor in the office doesn’t need more than 15 or 20 minutes to see a patient so that is all we are going to pay for, and we are going to pay this small amount of money. So there is something called a Medicare screening fee in the ER. It is very interesting. So if patients have Medicare and Medicare deems that I have earned the Medicare screening fee, I will probably get $50 for seeing that patient in the ER. That is what the reimbursement will be. It doesn’t matter if I put a chest tube in and gave the patient a blood transfusion and got them up to surgery for their aortic aneurism. So that really happens and it is really discouraging to physicians.
And it results in this hospital game of, you know, the hospital buys a drug for $14,000. I am thinking about tPA I spoke about earlier, thrombolytic drug for stroke. The hospital buys it for about 14,000 from the manufacturer. They charge $80,000 and they get reimbursed about 32. So it is this shell game that goes on. And in the outpatient setting, the insurance model has forced things. And then a lot of the education has been focused on drug therapies for things because if you only have 20 minutes and someone comes along and says, “You know, that patient that you are seeing again with constipation, we have this new medication.” As a physician, you are thinking, “Gosh, finally something, you know, this person hasn’t responded to anything traditionally, so let’s try this new thing.” And I think that is what is really behind a lot of what happens.
And so you become very dependent as a physician on the model of pharmacology, to give a patient medication for this and medication for that. And, we have kind of lost the ability to question in medicine. So it is unfortunate. And I always tell patients when they ask me questions about controversial topics, whether it is PANDAS or diagnosis and treatment of Lyme disease or even vaccinations, I always say like, “We unfortunately have taken science out of these discussions.” It is just all emotion, right? So, people will make these emotional appeals and won’t even listen. So if you stand up and say, “I would just like to ask a simple question.” People identify you with one particular group and just silence you. And unfortunately, that has happened with medicine. So anytime, if I am in a mixed group of colleagues where there’s conventional physicians, you know, I will say, you know, “Boswellia is really good for that arthritis pain.”
People kind of roll their eyes. And it is interesting. My partners in the ER initially gave me some grief about studying functional medicine and how much time I was spending. Whenever it gets slow in the ER, I would be pulling up my videos and kind of watching to take my test. But now when I work, they will come to me and say, “You know, my wife has migraine headaches. What would you tell her to do?”
Ari Whitten: Yeah, “My wife has been [crosstalk] on painkillers? What can I do for migraines.”
Dr. Scott Antoine: I have been there so long that I think, and I kind of enjoy that, that I have a bit of respectability, that they will come and ask me those things. They don’t always follow my directions when I say, “How about like not eating so much junk, or stopping smoking or testing for food allergies,” all those things.
But, yeah. So we have gotten forced into that model and it is really unfortunate because a lot of us went into medicine with really altruistic beliefs in really wanting to help people. I have colleagues in primary care who run an office and they haven’t given themselves a paycheck in five years. You know, people wouldn’t expect that, and so physicians are among the highest groups of suicide in the United States right now.
Ari Whitten: Yeah. I was going to say burnout, suicide, depression, are huge problems among physicians. Why do you, I mean, what do you think are the core causes of that? I know you have alluded to that already, but what, if you were to crystallize it into a few core things?
Dr. Scott Antoine: Right. I think, you know, if you went into a particular job or area of service, let’s say, and then just felt like what was promised to you or the story that was told to you is not quite what it ended up being.
And at the same time, you are expected… And the folks that dictate how long you should see patients or how much money that you get to see a patient don’t see patients. So, there is a chart out that I have seen a few times now that talks about the rise, it is a graph representing the rise of physicians and the rise of administrators in the last, I don’t know, 80 years. And it is amazing because the physician curve is kind of a slow, steady rise maybe a 15, 25 degree angle. The rise of administration is a logarithmic ski slope up. So there are a lot of administrators, a lot of people making medical decisions. And rightly so the insurance companies will say, “We don’t ever deny…” They don’t say, “We don’t ever deny care,” they would say, “We don’t prevent people from getting the care they need.”
Yet when you take a family of a child with PANDAS, it is extremely hard to get IVIg approved, intravenous immunoglobulin, because it is about $17,000 a dose and it is extremely hard to get it approved. So I usually have to go to bat and be on the phone arguing with the insurance company and trying to get it approved for another… A lot of these kids have immune deficiencies which you can find and document and if so, then the insurance will approve it. But, you know, you have these parents that their child has left their body and IVIg may bring them back and if you deny coverage to them, you are not telling them they can’t have it. But if you have… Most families in the United States, they just can’t get it. So anyway, so that is… But yeah, being a physician and being in a field where you felt like you were going to know what your life looked like and know how to help people.
