Episode 58 | Nov 9, 2023

The Functional Medicine Impact with Stefanie Defiglia

In this episode, join Dr. Sandi as she sits down with Stefanie Defiglia, a highly experienced Functional Medicine Nurse Practitioner. With a background as a John Hopkins-trained nurse practitioner, Stefanie felt compelled to explore new avenues beyond the limitations of conventional medicine. This journey led her to discover the power of Functional Medicine and IFM.

As an IFM-certified practitioner, Stefanie is an expert in addressing health concerns using cutting-edge tools like the IFM Elimination Diet. However, embarking on behavior changes can be challenging for patients. Tune in to discover how Stefanie works with health coaches to provide the best outcomes for her patients.

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Episode Transcript

Dr. Sandi: Welcome to Health Coach Talk, and I am very excited today, because I am talking to a practitioner who is certified in functional medicine. She’s a nurse practitioner, and her name is Stefanie DeFiglia. And, Stefanie, welcome to Health Coach Talk.

Stefanie: Thank you for having me.

Dr. Sandi: Thank you. Well, I am wondering what got you started because you were trained, John Hopkins nursing program, and you made a shift to functional medicine. Can you describe what caused you to make that transition?

Stefanie: So, I graduated from Hopkins in 2005 and started out in community health. So, I worked in large health centers, small health centers. I was on a mobile van taking care of people like real true street-level outreach. I did that for about five years. Really had a strong affinity for underserved populations. So, once I was done with that, I moved on to long-term care and palliative care, and long-term care facilities aren’t necessarily thought of as underserved. But where we are, there’s a lot of Medicare, Medicaid population, so it really was again, kind of, that underserved population I was really passionate about taking care of.

I really loved the work. I loved being in the clinics. I loved being in long-term care. What I didn’t love was the thinking. We were very limited in terms of how we could approach things even in long-term care. You know, there would be situations where I would say, “This seems to me like a food issue. Can we make these changes?” But dietary would say no. Or, “I’d like to try… Can we add these nutrients to this patient’s diet?” and they would say no. The insurance company would say no. It was, as long as the care that we were giving was fitting in that nice box of conventional medicine, that’s where we had to stay, and I felt like that was really limiting to me.

So, the more I looked to learn more about integrative and functional medicine, Institute for Functional Medicine just really rose to the top as the place where I wanted to get my training. It’s really well-respected, very science-oriented. So, for me, I went back in 2019. In March of 2019, I started my training with IFM, and I’ve never looked back. It has been eye-opening to say the least. And so for me, that first training, the AFMCP opened my eyes in a way that I just couldn’t return back to doing the kind of healthcare I was doing. So, in August of 2019, I opened my own practice, and that’s to train integrative health where I am right now.

Dr. Sandi: Oh, wow. What an amazing story. That is very common. I really had the same journey just about. I was working as a clinical psychologist, a very conventional world, and I discovered functional medicine and went through IFM, became certified, and was also limited in terms of what you can do as a psychologist. And so I chose to pivot and start a program to train health coaches. Tell us about your practice today. What does it look like?

Stefanie: So, I’m in a relatively rural community in Maryland on Maryland’s Eastern Shore, and we are very limited in providers in general. PCPs are in short supply, specialists are in short supply, and integrative health providers are in even shorter supply. There’s essentially three of us for a six-county region. So, it’s a pretty small number of specialists that do this kind of functional and integrative medicine work.

So, I find myself in the generalist category. I do auto immunity. I work with fatigue, fibromyalgia, gut health, and the perimenopause to menopause transition, which is probably my favorite place to be. There’s just so much you can do for women, and I feel like a lot of my conventional colleagues are, again, stuck in what we’ve been trained to do, and there’s so much we can do with food, with blood sugar control, with herbs and bioidentical hormones that can make such a huge difference for women.

So, I do a little bit of everything by necessity, because there’s just so few of us out here. And once you step into that space, you start to see a lot of patterns among all of these folks. The gut health piece, the elimination diet is a huge part of what I do, and so that’s really what drove my interest in hiring health coaches because that’s something that they do really well.

Dr. Sandi: So, can you first start by describing the elimination diet for listeners who may not know what that is?

Stefanie: So, the IFM elimination diet is a seven-food comprehensive elimination diet where essentially what we’re doing is eliminating the most common inflammatory foods from the diet, so that is gluten, dairy, corn, soy, eggs, peanuts and shellfish. So, those are the foods that are most likely to cause reactions.

