From Pharma to Functional with James Maskell – #357

Why you should listen –

James Maskell is the founder of Functional Forum and Evolution of Medicine, two platforms that encourage shifting the paradigm in healthcare. James’ career in healthcare economics led to his founding of Evolution of Medicine, an eCommerce site that helps doctors escape the shadow of Big Pharma and use online tools for functional medicine. On today’s episode of Bulletproof Radio, Dave and James talk about telemedicine, health and life coaching, finding the right functional medicine doctor and more. Enjoy the show!

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Automated:    Bulletproof Radio, a state of high performance.


Dave:  You’re listening to Bulletproof Radio with Dave Asprey. Today’s cool fact of the day is that I just spent the last 20 minutes talking sitting on my microphone so you couldn’t hear any of it, so I’m rerecording this for you because I love you that much. Today’s real cool fact of the day is that holistic medicine is used by about half the world’s population and that the WHO, the World Health Organization, which is not a friend of alternative medicine or quite often stuff that works, other then very basic sanitary measures, but they’re estimating that between 65-80% of the world’s population uses what they call alternative medicine as their primary from of healthcare compared to only 10-30% of people who use conventional medicine, which actually means that since the vast majority of people use alternative medicine that’s conventional medicine, and what they call conventional medicine is actually a radical alternative, if only 10% of the world is using the burn and poison model of medicine, which is the one that’s quite often promoted that way.


What’s nice is there’s a refreshing change coming in that the WHO is now recommending Traditional Chinese medicine for world-wide propagation, which is kind of neat, so Traditional Chinese medicine, acupuncture, and herbs are really, really cool. I just have some concern that if the WHO does that they’ll turn it into something else, because they have a history of doing that. It’s very much about business not about human health. WHO executives listening, if there are any of you, dude, we’ve get your number, like we know what you’re doing. It’s no great secret, sorry, guys, that’s what social media, and this what research, and truth, and facts, and all could do.


If I didn’t already hint a little bit, we are going to be talking about medicine today, not just human performance. Quite often I’ll interview researchers, I’ll interview super top performers, top performing executives, or occasionally a celebrity, and occasionally we’re just going to talk about the business of medicine, because it directly affects you and how you have access to the things that make you feel good all the time. If you like the show today I would love it if you went to iTunes and shared this with a friend and just left a quick five-star feedback. It means the world to me when you decide to do that.


Let’s get going. Today’s guest is James Maskell. James started his career as an investment banker, but he had studied health economics, which is a really interesting field because we’re looking at not just economics but we’re looking at how do people spend their money to live longer, and feel better, and to stay well, and decided after a year in banking that he wanted to work with integrative medicine or functional medicine, and he founded something called Evolution of Medicine, which is an eCommerce platform that lets doctors manage their practices better with customized tools and things like that so they can become more functional doctors, just to make it easier for the transition to come from basically a trained representative of Big Pharma. By the way, a huge number of doctors listen to that and I don’t mean to denigrate what you’re doing there, I just mean that the training is quite often sponsored by Big Pharma.


A lot of the best physicians, the ones who are my personal friends, they spend a lot of time and money paying for training after medical school to learn about stuff that works that simply is not in the paradigm that is taught in traditional school. You learn one set of things in school, then you go out to start your practice and you’re like, “I needed something else.” That’s why we have James on the show today, because he’s spent a lot of time looking at what doctors need to have that something else so that they can do things that provide the best possible care for patients, whether it’s conventional or alternative. Welcome to the show, James.


James: Great to be here with you, Dave, and thanks for that great intro.


Dave:  Now, what’s your definition of functional medicine anyhow?


James: Functional medicine is a new paradigm, an operating system, essentially, for delivering care that’s really designed for chronic disease. The reason why my company’s called the Evolution of Medicine is because medicine is adapting to its now environment. Conventional medicine, as you called it earlier, was created in response to mainly acute disease where you have a single cause and single effect, and now medicine is trying to adapt to this now environment of chronic disease, which is driven by lifestyle, it’s multi-systemic, it’s across many different organs, and so that linear model of thinking doesn’t really work.


Functional medicine his been around since 1991, was started by a guy called Dr. Jeffrey Bland. It’s growing in popularity. It’s now in the Cleveland Clinic. There’s many definitions of it, but it really focuses on a few main areas. One, root cause resolution, so getting to the cause of the dysfunction. Two is the therapeutic partnership between the patient and the doctor, so you’re really looking to involve the patient in their care so they actually have to participate, it’s not just done to them. The third thing, I think, is that it’s a system approach, so you don’t see each organ in isolation. You see it as the systems interacting and the interdependence of systems.


Those are the sort of building blocks on which is built. Essentially what we saw … I got involved in integrative medicine and even bioenergetic medicine. When I start asking the question, which I thought no one else was asking, which is, “If this is the future of noncommunicable disease which, … By the way, I was at a conference earlier this year where the WHO was present, and they were essentially coming to the conclusion that this medicine is the future of noncommunicable disease. What I realized is that functional medicine was kind of difficult to learn. You said your doctor friends who go to these conferences. You have to pay $1000 to go to the conference. There’s no content online at all about it, professional content. The companies who were delivering it are acting like it’s the 1980s, so the first thing we did was just to put it all online for free so doctors could find out about it.