And then being in a position where you almost feel like a rubber stamp. Someone comes in, you have a very limited amount of time, you reach for your prescription pad. You give them things really wanting to do the best that you can. You know, I hear a lot in our circles, kind of the natural medicine circles, I see a lot of people talking really negatively about, you know, drug companies, etc. And I think there is definitely a profit motive. But I think a lot of those folks that are developing these things are trying to help people. They are trying to solve a problem. And, you know, the medicines that I use in the ER are so darn expensive. I always tell people, if I could have found a way to get kickbacks, I would have gotten kickbacks. But you hear that a lot. Doctors get kickbacks to write medications for patients. I have not seen that in my career. I have been in medicine 26 years and I haven’t seen that on any large scale.
Ari Whitten: Well, if it does exist, you have got to get in on that.
Dr. Scott Antoine: Well, I wouldn’t, but… So I always try and tell patients when they come in, because sometimes they will come in and sit down with me and they are thinking, they have only seen conventional physicians and they are thinking, “Oh gosh, what is going to go on here?” I don’t know if they think I am going to put them in a trance or meditate or hypnotize them. But I always start out by saying, “You know, medications are great. Medications help a lot of people. But if you are on medications right now, let’s see if maybe we can do some things to get you off, reverse the root cause, get you off these medications because a lot of them have harmful side effects.” At the same time, some patients really need conventional medications. So that is my kind of view. But we have been really skewed. And the other thing that has happened, you know, whether it is politics or, as I said, these controversial medical topics, people have really lost the ability to have discourse.
Ari Whitten: Yeah, vaccines right now is a prime example where there is just not a healthy discourse happening at all.
Dr. Scott Antoine: Right. And I think… So what I tell patients when they ask me about a particular vaccine, I say, “The only thing that is relevant is, you know, how bad is the disorder that you are vaccinating against? If you get the vaccination, are there side effects? How bad could they be? How often do they occur? How effective is the vaccine.” And then that is what you use. And then you look at your own child or adult, whoever is getting it…
Ari Whitten: That sounds far too rational.
Dr. Scott Antoine: Are there risks?
Ari Whitten: I think we need to, I think we need to have entirely dogmatic positions on that issue that are devoid of any discussion of any of the questions you just mentioned.
Dr. Scott Antoine: [Crosstalk]. Right. Because what happens is someone will want to prove that you should get a vaccination by showing a picture of a disabled child or a child who died because they got the disease.
Yet on the other side, someone might be showing a picture of a child in a wheelchair because they got a certain vaccine and had encephalitis, for example, as a reaction. Both of those cases are super rare and you really can’t use them in science. Both of those cases are irrelevant. What is relevant is only the numbers and how you can have a discussion. What really has happened with science, if you look at nutrients, right? I will go in places and I will give a lecture on vitamin D and I will have someone stand there and say, “The Institute of Medicine said vitamin D doesn’t do anything.” At which point I will try and have a conversation about the studies that they are referring to because I know those studies. But we have also been stuck in this motive of evidence based medicine. It certainly was a great idea. But now people will say you should never prescribe any medicine, any intervention, anything, unless you have a double blind placebo controlled study, which is 40,000 patients that has been replicated three times all across the country.
Then you can finally do X. And they will say such things about vitamin D. And I am thinking, “It is vitamin D or it is vitamin C.” And if you look at the original evidence based literature article that came out in 1991 it had three pillars that were required to satisfy it. One was peer reviewed studies, the second was patient preference, of all things. And the third was clinician experience. So I can tell you most physicians, even though they might not want to admit it, if they have seen a patient in the office and they always give lisinopril or something for blood pressure, and it works the vast majority of times, that is why they do that. People aren’t… Medicine, a lot of patient care medicine is just sort of on the job training. So you are a third year medical student, you are saying, “This lady’s thyroid is disordered, what do I do?”
