IFM recently had a chance to talk with longtime Functional Medicine educator Joel Evans, MD, a board-certified OB/GYN and international lecturer who is a regular presenter at IFM’s Applying Functional Medicine in Clinical Practice (AFMCP). Dr. Evans is a senior faculty member at the Center for Mind/Body Medicine and has served as the “external lead” of IFM’s Hormone Advanced Practice Module since its inception in 2011. He is a founding diplomate of the American Board of Holistic Medicine, and is recognized as the first physician in Connecticut to be board certified in both integrative medicine and obstetrics and gynecology.
Having pursued studies in spirituality, metaphysics, and personal transformation, Dr. Evans has created curriculum designed to share ancient spiritual wisdom with others to help bring health and happiness into their lives. We spoke with Dr. Evans about his path to practicing Functional Medicine and about the dedicated, whole-person care he provides to his patients.
IFM: How did you start practicing Functional Medicine?
Dr. Evans: It became clear to me that my conventional way of treating patients just wasn’t enough — that the depth and breadth of my care, which was very sophisticated allopathic medicine, wasn’t enough. This awareness became clear to me through caring for patients of mine who I had the unfortunate experience of diagnosing with cancer. One was a 26-year-old with breast cancer, diagnosed six months before her wedding, and the other was a 40-year-old operating room nurse, with whom I frequently worked, that I diagnosed with stage IV ovarian cancer.
These patients challenged me by asking me questions that I couldn’t answer. For example, “Does it matter what I eat?” Back then I said, “Ask your oncologist.” The oncologists, really, mostly said, “It doesn’t matter. All that matters is that you keep your weight up, and if you start losing weight, just have a dozen doughnuts every day.”
My response was: “Well, that doesn’t seem right to me.” So, we investigated further. Because of the doughnut recommendation, the patient came back to me and said, “Well, I heard that sugar preferentially goes to cancer cells.” I said, “That’s ridiculous! I’ve never heard of that.”
You know, I went through very prestigious programs — both medical school and residency —and I thought, if it were that simple, then I would know about it. Just to humor my patient, I did some research, and I found that there were over 10,000 articles on cancer and sugar.
Right then and there I knew that I hadn’t been exposed to everything that mattered.
Coincidentally, I then ran into Jeff Bland, and his talk rocked my world. That’s how I started learning about, becoming expert in, and then ultimately teaching Functional Medicine.
IFM: I understand that you also pursued studies in spirituality, metaphysics, and personal transformation. Can you tell us about this journey, and how you incorporate what you learned during that time into your patient care today?
Dr. Evans: My spiritual journey started through mind-body medicine. I have to credit Dr. Jim Gordon and his Center for Mind-Body Medicine, when I went to a conference on mind-body medicine for health professionals back in 1997. There, I realized the importance of meditative techniques in health and the damaging effects of stress. It wasn’t just an academic understanding of these two topics, it was actually a practical experience as well, where we were taught how to meditate and feel the changes in our bodies and in our emotions.
I realized the importance of meditative techniques in health and the damaging effects of stress.
Having had this personal experience combined with the scientific understanding of the benefits of meditation, I knew that meditation had to become a part of my patient care. I started by simply saying to my patients, “Let’s talk about stress. How stressed are you?” At the same time, I would delve into the classic description of what happens to people once they start meditating. Meditation, which is about quieting the mind, naturally leads to spirituality because people have experiences while they are meditating that allows them to realize that there is something deeper within themselves than they have ever experienced.
As I became more expert at mind-body techniques, instead of referring people out, I started running groups that taught people how to meditate. I did some medical research and discovered that people who self-identify as being spiritual are healthier and spend less money on medical care.
Everyone has difficult circumstances that pop up in their lives, and having a spiritual belief system helps people process those issues so that they become less reactive; they experience a diminished physiological stress response because they have a framework in which to process the stressors. This is the wonderful connection between health and spirituality: we know that people who are spiritual are healthier, and we know that a spiritual belief system diminishes the stress response, and we know that the stress response is a major cause of ill health. When we connect stress to the Functional Medicine Matrix, we can see that every area of the matrix is made worse by stress.
IFM: Can you talk more about chronic stress as a key factor in the development of chronic disease?
Dr. Evans: Stress has many impacts on the body; it changes your hormones, it changes your immune system, and it will also change your digestive system. What stress does in terms of your hormones is it shifts you into a fight-or-flight response, which is also called a sympathetic response. This leads to some of the common issues we see — like elevated blood pressure, increased heart rate, and the impact on digestion — it can lead you to feeling anxious. So those are the primary hormonal responses from the part of the adrenal gland called the adrenal medulla. Then you have the adrenal cortex, which secretes its own set of stress hormones, and those sets of stress hormones can cause problems with blood sugar, with the lowering of sex hormones, and with decreased thyroid function.