Then what we really realized is the roadblock wasn’t necessarily the clinical understanding of why this is a better form of medicine, because I think most doctors intuit that they’re not getting to the cause and that they need a different set of tools to work with chronic disease. I think what we realized is that what’s really difficult is to actually build a practice doing it, because the practice of this type of medicine looks very different than the other practice. You can’t really industrialize it in the same ways you can with acute disease, so we’ve spent the last 3 years really looking at what are the best technologies, tools to be able to run a successful practice, and that’s where we find ourselves today.


Dave:  I’ve often sort of scratched my head when I look at this model that says, “All right, we’re going to do a big double-blind clinical trial. We’re going to spend a million dollars and we’re going to look at … These are the things we’re going to look at. We’re going to look at patients, and we’re going to look at methods and we’re going to see which methods work on the patients.” Now, the fact is that every patient is different genetically and they’re certainly different environmentally, and often times we ignore a lot of those things. For some reason that doesn’t make any sense to me, the other variable that is just as important is the professional, the healer, applying the method. If you were to do a true double-blind study, look the patient has to do the method on themselves and then its double-blind. Otherwise, could it be entirely possible that, James, if you were to do acupuncture on someone and I, as an untrained person, was to do acupuncture on someone that we might get different results even if we were using the same method, right.


James: I think it’s totally, totally justifiable and never mind the microbiome, right. The microbiome is completely different on everyone so how do you control for the microbiome, something that if you asked a Gastroenterologist 10 years ago what it was they have no idea even though that’s their organ of specialty.


Dave:  In fact, I just interviewed David Perlmutter of Brain Maker fame, who is certainly a big functional medicine guy, just a little while ago and we talked about exactly that. When we look at these things I think it’s just as important that we include the training and the quality of the functional medicine provider versus just does this form of functional treatment work, because it’s not like that. It’s like paint by numbers doesn’t work for what works to make people feel good.


James: Absolutely. Well, I know, Dave, you’re involved with the Silicon Valley Health Organization. If you go to Silicon Valley and you ask people who are really smart, like Dan Kraft, who runs the Singularity University Futuremed, they point to a type of medicine as the future of chronic disease, which is called P4 medicine, and that was from Lee Hood, I think, came up with that idea. It’s personalized, it’s preventive, it’s participatory, and predictive, that’s the fourth one. It’s really looking at this sort of new era of medicine. Then you step back and you go, “Okay, well we need predictive, preventive, participatory medicine, personalized medicine, not medicine for the average human but for this human in front of me,” and you think, “Well, how could we scale that up. How could we get a million doctors trained in this now type of method?”


The thing that functional medicine has that none of these other methodologies have is a reproducible operating system to be able to train as many doctors as you need at the same time. That’s why we decided to call our show the Functional Forum and really double down on functional medicine because it has that core operating system. You’re totally right, the old medicine was what’s the best for the average human? Now we realize everyone’s unique and technology is arriving for us to be able to deliver that at a certain scale, and so what I’ve described it as is a grand convergence. You know, the convergence of biohacking, and technology, and the massive rises in chronic disease, the huge payer issues where no one can afford to pay for all of these chronic diseases. America, it’s the worst as far as the cost but all other countries are moving this direction as we explore McDonald’s, and Coke, and all the stuff that caused it in the first place.


Dave:  It’s tough for people listening. I get this question all the time. They’re saying, “All right, how do I find a good functional medicine practitioner?” I’ve get a few people listed on the Bulletproof site, like kind of a little physician’s directory. These are people that our super bulletproof. You can go to IFM, and you can go to sort of different places, but how would you? By the way, I should tell people you wrote a back called The Evolution of Medicine, like you’ve actually studied this. How would a listener know that they’re finding the right functional medicine practitioner.


James: I’ve get a stat for you. Three years ago about 200,000 people went to that IFM website. In 2016, over a million people will go there. There is a massive demand for functional medicine. It’s growing very, very quickly. The truth is, if you look out at the ecosystem and you say, “Okay, how could we actually build a medical system built around functional medicine?” The truth is the biggest elephant in the room, there’s just not enough doctors, right? If you go to the IFM website what you’ll be sort of horrified to find is that not all of those doctors on that listing are practicing.


In fact, that’s the biggest problem, you call up a number, this guy took a course two years ago but he’s still working his job in emergency room medicine because he couldn’t work out how to build a practice, because at this moment in time the only way to practice functional medicine is to be an entrepreneur. There’s no jobs. The Cleveland Clinic’s hiring. Some practitioners have done a good job and have built a strong practice and they’re hiring another physician, but there’s no jobs going around. If the only doctors you can see are ones that just tend to be good at entrepreneurship, I’m not sure if you’re going to get the cream of the crop.