And they say, “You give this much thyroid medication,” and then you carry that through your career. So unfortunately people talk about that. But they will use evidence based medicine as a reason not to listen to really good studies that might be smaller, or clinician experience. There are, now a lot of us in this area are using ketogenic diet or we are using low dose naltrexone for autoimmune conditions or a lot of things. And, you know, I mean, there are studies for these things, you know, at some… And there is a lot of clinician experience. So there are very few studies for IVIg for PANDAS. But the few that are there are pretty impressive, 40 patients, 60 patients. And then when you sit in your office and you give these patients IVIg and they have such a dramatic improvement, I mean that wasn’t a spontaneous recovery.
My daughter or the other hundreds of patients I have seen since then that we have helped, either through natural means or dietary adjustment or dealing with occult infections or just regulating the immune system. So, evidenced based medicine has become a club for some physicians to hit other physicians over the head. And I have heard that numerous times when I have been places speaking. And fortunately I know most of the peer reviewed literature. And my feeling is, you know, if you have some basic science for why something works, and we have plenty for vitamin D, then you have to look at the way a study was done. If you are going to show me a study and say, “This shows vitamin D doesn’t do anything.” The last time someone showed me a study like that, they gave adult patients 400IUs of vitamin D. That is like a homeopathic dose.
Most adults, as you know, need 4-5,000 and you really have to check levels because people have vitamin D receptor mutations and some of our patients have, they take 1000 units of vitamin D and they have a level of 80 and we have other patients that required 12,000 units a day. Very individualized. So you will see studies like this and it will pop up in the New York Times, vitamin D useless. And then everybody will say, “Vitamin D is useless,” without reading the study. So I am sort of picky about reading studies and knowing the methods and how it has done before I make any decisions.
Ari Whitten: Yes. I want to come back to something that you said earlier. You know, you have mentioned that in modern medicine there is this pressure for physicians to see, you know, 30, 40, 50 people a day and to confine these sessions to, I don’t know, 15, 20 minutes. What can you do with someone who has, who is obese and diabetic in a 15 minute session with them? What can you do with somebody who has got cardiovascular disease from decades worth of poor nutrition and lifestyle habits? What can you do with so much of these other chronic diseases that we know are entirely or mostly caused by nutrition and lifestyle habits, neurological diseases and so many others? Fatigue, obviously for people listening to this Podcast is hugely, obviously hugely influenced by lifestyle habits. What can you do in 15 minutes with somebody?
Dr. Scott Antoine: You know, a lot of us now in most primary care offices I would think use electronic medical records. So what commonly people will do is they will put a template in for fatigue and it will say, you know, try and get some sleep and, you know, get a hobby and, you know, don’t drink coffee to keep you up at night.
It will have some general information. In terms of cardiovascular disease, it is mainly managed with medications and so they all have side effects and, you know, sometimes it is just about asking questions. Patients will say, “You know, I have had a really good outcome with you. Why do you think that is?” And the first thing I usually say is, “It is because of the work you have done.” But a lot of it also has to do with just asking the right question. So you are right, though, in an office visit that is that short. Most new patient visits if you go to see a physician are 30 minutes and that is considered a long visit and you really can’t do much. You can kind of make some suggestions. And a lot of the suggestions that are made, for example, for cardiovascular disease, we know are just wrong, not right. So the low fat diet. We have made more patients diabetics with a low fat diet than anything.
And I am right there with you, right? So I was there in the 2000s and before I took my functional medicine training say, “You all need to eat a low fat diet,” assuming that that was what triggered cardiovascular disease, not inflammation and inflammatory sugars really, carbohydrates and a sedentary lifestyle, etc. But, the CDC estimates that the top five killers of Americans are all lifestyle related and could have an effect, you know. But yes, if you are in a short office visit there is really not a lot you can do. You do your best. You may prescribe a medication and see the patient back. And there are a lot of physicians who buck the system and spend longer with their patients. So it is not everybody. There are phenomenal physicians who have chosen to say, “I am not going to make as much money. I am going to be a true servant.” But it is hard because even if you get past the time charade, you still end up with a smaller tool box. And so I am super careful never to criticize anyone because I am not perfect. I make mistakes and I may miss things or not think of something. So when patients come to me and say, “My doctors asked me to do X, what do you think about that?” I usually just say, “You know, there’s a lot of ways to skin a cat. It might not be the way I would do it. Let’s talk about what caused your problem and let’s see if we can overcome it.” But in a really short period of time in that model, it is hard just like it is hard in the ER. My partners like me because I tend to see the chronic abdominal pain patients that come into the ER and I will sit down with them.