We think of food allergies as the mouth swelling, throat closing up kind of allergies that go with a kid with a peanut allergy. And that’s more of IgE-mediated food allergies. Sometimes people can have other types of food sensitivities that don’t present quite like that. So, it can present as gut issues, maybe diarrhea, sometimes skin stuff, acne, rashes, fatigue, insomnia. There’s different reactions that we can have to food.

And so when you have folks that come in with a more complex clinical picture, they’re having autoimmune conditions, they have multiple complex problems, fatigue, but that’s one of the things that I’ll do is to try to figure out, are there food triggers that are part of your symptom picture? If there are, if you’re eating something like, for example, gluten that’s triggering additional joint pain for you and your rheumatoid arthritis, you can’t really supplement your way out of that. You can’t medicate your way out of that. You have to stop adding fuel to the fire. And so when we identify what those trigger foods are and pull them out of the diet, for some people, just that in and of itself can be life-changing. And it’s a part of what I do for probably 75% to 80% of my patients. I’ll put them through that elimination diet. It’s just such a core part of what we do in functional medicine.

Dr. Sandi: Oh, it totally is. It’s the first principle. Remove. Remove and then you replace, and you take out the bad stuff, put in the good stuff, as Mark Hyman likes to say.

Stefanie: Absolutely.

Dr. Sandi:And the elimination diet, while it’s so important and it’s also very hard for many people to be eliminating, because in addition to those foods you mentioned, they’re being asked to give up coffee and chocolate, many of the foods and beverages that they are eating and drinking on a daily basis. And that’s where the health coach comes in. We did our own randomized controlled trial with IFM, where we matched our graduates with their trainees who were suggested to go through the elimination diet themselves, and they were struggling. So, it’s very important to have that health coach guide you, support you on that initial part of your healing journey, which is the remove part. So, can you comment on how you use health coaches for the elimination diet and then, in general, how you use health coaches in your practice?

Stefanie: Sure. So, for the elimination diet, the way I was doing it before when it was just me, because I started out as a micro practice, I didn’t want to hire anyone. I didn’t want to be anyone’s boss. I didn’t want the insurance company to tell me how to practice. I was cash-only, you know, kind of doing my own thing the way that I felt needed to be done for patients.

But what I was able to do with the elimination diet to support patients was pretty limited. I would go through the food plan. I have a television in my exam room, so I’d bring it up on the TV and I take people through the proteins that are on the diet, the things that you can’t eat. So, we’d go through that one by one. I’d provide them with the the guides that the IFM provides and talk them through some really basic things. And then they were on their own. So, if they needed help, they would message me, they would call me, but there wasn’t really a great system in place. It was, “Let me present the information. Here you are. Take it and run with it.”

And and so when I made the decision to hire the health coaches, that’s the first place I knew that I needed help was to have a little bit more structured support in place for patients, because what people don’t realize is that you go through an elimination diet like that, your little go to’s may not be your go to’s anymore. You can’t stop at Panera and grab dinner on the way home, and Chipotle is going to be off-limits because of the things.

So, it’s not only just an elimination diet, but then people who are not used to food prepping all of a sudden have to figure out how to food prep, and they’ve got to figure out how to snack in a way that’s compliant on the elimination diet. So, there’s a lot of questions that come up around food prep, around snacking, around those kinds of things.

So, once we brought the health coaches in, they’re meeting with people three times during that process. So, in the initial visit, getting more information about their history, what’s happening with them, what’s their current diet, where do they think the challenges are going to be with this elimination diet, what are they afraid of, and then really putting a very structured plan in place, providing them with resources above and beyond what we have through the IFM, links to additional blogs where they can find more recipes, family-friendly recipes, sheet pan recipes, things that they can make quickly, prep it, stick it in the oven. Forty-five minutes later, you have a meal that you can eat for the next three days.

So, their support for the patients has been overwhelmingly positively received. People are really happy with the support that they’re getting. They’re happy to have another person to reach out to. And the approach from the health coaches has also been different. People have noticed that as well, because as the provider, we’re trained to assess, find the patterns in the data, and then fix the problem, “This is what we’re going to do. Let me present it to you. This is what we do.”