Dave:  By the way, I just want to say, the percentage of doctors who are good at entrepreneurship as a percentage is way lower then any other profession on Earth.


James: Totally. Go to another country, like the UK, where everyone who’s a doctor has been trained that they’re going to work for the NHS and then it’s basically approaching zero. It’s a crazy world in that way. What we decided to do is just … We saw this blockage. I’m not a doctor. I have no medical training. I happened to build the biggest conference in this space because we just basically put it all online for free and tried to make it interesting, and fun, and not boring like most conferences, and we really set about looking out to the industry and saying, “What is the model that’s actually working? What we’ve soon, Dave, and I’ll think you’ll like this, is this idea of a functional micropractice.


A micropractice basically means a low overhead practice where you can essentially deliver functional medicine off a laptop. You don’t need so much stuff to deliver functional medicine. It’s really about building relationships. It’s really about getting to the cause, uncovering the cause, and then there are all these technologies now that are being funded by Silicon Valley to help the delivery. One of the coolest ones that I think you’ll get a kick of, these are one of our sponsors on the show, are called Iggbo, so they’re Uber for phlebotomists. Rather than having a phlebotomist in your office you can sound a little, basically like an Uber driver, who happens to be a phlebotomist, to your patient’s house and they can do the blood draw at their home or office. It takes compliance from about 60% to over 98%. That’s one example of a technology that can help to reduce the overhead, and now you see these kind of practices popping up in businesses, in co-working spaces, in community centers, in gyms, in CrossFits where people actually are.


Dave:  By the way, it’s funny, we’ve got Bulletproof labs opening in Santa Monica. We actually have a blood phlebotomist because we’re doing intravenous nutrition, and that is through a medical partner that is affiliated with the location, but primarily it’s a human hacking laboratory. That’s just one thing that you can do when you’re at that location, but then there’s all this big gear that isn’t what you find in a club.


The whole reason for doing that, aside from the fact that getting IV nutrition is good, is it’s damned hard to get a blood test if you just want one. You have to go wait in line at your normal doctor. You have to get a permission slip. You have to pay the doctor. You have to beg the doctor to say, “Yes.” If they’ve never heard of the test they often won’t do it. Then, you got to go wait in line at LabCorp or Quest to get blood drawn and then they give you crap about it, too. I hope those Iggbo guys put LabCorp and Quest out of business for their phlebotomy site. I’m happy they’re running tests but it’s the worst customer experience you could ever have to get your blood drawn. It actually pisses me off.


James: It pisses a lot of people off, and I would say one thing that’s working, another thing should I say that’s working, in our favor here in this grand convergence is there’s a massive movement towards consumer health. There’s now all these resellers of Quest and LabCorp where you can actually go directly and do it directly, so that’s changing. It’s changing right now, where like 23andMe started the [rod 00:16:18] where suddenly they realized, “Oh wow, if you left patients order their own labs then it’s much more efficient, and people have their data, and people actually like doing that. You’re now seeing it starting to move in that direction.


I could tell you an insider tip. I can’t tell you who told me this, but I can tell you that Quest and LabCorp’s business model right now is to crush everyone else, to literally put all the small labs out of business. That’s one of the reasons why Iggbo is valuable because they’re making it easier to do the kind of labs that actually describe what sort of function you have, the functional medicine blood chemistries, the functional gut labs, the functional liver and kidney labs. Those are not traditional labs, but they’re super useful to understand where you are and where you’re going. They’re making it easier for doctors to use those labs.


There’s a lot of people working on behalf to push functional medicine forward. I think that if you’re a biohacker, if you’re a listener to Bulletproof Radio, or you follow your work, I would say that the majority of those people would aim for a functional medicine doctor, because they want someone who knows as much about nutrition as them. They would be super embarrassed going into a regular doctor’s visit and the doctor has no idea what’s going on. It just wouldn’t fit with their philosophy now that they’ve educated themselves.


Dave:  It’s interesting. There are thousands of functional medicine doctors who actually recommend Bulletproof coffee to certain of their patients, or carry it in their practice. Those are the more entrepreneurial ones because they’re carrying products because like, “I’ve got to make a living so I’m going to keep some products here to be convenient for my patients,” and all of that. For every one of those there’s probably 10 more doctors who are like, “I have no idea what that is, but I’m concerned about something or another.” Its a very mixed experience.


I’ll maybe ask the question a little bit of a different way but, how the heck am I supposed to know? I would know because I’m friends with a lot of these people. How the heck is a normal, non-Bulletproof Radio host, going to be able to go to Yelp, which is a terrible place because Yelp has a model for charging you more if you’re on Positive Radios. Where do you go to know if you’ve got someone who, like you said, took a course 3 years ago, or someone’s who’s like quality, someone who has availability? A lot of the best functional guys have a two-year waiting period. What’s the secret sauce to just know if you’re wasting your time?