Stress has many impacts on the body; it changes your hormones, it changes your immune system, and it will also change your digestive system.
Stress is also pro-inflammatory. It leads to an up-regulation of the immune system such that you have more inflammation in your body. The production of pro-inflammatory chemicals, cytokines, leads to inflammation and prolonged wound healing; people get sick more often when they’re under stress. Stress also leads to gut issues and inflammation in the gut. It leads to problems with oxidative stress and problems with your mitochondria, such that mitochondrial function is diminished. These are but a few examples of the host of problems associated with stress that will lead to illness.
IFM: In your lecture on the HPATG axis, you talk extensively about stress and cortisol levels, and the importance of bringing one’s life into balance in order to balance hormone levels. What do you recommend that your patients do to achieve such balance?
Dr. Evans: That’s a great question, and it’s different for every patient. I start by having a conversation with my patient about what they see as their stressors. Sometimes it’s very obvious what people need to do in terms of making changes in their lives, and sometimes it’s not so obvious. And if it’s not so obvious, I do a mind-body technique that is a type of meditation where I help people identify the areas that are priorities in their lives for change. But in general, I ask people, “What it is that you think is keeping your life from being in balance?” They frequently know the answer right away, and that’s where I start. I’m really looking for causes of imbalance.
IFM: What do you think are some of the main challenges clinicians face when presented with a patient with hormonal dysregulation?
Dr. Evans: The biggest problem I see with patients who present with hormonal dysregulation is that they come in believing that a prescription for hormones is the pill that will cure their ill. If you go back to the concept that I just mentioned, which is: “You can’t have balanced hormones without a balanced life,” then you see the mismatch. Patients come in wanting a prescription, and I’m trying to get them to put balance into their life. Therein lies the challenge.
The biggest problem I see with patients who present with hormonal dysregulation is that they come in believing that a prescription for hormones is the pill that will cure their ill.
What I have to do is use all of my skills as a practitioner so that, at the end of the appointment, my patient understands how I look at things. And I always consider hormone replacement — I never say “never” to it — but I like to look at it as a last resort as opposed to a first choice. My priority is to co-create a plan with my patients that they will embrace.
IFM: How have you seen Functional Medicine improve the quality of your patients’ lives?
Dr. Evans: The beauty of Functional Medicine, and the reason I teach it year after year, is because it’s real medicine. It’s the real way to take care of people, make them feel better, and address not only their symptoms and how they feel but also address underlying metabolic abnormalities. The results are that people feel better. Their mood is better. Their energy is better. They’re sleeping better. They’ve found a lifestyle plan where they know what to eat, how to eat, know what to do in terms of exercise. They’ve found a way to bring in an exercise plan, a food plan, a mind-body meditation or prayer plan, and supplements that work for them. And then whatever the issues were that drove them to see me — whether it be digestive issues, joint pain, depressed mood, anxiety — the complaints they had that brought them to me are addressed; they have more vitality, are stronger, happier, and healthier, and then ultimately, their lab abnormalities correct. They feel better, the labs get better, and the presenting complaints go away.
The beauty of Functional Medicine, and the reason I teach it year after year, is because it’s real medicine. It’s the real way to take care of people, make them feel better.
IFM: What would you tell a clinician interested in applying the Functional Medicine model?
Dr. Evans: I think what happens is that clinicians get so excited about Functional Medicine once they are exposed to it that they want to just change the way they practice overnight, and that’s a problem. Just like we don’t expect our patients to severely change on a dime, I don’t expect practitioners to change quickly. It doesn’t make you a better Functional Medicine practitioner to try to do everything all at once.
Functional Medicine is best learned by practicing it one step at a time — one small step at a time. I recommend that clinicians find the area that they’re most comfortable with. For me, as an OB/GYN, I was most comfortable with hormones, and so I worked on stress. And then whatever percentage of my patient’s symptoms weren’t improved, I had to understand other Functional Medicine interventions, like gut health, probiotics, and digestive enzymes— things that were totally foreign to me as an OB/GYN. But if I was coming at this from being a gastroenterologist, I might be very comfortable starting with the gut first.
My recommendation to new practitioners is to begin where they are comfortable. To start with the patient base that they already have, and once they became clinically proficient, then they can change their practice model. First they have to learn how to practice Functional Medicine really well.