The health coaches take a very different approach. They’re asking about barriers. They’re bringing stuff out from the patient that sometimes they don’t tell me as the provider, but they’ll confide in the coaches because they have a different approach. And so that support from the beginning through the end, mapping the reintroductions through the reintroduction process, “I’m having a problem here, how do I fix this?” That type of support has been really a huge change in my practice, and overwhelmingly the patients have been very happy with that support.

Dr. Sandi: I love it. And it really shows how this is helpful for you as the practitioner as well as for your patients, because it sounds like, in the past, before you had health coaches, you were spending a lot of time talking to people about going on the elimination diet, answering their questions, talking about potential reactions that they were having. And it was very time-consuming and taking away from your role, which as you said, is the diagnostician. You find patterns in the data. You are the detective, and you are thoughtfully developing a treatment plan. And so this allows you to practice, as we say, at the top of your license when you have health coaches.

Stefanie: Without a doubt. And so the time savings has been huge for me as well. It’s not just about the the support that they’re providing to the patients but also what that’s meant for my schedule. So, that means that, you know, those three appointments that they’re working with the health coaches, I don’t have to worry about what’s happening with them. I’m not checking in with them. We have a very high-touch practice. So, the fact that I can step back during that time means that I can fit more people in my schedule.

And that’s been a an ongoing challenge for me is to keep up with the demand in this community. So, when I was working completely by myself as a solo practitioner, doing everything on my own, there were only so many appointments I could fit in the day. Now that I have their support, I’m able to see more patients and that in itself has been huge for me. And initially, I was nervous about how my patients would accept them because they have been working with me and only me for four years, and I think that concern was really unfounded because of their approach and just how supportive they’ve been to the patients. I have not had any issues with people not seeing me that month for our monthly visit. They’ve been very happy with where we’ve gone.

Dr. Sandi: This is just so wonderful to hear. How many health coaches do you have?

Stefanie: So, at this point, I have one health coach and one in training. So, I hired Valin. She was my first hire in February, so she was actually a patient of mine. So, she had been through the entire functional medicine journey kind of from the patient side. And so when I hired her in February of this year, one of the stipulations of the employment was that she was going to have to do the health coach training, so I paid for 50% of her FMCA program with the assumption I’d get admin support in the beginning, and then she transitioned to health coaching later. And that has been beautiful. So, watching her go through the process, do the elimination diet again through the health coaching when she went through it as a patient but now she’s seeing it on the other side, I think that has been huge. And she’s able to provide a level of support, even on the admin side, as she’s going through the program. And I see this development in her and growth in her and management skills coming out just even as part of that program as it’s progressing.

And then in June, I hired Barb. She graduated from FMCA in 2021 and was part of the alumni program. So, she had health coaching experience coming in, and so she’s been mentoring Valin as well, and she’s been providing most of the health coaching that we’re doing now. So, in March of 2024, when Valin finishes her program, then she’ll be stepping into that role as well.

Dr. Sandi: Great. Could you walk our listeners through a day in the life of a health coach working in your practice? What would it look like? And, also, how do you introduce the concept of health coaching to your patients? It would be really helpful for our listeners to hear how you do this.

Stefanie: Sure. So, I’ll take the second one first. So, in the last four months, we’ve transitioned our practice from a monthly membership practice to more of a program-based practice. So, we have something we call the signature wellness program, which is a six-month, pretty comprehensive, high-touch program for those folks that we talked about, the autoimmunity, the gut health, the perimenopause to menopause transition where they see me for that first initial appointment. So, that’s a two hour long appointment to get all the history and figure out what the path forward will be for that patient.

And then the next step is the health coaching while I’m waiting for the comprehensive stool test to come back or the DUTCH test to come back or the lab work to come back. So, they’re making good use of that time by finishing your labs, going straight to the health coaches, and finishing their elimination diet while all those lab tests are running, because some of those can take some time, especially those comprehensive stool tests can take three, sometimes four weeks to come back.

So, in that first appointment, as I’m explaining the program to people, I describe the health coach as, kind of, their partner within the elimination diet. They’ll walk them through. They answer questions. They give additional recipes. They provide a level of support that you don’t get in other practices. So, they go into it knowing exactly what they’re going to get. I ask them to read over the materials before they even meet with the health coaches. So, that first appointment, when they first meet with Barb is really that level setting for that patient.