James: I think the systems that will deliver that sort of knowledge are underway and being built. I think the industry has that much … We’re looking to solve that problem. When we look to the bigger landscape, Dave, what we saw was the number one thing … You could build those systems today, but the biggest problem is there’s just not enough functional doctors to go around. If you built a really beautiful system you could drive a lot of demand for them, and you could have a great Uber-style feedback system, but at the end of the day there’s just not enough doctors to go around and everyone would be too busy.


What we set out as the first part of our mission is let’s increase the supply. Let’s convince … First of all let’s create a system for those current doctors that know this is the right thing, that have this sort of moral obligation to practice it but still can’t work out how to do it because they haven’t worked out how to be an entrepreneur so this low overhead model can work for them. Then it’s like the next group of doctors, primarily care, family medicine, that realize that something’s wrong, maybe they’re working in a hospital that has a McDonald’s or Burger King in it, maybe they are just sick of seeing people getting sicker and sicker, and putting them on a treatment plan where there’s literally no ends in sight, and having sort of a moment where they realize this is the kind of medicine they want to practice, but they don’t know how to get there, let’s bring those people across, let’s get them set up with a functional micropractice, and then phase 2 could be something like what you’re talking about.


On the general, I would say those doctors that have made it to functional medicine thus far have pretty much made it because their kid was sick, or they were sick, or their wife got sick, and they felt like they were morally obligated to practice it. In general, and there are outliers to this of course, it’s probably like a bell curve, but the middle of the bell curve functional medicine doctor cares about doing the right thing, really wants their patients to get better, is trying to learn to be a better physician, and is just probably a better clinician than a business person and so hasn’t been able to develop like a scalable practice where they could see where they couldn’t deliver value outside of just sitting across from someone and just working with them. That’s what we’re really helping people to do.


Dave:  The problem is that if you are a healer, you’re attracted to the practice of medicine, you’re not an entrepreneur and attracted to the practice of entrepreneurship. That’s perfectly okay. It’s actually a different mindset, and there are a few. I’m thinking like Daniel Amen has a successful practice and he’s a successful physician. Mark Hyman. These are all friends, people who’ve been on the show. Mark Hyman, he has his own practice. It’s a thriving practice and it’s run like a business. All of the ones I know who have successfully created a practice like that, that’s not just a micropractice where they have other people working with them, they’re all partnering to find someone who is either operational or entrepreneurial to build it, because there isn’t another way.


If what you’re doing is allowing them to do it, or to have a less expensive head of operations it’s get really cool, but even the idea, and I say this having worked with a lot of doctors and just being an entrepreneur, the idea of giving up control … You’re a healer, you’re supposed to be in control. A doctors like, “For god’s sake I can stop a human heart and hold it in my hand and start it again,” that’s kind of the ultimate control over life and death, so to give the control up to allow the business to run while you focus on healing is one of the scariest things you can do.


If there’s a tool set, the stuff you’re working on, James, that allows even just better visibility into what happens, then you could enable a lot of doctors, who frankly have no business being entrepreneurs because they’ll be crappy entrepreneurs, and when they put their energy away from a patient and into running a business they will be unhappy as human beings and they’ll be a less effective care provider. It’s actually a waste of a precious physician’s time to like worry about an advertising budget. It’s a sin to do that, but someone has to do it, and you’re giving tools to make it less of a sin.


James: Totally, and whether-or-not the industry ends up looking a bit more like CrossFit where you have sort of like the low overhead environment where it’s owned by the local provider and you’ve made it easier, or it ends up looking a bit more like, I don’t know, Massage Envy, where there’s a company that owns it and the practitioners are just sort of the employees, really just depends on to what degree physicians want to stand up and be entrepreneurs and how they can set up their systems. The other thing is, Dave. You’re an entrepreneur, imagine being an entrepreneur in an environment where, one, there is so much paperwork that you have to do that it takes 2.4 paperwork people per doctor to get it done. Two, the company that pays you can chose to pay you after 90 days, or whenever they want. Three, if they change their terms of service after they paid you, they can go back into your bank account and take the money back. That is not an environment where entrepreneurs thrive. That is the insurance system. Some of the things that we’re looking at is, how do you get out of the system?


Some of the most progressive practices that we’re seeing are using something called Direct Primary Care, which is essentially super easy model. I pay $100 a month. Actually, my doctor in New York uses this and she has a functional medicine practice. I pay $150 a month. That’s a flat fee. I get five visits during the year. I have unlimited access to health coaching. They use all the technology, so I own my own data. I have an online portal where I can ask questions. They have no phone number. You can’t call that clinic. There’s no phone number at all. They don’t even have a front desk person because they’re bringing down the overhead to make it affordable for me.


That’s the kind of model that we’re helping people to provide. You get out of the system. You just take cash and so a regular doctor who can see 500 patients out of a co-working space at $100 dollars a month, they’re making 50 grand a month and they’re in good shape to be able to build a successful practice. Those are the kind of things that we’re looking at. Trying to be entrepreneur in the environment of insurance is insane by itself.