So they are willing to give me a few extra minutes with these patients because they don’t want to see them because there is not a lot to do. You know, they come in and these poor folks, they are 30 years old and they have had literally 20 cat scans in the last 10 years cause they go hospital to hospital trying to find relief. And then a lot of those folks end up addicted because someone well-meaning along the way gave them pain medication because they just are so miserable. And so I really sit down with these folks in the ER and I am fortunate to be in a group that allows me a little bit of that and I will give them templated instructions, believe it or not, with an elimination diet and say, “You know, you may not be able to see me in my office, but try some glutamine to heal your gut lining, add a probiotic.”
And you are never sure how much that is going to help until just recently I got a call from a guy who said, “You saw me three years ago in the ER with abdominal pain and I was mad because you wouldn’t give me a shot of morphine, but you gave me all these crazy instructions. And I followed your instructions. I lost 80 pounds and I no longer have any abdominal pain. It all went away. I have a job, I have a family.” So it was like one of those moments. And I get a lot more of those moments in the office where you see these people with chronic conditions suddenly reversed, not suddenly, but with a lot of work on their part first. And it is just, that is an amazing feeling. That is what we went into medicine for. So I think what is happened with chronic outpatient medicine is you never get that feeling or you very, very, very rarely get that feeling.
And in our office, I get it a lot more. So actually this November I will be working my last ER shift. So 26 years. I am going to dedicate it to seeing more patients in the office, and we are going to start doing some other things and I am really going to start working on this issue. I really shouldn’t call it medical mediocrity. I don’t want to offend people. So I would call it more medical excellence. And my goal, I really have a heart for physicians and I would love to just reach them and say, “Listen, I was you. I did everything I could and I was unsatisfied and I felt like I wasn’t helping people. And I had no good answers for people that were really suffering. Let me show you a way out.” And sort of help these folks. And so we have talked about developing a training program to help people and not just address, you know, training in functional medicine and certification and those questions. But also, you know, how do you deal with a hospital that is exploiting you or how do you deal with insurance and run a non-insurance model or something else, a subscription model that is affordable for patients. Something where you feel like you can breathe, where you can just come up out of the water for air.
Ari Whitten: Yeah. I am wondering what you think the solution is. So, you know, there’s a couple of sides to this and I think it is really nice that you have spoken to the physician side of things, too. Like this is not just about getting the patients the care that they need to actually get better. But there is also this other side of it that I think most people don’t consider in this conversation, that physicians are suffering. Physicians are not seeing these wins that they need to actually feel good about the work that they are doing because they are being confined to these tiny sessions where they can’t really do the work that is needed to help people. They are obviously, in many cases, not receiving the education in nutrition and lifestyle to even really effectively help people with predominantly lifestyle related disease like the top five major killers in the country are.
And because they are not seeing those wins and they have these constraints on them, they are getting overworked, they are getting stressed and burnt out and depressed and suicidal. And so I think that issue is there. And then of course, there is this issue that, you know, so many people who are getting cardiovascular disease or getting diabetes, or are going to the doctor for chronic fatigue or sleep problems are not actually getting the interventions that they need on the lifestyle level to solve the root causes of those issues. They are just being handed a prescription for a medication in the vast majority of cases. So there is kind of these two… You know, I think both people, you know, on both sides of that dynamic are really suffering here. What do you think is the path forward? What do you think is needed as far as, what is like the ideal of how a physician should interact with their patient?
Dr. Scott Antoine: I think it it is really hard to, when you are really overworked, and I can say this because I served as a military physician and the base we were at was really understaffed. It gets funded basically by Congress. And so there wasn’t enough, they wouldn’t pay for enough slots for physicians. So when I worked in the ER there, I was working 12 hour shifts and I was working 26 of them a month. And the four days I was off, they would give me a beeper. And if it got busy they would call me in. And they called me in every time. So for a period of two years, I worked virtually every day, holidays, nights, weekends, even when I was on call. And after a while, what happens in that setting?
And I can imagine it is what happens in a primary care setting in the outpatient is that you get compassion fatigue. And I am a compassionate person. I am an empathetic person. I cry when my patients cry. But just being worked that much, it is really hard because after a while you don’t care. So I think the first step back is for physicians to regain that empathy for patients. And it is hard to do when you are overworked. So my hope is that, I really feel like, I don’t know where the change is. People have talked about single payer healthcare or government healthcare. I can tell you from working in the military, we had single payer healthcare. It was called TRICARE and it was super hard to deal with and their focus was really on denying most elective procedures and most things. And they made the system almost impossible.
