The Role of the Practitioner in Integrated Functional Medicine

Integrated Functional Medicine is not a profession. It is a method, a way of understanding patients and organising their care, that can be practised by several professions. This raises a practical question: what is the role of each practitioner? A doctor, a clinical nutritionist and a health coach may all use the timeline and matrix, all take an integrated history and all think in terms of mechanisms and mediators. They do not all do the same things, and the model works best when each understands their own role and the roles of others.

What every practitioner does

Whatever their profession, practitioners of Integrated Functional Medicine share several responsibilities:

• taking a patient centred history that includes the timeline, the matrix, lifestyle factors and every form of care the patient uses;
• recognising red flags and referring promptly;
• evaluating the evidence for interventions honestly and communicating it clearly;
• supporting patients to make sustainable changes;
• coordinating with the patient’s other clinicians and practitioners;
• working within the limits of their own training, registration and licence.

Roles by profession

These boundaries differ between countries. In some, the title nutritionist is protected; in others it is not. In some, dietitians may order laboratory tests; in others they may not. Each practitioner must know the rules where they practise.

The integrator

A distinctive feature of Integrated Functional Medicine is the role of integrator: the person who brings together the patient’s care into one coherent picture and plan. This role can be taken by any trained practitioner, but it must be clear who holds it. The integrator:

• maintains the complete inventory of care;
• keeps the timeline and matrix updated;
• ensures that the plan is consistent and not contradictory;
• communicates with other practitioners;
• makes sure that someone with appropriate authority addresses medical issues.

When the integrator is not a doctor, a clear line of communication with the patient’s doctor is essential.

What should not happen

• Practitioners without prescribing authority advising patients to stop or change prescribed medicines.
• Diagnoses made outside a practitioner’s scope.
• Traditional or complementary medicines prescribed by practitioners not trained and licensed in those systems.
• Tests ordered and interpreted beyond a practitioner’s training.
• Conflicting advice from different practitioners that the patient must reconcile alone.

Communication between practitioners

Structured communication makes collaboration more effective. A widely used format in healthcare is SBAR:

An example of a letter from a clinical nutritionist to a doctor: “Situation: I am seeing Mrs A for nutrition support for prediabetes. Background: she takes metformin and ramipril; she recently started a berberine supplement and a potassium based salt substitute. Assessment: she has reduced refined carbohydrate substantially and reports occasional shakiness; her home glucose readings are lower. The salt substitute and ramipril together may raise potassium. Recommendation: could you review her glucose lowering treatment and check her potassium? I have advised her to pause the berberine until you have reviewed.”

Documentation

Good records protect patients and practitioners. They should include the history, assessment, reasoning, evidence basis for recommendations, advice given, communications with other clinicians and the plan for follow up. Clear documentation of what was recommended, and of what was referred, is particularly important in integrated care, where several practitioners may be involved.

Competencies for integrated practice

1. Clinical method: timeline, matrix, prioritisation, root cause mapping.
2. Evidence appraisal: judging interventions from any system by the same standards.
3. Communication: patient centred interviewing, motivational interviewing, honest explanation.
4. Safety: red flags, interactions, scope.
5. Coordination: working with other professionals and systems of care.
6. Cultural humility: respect for patients’ beliefs and traditions.
7. Ethics: managing conflicts of interest, informed consent, honest advertising.
8. Continuing learning: keeping up with evolving evidence.

An illustrative team

A 57 year old woman with type 2 diabetes, fatty liver disease and knee osteoarthritis receives care from her doctor, a clinical nutritionist trained in Integrated Functional Medicine, a health coach and a physiotherapist. The nutritionist acts as integrator, maintaining her timeline, matrix and inventory of care. The doctor manages her medicines and orders investigations. The nutritionist designs a cardiometabolic nutrition plan and monitors her progress. The health coach meets her fortnightly to support habits and address barriers. The physiotherapist designs a knee friendly exercise programme. A shared plan, updated after each review, ensures that everyone works in the same direction. At a year she has lost 9 percent of her body weight, her HbA1c and liver tests have improved, her knee pain is reduced and her doctor has reduced one of her medicines. Each practitioner contributed what their training allowed; the method held them together.

One method, many roles

Integrated Functional Medicine asks practitioners from different professions to share a way of thinking while respecting their different roles. When each practitioner works within their scope, communicates clearly and understands the contributions of others, patients receive care that is broader than any single profession could offer and safer than uncoordinated care from many.