Dave:  For more than 10 years I’ve said one of the primary ways to tell that you’re dealing with a really good functional medicine practitioner is that they refuse to do insurance paperwork. This is sad. By the way, the doctors who care enough to do insurance paperwork and are good functional medicine people, I’m not saying you’re not, I’m just saying that so many of the rock stars just realized … They wake up one day and they’re losing sleep and they’re spending hours and hours of their precious time as a healer who spent 20 years learning how to help someone, instead of helping someone they’re signing papers, and like, “You know what, I’m done.” They’re just like, “My time is valuable enough. I’m going to charge $400 an hour, or I’m going to do this concierge, or this monthly primary pay thing.” It makes me happy to hear that you’re enabling that for people.


There’s a little story here, too. My wife is a Karolinska-trained physician who ran emergency rooms. Karolinska’s one of the top 10 schools out there. She’s “a real doctor,” and her practice today is over Skype. It’s not a medical practice. It’s a consulting practice and it’s based on our first book, The Better Baby book, and she has a small number of clients and she works with them on a weekly call basis, or a monthly call basis, to help them get pregnant without IVF. She works with their physicians and they pay their physicians, they have insurance, or they don’t, it’s none of her business, but she acts as an advisor and a coach. It’s a phenomenally successful model, and she can do this basically from home. We have our kids. She has Skype and her clients are around the planet. Some of them are like really influential people, and they love it and they pay a few hundred dollars an hour. I don’t even know what her exact billing rate is, but it’s completely changed her stress levels.


If you look at the earnings from someone who has gone down that path, they might be the same, they might be less but it’s almost all word-of-mouth. It’s chill. That’s something that healers need to be the best doctors possible, is they need to not take their extra time and use it on boring business operations. They need to use it to recharge themselves, and to study, and to become better at what they do instead of better at paperwork. I’ve watched the transformation in her from doing that, and we’re very, very fortunate because I’m running Bulletproof and all and she has flexibility that maybe a primary breadwinner wouldn’t, but it is a viable model, and she’s got a better lifestyle than most doctors.


James: Totally. Telemedicine is a game changer. Look, I know plenty of doctors that are breadwinners that are basically doing exactly what your wife is doing. They maybe see … I’ve got a doctor friend in San Francisco. She went from … talk about micropractice, she went from seeing all of her patients in San Francisco to then now she has one day a week where she sees new people and people that need to see her. Everything else is via telemedicine. Patients like it more. They don’t have to drive to your crappy office to go see you, and once they’ve developed that initial relationship it’s so easy. That is definitely the way of the future.


You hit on a big point there, Dave. The subtitle for my book is, Join The Movement To Solve Chronic Disease and Fall Back in Love With Medicine, because the other massive issue that we’re facing … Chronic disease is a huge issue, but I don’t know if you know this, but physician suicide is a massive thing in America, so much so that a million patients … If you multiply the numbers of doctors that commit suicide each year by their patient base, it’s over a million people, and that’s really scary, and there’s a lot of suicide.


It’s just a function of the fact that some doctors … First of all, medical school is like Post Traumatic Stress Disorder for sure, and then you add on top of that doctors who like get stuck in industrialized medicine, it’s not what they thought it would be, they realize they’re just pill machines, they’re seeing the 7-minute visits, and it’s really disturbing. What we see … If you ask a group of functional medicine doctors, “Do you enjoy your work?” All hands go up. They love it. In fact, the Institute For Functional Medicine did a survey recently that showed that the majority of functional medicine doctors want to practice beyond their 75th birthday, because they’re so jazzed by being able to really help people in the way that I think that most doctors thought they would when they started medicine.


What my book is is basically a handbook. The first half of it is a hero’s journey, essentially, to try and get doctors to call them to adventure, to practice a type of medicine relevant for today’s diseases. The second half of the book is a step-by-step guide on how to build this low-overhead micropractice which could form sort of the basis of the mega practice down the road. One of the other things that we’ve soon in this first year is everyone wants the big practice. They want to have a big wellness center with all the providers and then you’ve got the huge overhead that you’re trying to fight, and you’re trying to learn how to be an entrepreneur in a large overhead environment. It’s led to a lot of failed wellness centers. The most effective model is to build the client base, build your marketing skills, build your word of mouth while you’re in a low-overhead environment. It’s more like the difference between build it and we will come, or they will come, and the lean start-up, and this is a lean start-up medical practice basically.


Dave:  It’s important work that you’re doing which is why I had you on the show. A lot of people wouldn’t know this. My career’s in Silicon Valley. You would know that. One of the very first jobs I had out of college, I was the main IT support guy for a hospital with 500 doctors.


James: That sounds horrible.


Dave:  The only people who may be worse than doctors, this is speaking as an IT professional, are maybe bankers, just in terms of demands and just high maintenance. These doctors, that same thing, “I can stop a human heart and I can’t reboot my hard drive, like augh.” They just lose it but this was in a traditional hospital setting in Central California, and you could watch what happened. You have these people who are good at healing, they’re medical people. I fundamentally believe that doctors they get energy from helping people. That’s why they do what they do.


James: Totally.