So I feel terrible when I see a patient in the ER. In the ER there are federal statutes, so I never know what insurance anyone has when I walk into the room. They get the care they want, they need rather. But if I have a patient with a hand injury and I have to refer them out to a hand surgeon, here in Minneapolis, for example, a lot of surgeons don’t take Medicare or Medicaid. And so I really have not a good solution for those folks and I am not a hand surgeon. So we definitely have an insurance crisis where people can’t get this outpatient care they need. I think for physicians, for the patient interaction it starts with care, it starts with empathy, it starts with really listening to people. And, I think it is, kind of like what makes a good relationship with your significant other.
It is just listening with a non-biased heart. And one of the things I tell, I train residents and medical students now. And I always tell them what my teachers told me, “Beware of the patient you don’t like when they come into the ER, you know, the patient who is drunk and yelling. And just try and think of them like they are your Uncle Jerry, right? There is like a family party and it is your job to drive him home.” So that is how you have to approach patients. So empathy and that is hard. The insurance question is big. I am not sure how to answer that because clearly everybody deserves healthcare. And they get emergency healthcare. But follow up healthcare, super important as you said. I think that medical schools need to change their curriculum. I think there needs to be a push and it is hard to figure out how to make that push.
That is why I have kind of targeted physicians because I think it is something we have to do is make that push and say… So I try and get my message out. I try to speak to all sorts of groups and say, “Look, I am just a physician, trained like you guys and girls and this is what I have found in my patients.” And that is pretty powerful for a physician to stand up there and say, “This is a guy with a cholesterol of 300. I put him on no prescription medications. I did lifestyle medicine, maybe some fish oil, maybe some niacin. And the next time I see him, his cholesterol is 180.” I mean, that is pretty powerful for a physician to hear that. And then when I present six, seven, eight of those cases in a row like I did at a cardiovascular conference last year in Indianapolis, people kind of approach me afterward and say, “Where did you say you got trained again, and how do you do that kind of thing?” And so I think we have to do that. I think consumers have to demand it. I will tell you, consumers are really powerful. Moms are super powerful. Almost every one of these PANDAS patients that I see, the mom was up all night on the Internet and stumbled across something and said, “That is what my kid has,” after everyone told them, “We don’t know what this is,” or, “It is behavioral,” or, you know. And so it is amazing to me. So I think people in your audience really need to press for a different kind of healthcare experience and physicians who ask the questions and dig deep and look for answers. And it is hard in the current model we have. But, that is my sort of long answer to a very complicated question.
Ari Whitten: Yeah. Well, Dr. Antoine, thank you so much for your time. This has been a wonderful conversation. I have really enjoyed it. Thank you for sharing your wisdom with my audience. And thank you for putting forth these ideas that I think are so needed for people to hear. Is there anywhere where people can follow your work or do you have a website or social media account or anything like that that you want to direct people to?
Dr. Scott Antoine: Sure. So our website is www.vinehealthcare.com. That is our practice, Vine Healthcare. And Dr. Scott Antoine on Instagram.
Ari Whitten: Okay. And do you see patients remotely as well or only in person if somebody is interested in coming to see you?
Dr. Scott Antoine: We have patients from all over the country and we do see patients remotely. But just due to medical legal reasons, we require them to come to our office for their first visit. And that is also so I can do a good physical examination. I think that is super important. And I know there are some folks doing remote work that don’t do that. I just am such traditionally ingrained to do a physical exam. So we see them the first time in the office, do a physical exam. If they are remote, then we will kind of do everything and we will talk to them, present a plan. They will usually fill out some things ahead of time and I will usually have a good idea of where we need to go when they get here. And then follow up appointments for lab results or routine followups we will typically do remotely, either over Skype or Zoom or by phone. Not my favorite, because I like to see people and see their facial expression when they are getting better. So…
Ari Whitten: Nice. Wonderful. And your website was vinehealth…?
Dr. Scott Antoine: Vinehealthcare.com.
Ari Whitten: Excellent. Thank you so much Dr. Antoine. It was really a pleasure.
Dr. Scott Antoine: Great to talk to you. Thank you, Ari.
The Biggest Problem With Modern Healthcare with Dr. Scott Antoine – Show Notes
PANDAS and the modern medical approach to this condition (8:22)
Medical mediocrity and how it affects patient’s visits (21:12)