Dave:  You turn them into administrators and they’re some of them that are like, “You know, I learned medicine, I practiced for 2 years, and I love administrating,” and they’re good people, and they’re good administrators. They probably weren’t the best doctors, which is why they were naturally brought into their calling which was, “I could help doctors instead of helping people,” not that doctors aren’t people, but helping patients.


This just doesn’t work. Like you said, if you build a medical practice and you build this big wellness center you better have big financing. I just opened the 40 Years of Zen. I’ve been doing this through partners and cobbling stuff together. This is a neurofeedback facility. It’s non-medical but it’s a 2-1/2 million dollar facility and the overhead’s insane on the place, but it was the only way I could do it, because there was no leaner startup model available for what I wanted to do, because of the equipment cost and the specialist cost in order to do brain hacking.


I look at that. There’s no way I could have done that if I wasn’t doing all the other things I’m doing and if I hadn’t spent a long time learning to be an entrepreneur. If I went to medical school today I would be a crappy entrepreneur for about 8 years until I got my medical degree. There’s a diversion there. I want doctors hearing this. There’s a lot of physicians who listen to this. It’s okay to not be an entrepreneur. You might actually suck at being an entrepreneur, like most human beings. You kind of need to have a broken brain to be a profoundly good entrepreneur.


That’s why instead of trying to go out and hack it with this model, do the lean startup micromodel where you don’t have to be an entrepreneur. I spend 80-90% of my time providing the standard of care that I dream of for my patients, and I spend a little bit of time taking care of the stuff that needs to be done because I have tools that automate it. That’s freedom. That is such a cool thing.


James: One of the stories that I talk about in my book, this doctor sort of had a meltdown. Her name’s Dr. Pamela Wible. She’s actually the same woman that talks about physician suicide. She goes into … She lives in Oregon, and she decides that she’s going to start her own practice. Talk about lean startup. She holds a town hall meeting in Eugene, Oregon, and invites as many people as she can. There’s a couple hundred people in the room and basically just asks them to air their grievances about medicine, what they like, what they don’t like, and what they would like to see in an ideal medical practice. Guess what, they want to spend time with their doctor. They want to know their doctor. They want to maybe have appointments in the evening that aren’t during work times. She’s like, “Oh, that sounds interesting. This is all doable. Would you be willing to pay for a service like that?” They’re like, “Yeah, I would.”


Look, she just pre-sold her whole community on her cash practice. Now, she has direct primary care. Her overhead of her practice went from 74% to 10%. Low-overhead environment, relationship focused. She’s happy. The patients are happy. Everyone’s getting what they want. It’s not like a fancy concierge medicine practice where you’re charging 30 grand a year over and above insurance. I’ve soon Direct Primary Care practices in the deep south that are $60 a month and are mainly just regular people who just want to know their doctor, don’t want to get shuffled off in a 7-minute visit to someone who’s only skill set is the differential diagnosis and handing over the prescription.


I think there’s such a desire in the patient population for relationship medicine, and what functional medicine does is provide a structure to that. The sort of elephant in the room has been that functional medicine has been so inefficient because you take an hour and a half at the beginning and the visits are longer that we just couldn’t scale up to meet the demand. With the lean startup methodology, with technology, with things like provider teams, so using health coaches, maybe even a Bulletproof coach, and even things like using group structures. That’s one of the ways that we’ve been able to get it to the underserved. You put 15 people with the same disease in a room and you start them talking. Guess what, peer-to-peer accountability and support. People become friends and help each other out. They make each other their Bulletproof coffee, or whatever. You’re starting to actually access resources that are unlimited like peer-to-peer support, and that’s why we can scale this up.


I hope that some of the things that we’re seeing right at the beginning of this industry will actually lead to us being able to scale up functional medicine in America and then everywhere else needs it, too. Literally, noncommunicable disease is … My dad lives in South Africa. You think African health issues you think TB, and cholera, and typhoid. No, type 2 diabetes, heart disease, and cancer all the way.


Dave:  I love the idea of this going global. You just mentioned something. I know that the Bulletproof coaching program we’re getting a lot of these executive coaches, and to some extent health coaches, but they’re more focused on human performance. You take a business person, or just a person, and show them how to perform better, which may include referring them to a functional medicine person if it’s medical. If its lifestyle just showing them, “Here’s how to make a shift.” How are you working with the Bulletproof coaching program? How does Evolution of Medicine, your work, fit in with non-medical coaching. By the way, 20% of my coaches are medical anyway, but the non-medical part of those? What’s the story there for essentially the health coaches listening?


James: It’s a perfect tie-up, Dave. First of all, the thing that I think is the most important is that everyone in this world needs to have a common language. For me the most likely common language is this functional medicine matrix because it has this timeline. Everyone can understand a patient’s timeline. Hardly anyone does it but its important. You can look at the things that cause the disease and basically you get a good idea of how someone’s health has changed over time. We’re actively pairing doctors with coaches. The first thing we did was start this thing The Functional Forum. We’ve got 200 meetups of practitioners across the country. We’ve heard so many situations. All we wanted to do was create collisions, so we invite health coaches to go, we invite doctors to go, and at these events they meet each other and they’re like, “Oh, I’m a doctor. I just realized I need a coach.” “Hey, I’m a coach. Hey, let’s see if we can work together.” The Bulletproof coaching is just one of the trainings, but through that training people are understanding inflammation, how to change behavior, looking at the things.


Our thinking process of the future of medicine is that functional medicine is the operating system, coaching is the actual delivery system, so that’s actually how you get change is through coaching, and then technology is what scales it all up and makes it all automated and efficient. I think you’re right on point with the coaching. I know you have some goals for physician training, too. I think part of the reason why people are stepping up, I was at the IFM conference last year. Anytime there’s a Bulletproof booth at a conference they’re always the most interesting people in the room.


Dave:  Thanks.


James: People are flocking over there, getting the coffee, and I think that functional medicine doctors are realizing that Bulletproof coaches are a good part of their clinic. I see these worlds coming together. That’s really exciting.


Dave:  It’s a weird model because I believe the vast majority of people listening to the show, and people out there, they have stuff that is a pre-disease state. In fact, we’re all going to get old and die so that’s just the way it is. Maybe not me. I’m planning to opt out of getting old and dying. Just kidding. What’s happening there is you don’t know if you’ve been walking around with something holding you back all this time because it’s always been there, or it crept in and so it’s out of your awareness. If you work with a performance coach, “So, why do you not have energy at the end of the day? You wanted to do it. You set an intention to do it and then you didn’t do it.”


One of the reasons might be because you have some psychological work to do, and you have some trauma. The story you tell yourself might be, “Oh, it’s just because I’m weak,” but what if there story is because there’s something sucking energy that you didn’t know about?” When one of the Bulletproof coaches figures that out with someone they’re going to say, “Now you pick up the phone. Now you call a functional medicine practitioner, and you go and you address it with lab work, and you address it from a medical perspective, and then you come back.” When you clear out the biological inhibitors of performance and then you put in the biological increasers of performance, like say Brain Octane Oil, then you get to the next level where you can do the hard work on personal growth and psychology and be a good entrepreneur, or a good parent, or a good CEO, or whatever your deal is.


That model of not having a medical referral network is tough, because most people don’t know they should see a functional medicine doctor. They only notice when, “I can’t walk anymore.” You’re like, “That pain you had 10 years ago might have been an indicator you should get it worked up.”


James: Absolutely. What I would hope … The reason why I created this book and the reason why it’s free and available to anyone on Amazon the week of October 11, and then will be cheap for anyone, I want patients who are fired up about this to go and give it to their doctor, to go there and say, “Hey, read this.” I hope that my book will be an asset that will convince the middle of the bell curve of doctors to practice functional, because not only is it going to actually allow them to practice the care that they’ve always wanted to practice and they thought they were going to practice in medical school, but actually give them a structure to be able to do that.


What we see a lot, Dave, is doctor wants to do it. They take some courses, they’re excited, they can’t quit their job because they’ve got a mortgage. They’ve got a mortgage. They can’t quit their job. Then it’s like, “Okay, how do I do this?” Now it’s like, “Oh, you start your functional medicine practice on a Saturday morning and you see a few patients here and there, you see family members who you’re just learning and now they’re getting better and then suddenly you renegotiate your thing with the hospital so instead of doing five 8-hour days you’re doing four 10-hour days, and now you’re practicing on Fridays. You get a bit more momentum and then suddenly a company wants to hire you because you were dealing with those employees and suddenly you can quit your job and you can build across. That sort of titration is the practical side. I spoke to thousands of doctors for a decade and it was typically some sort of practical thing that was holding them back from practicing this type of medicine.


I hope what this book will do is to give enough examples of incredible doctors, heroic doctors, who didn’t have a roadmap, didn’t really know what to do and worked it out on the fly, like Hyman, like Amen, all those guys, and now you don’t even have to be a health celebrity like those guys. What we’re talking about is a reproducible model in every zip code. Not every functional medicine doctor could be a health celebrity. We need to have a reproducible model for every zip code in the country, and I hope that the micropractice is going to be it.


Dave:  Well, I have great hopes, as well, and I appreciate the work you’re doing for doctors. For people listening to the show, the book is called The Evolution of Medicine, and if you’re a physician you totally should read the book, because it will let you re-evaluate what you do every day with your time, because it’s not about just putting food on the table. It’s about how you spend every minute of the rest of your life.


This is true for people who aren’t physicians, as well. You read the book, you want to know what your doctor’s going through. You want to choose the right functional medicine practitioner. There’s stuff in here for you, as well. I know there’s a huge number of physicians who listen to Bulletproof Radio, because I know I really piss them off sometimes with some of the things I say, but generally there’s something new and interesting, at least thought-provoking. This is change your life, physician wise, and this is a bring about change for everyone listening where you actually might like your doctor, you might know your doctor, you might have the same doctor for 10 years, and it might be more affordable than what you’re used to doing and, certainly, you’ll have more energy and you’ll feel better along the way. I think that’s one of the most important things you can do as a human being.


James: Absolutely, and I appreciate you sharing that, Dave. I hope they do read the book. One other thing that we’re offering for non-physicians, so anyone who’s listening, is you’re going to be able to, if you follow the link in the show notes, you’re going to be able to actually do your functional medicine intake form. Independent of the doctor you’re going to be able to go through the intake form. It’s going to be able to show you your health from a functional medicine perspective and then you can print that sucker out, take it to the doctor, your doctor, and say, “Hey, look at this. Take a look.” The doctor’s probably going to go, “Yeah, that looks super interesting but I don’t know what it is, and then there will be a link to the book, and they can get the book, and then they can find out more about it.


We’re trying to engage … There are people who are listening to your show who are super passionate about seeing wellness and medicine merge. That’s the bridge. You built it from the biohacking end, we’re building it from the medical end, and we’re going to meet in the middle, and the cool thing is the longer that the powers that be go on ignoring it the more likely that the medical system will be like Bulletproof for Evolution of Medicine and not like, I don’t know, Kaiser Permanente or any of the other, Aetna, or whatever. Do you really think anyone under 40 has any allegiance to Aetna, or Blue Cross/Blue Shield, or anything like that? No way.


I think there’s an opportunity right now for the people that have been doing this right all along, that have set up the right systems, or doing it because of their own moral obligation to actually potentially take over a whole industry and that’s what I’m hoping to empower.


Dave:  Well, on that note, there’s a question I’ve asked every guest on Bulletproof Radio, and I want to ask you because you might have a different perspective on this. If someone came to you tomorrow and said, “Look, I want to perform better at everything I do in my life.” What are the three most important pieces of advice that you would have for them? You look at it as an economist, as a health-oriented guy with all your knowledge of medical practice, but all the other stuff in your life, too. You’re a broad guy. What would you tell them?


James: I got one little hack that I wanted to talk about and maybe this is a good opportunity. Last year I was at a functional medicine conference. There was this guy there who’s from UCLA Stress Lab, and they’ve got this new world called Human Social Genomics, and this world has only been possible because now you can do genomic profiling every 3 months and see the changes in epigenetic expression. He says from their research that the biggest driver of all caused mortality is not nutrition, exercise, or smoking, it’s relationships, it’s the way that you interact with other people, it’s social isolation, it’s friendships, and connections.


One of the things that we really encourage all of our doctors to do, and you’ll read it in the book, as well, is to any time you’re encouraging patients to do healthy behaviors to do it with a group of people, because it can improve their accountability, but there’s just something really powerful about our tribal natures and wanting to be with other people. I would say that social isolation would be so, finding ways to connect with other people about things that you’re passionate about, especially if those things are health related, I think is the number one hack that I would recommend.


Dave:  That was your number one. What are your two and three?


James: Two and three, I would say I’m a big microbiome geek. I found out about that just as the research was coming out. I wrote like 12 articles for mindbodygreen back in 2012, I think, about it. Getting time to be in nature and just spending time to breathe in microbes. That’s another reason why it’s healthy probably to hang out with other healthy people is you’re building other people’s microbes. Getting into nature and getting sources of microbes that are diverse I think is a huge one.


I think the third one would have to be just meeting all different types of people, for the same reason microbially diverse communities. I met someone the other day who’d never left the state of California and he was the same age as me and I couldn’t believe it. Particularly in America, I think that it’s a very single culture, and I feel like some of the best ways that I’ve learned to understand myself and others has been through travel. I guess those are my three tips. You can see, they’re not medical, because I’m not a doctor.


Dave:  I hear you there and I appreciate your knowledge there. Thanks for being on the show. This is James Maskell from Evolution Medicine. What URL should people go to to learn about your book?


James: If you go to, our website is It’s available for free the 11th through the 16th of October, and you can get it on audiobook. I know a lot of people say that their ears have more free time then their eyes, so we got it on audiobook. You can get it on Amazon. Yeah, goevomed is a good place to get in touch with us and we look forward to helping as much as we can.


Dave:  Beautiful. Thanks, James. If you liked today’s show head on over to and try Brain Octane Oil if you haven’t done it yet. There’s coconut oil, which is good for you, and cheap. There’s MTT oil which causes gastric distress and raises ketones a little bit, and there’s Brain Octane Oil which has much less gastric distress and is shown in a clinical study to raise your ketone levels far, far higher. If you’ve been putting coconut oil in your coffee and you like it, you have no idea what’s possible when you put Brain Octane Oil in there.


It takes between 10 and 18 times more coconut oil to distill out just the precious good parts in Brain Octane Oil. Head on over to Check out Brain Octane Oil. You try it once it will change the quality of your day that day. It’s so amazing. While you’re at it, head on over to and check out the new book that James just came out with and learn a little bit more about what your physician’s going through and maybe you can find the perfect functional medicine practitioner to add to your arsenal for your personal performance. Have an awesome day.

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