So, they’ve read through the elimination diet, they understand what’s expected, they understand what the process is, and then the health coach can step straight into that support role. Where are the barriers? Where are the problem areas going to come up? How do we anticipate that ahead of time? How do we make sure that, when you come home from a late day of work at 6:30 at night on a Thursday, that you’re not going to order a pizza, which is what you normally do at 6:30 at night on a Thursday? So, they can walk people through that, and they’re expecting that from that first appointment.

And there are people who just for one reason or another can’t do the elimination diet. They don’t feel that they’re capable. Their lifestyle doesn’t permit it. There’s other reasons why. So, we have a process in place for that too, that in that first visit, if somebody is really not capable of doing that, or it’s not a great idea for them at this time, that we have other levels of dietary changes that they can make going more towards a whole foods diet from a standard American diet can be life-changing, cutting the sugar, cutting the caffeine, getting the blood sugar regulated, so you’re not having all those ups and downs all day long. That can make a huge difference for someone who’s in perimenopause or someone who’s dealing with autoimmune symptoms. So, we do have backup plans, and that first appointment is really a triage for that health coach to decide, you know, how do we support this patient the best way possible? What’s our path forward?

So, once they do those three appointments, then those patients come back to me. And so the health coaches will do…we block their schedules so that they’re doing three or four of them in a row. They have a break to catch up on their notes, and then they come back to it. There’s time set aside for admin. There’s time set aside for checking the patient portal, which is where a lot of our questions come in for making phone calls.

So, like I said, it’s a pretty high-touch program. There’s a lot of one on one conversations that happen with the health coaches. In the future, one of the things that we’re looking at doing to make our program more efficient and to provide even more support is to create have some content that we can put out there by video or by handouts prior to every visit so that we’re putting some of those educational pieces ahead of time, kind of that reverse classroom concept where we give you the information ahead of time. And then you can use that health coach time, that one on one time to do more Q&A, more support. So, a little less rote education and more support and problem-solving, troubleshooting for patients.

Dr. Sandi: And is this in-person or are you seeing people virtually?

Stefanie: Both. So, during COVID, I was 100% telehealth, which I don’t think I would have done had COVID not happened. So, it kind of opened me up to that technology. And now probably I’d say we’re 60% in person and 40% telehealth. For the health coaches, they’re doing more telehealth than in-person. It’s really easy for people to step out and sit in their car for 45 minutes and take a call and go back to work rather than getting in the car, driving over and seeing us. So, we’re flexible in how we see folks. The health coaches do see some people in-person. But with Zoom and Doxy.me, you can do an awful lot. You can share your screen. You can show handouts. You can circle things. You can do a lot on telehealth. Now almost everything is as you would do in person.

Dr. Sandi: Yeah, and given the need and demand for functional medicine practitioners, you can also expand your reach. You can see many more people outside of your tiny geographic area. You said something that I think was so important. Everything is important. There’s so many critical pearls here. And you said that the support that your patients are getting that in other practices, and so practitioners who might be listening or if you’re a health coach wanting to work with a practitioner, this is a key point that they grow their practice by having health coaches as opposed to that limited way of thinking, “Oh, I couldn’t afford to have a health coach. I’m barely making ends meet in my practice as I’m first starting out.” So, this is something we hear over and over again, that you grow your practice, and it’s much less stressful being a practitioner when you have the support of a health coach.

Stefanie: Absolutely. And I was stubborn in the beginning. I was very dedicated to doing it all myself, but the problem is when you are managing all your own patients, making all your own phone calls, doing all your own education, doing all your own admin, you’re really limited with your reach. There’s only so many people that you can see and do it well. And so, for me, the do-it-well piece non-negotiable. I am very dedicated towards the outcomes that we get in functional medicine. People come in with these specific complaints. That’s what we’re focused on. I want to make sure that your GERD is improved. I want to make sure that your pain level is better. I want to make sure that you can get through the entire grocery store without having to stop in the bathroom if that’s your goal.

So, we are very goal-oriented here and having the health coaches provide that level of support. We have never needed marketing. We have never needed advertising. We’ve grown organically through word of mouth and referrals from existing patients. And we’re getting more now than we ever have because people will say, “This is just a very different kind of healthcare. This is what healthcare should be when we’re talking about what you eat.”

And so some of the providers, if you don’t have time, you end up short-changing the educational piece. And the message that people get is, “You’re overweight, lose weight. You’re overweight, eat fewer carbs. You’re doing this, you need to do that.” But there’s not really an energy put into the how, it’s just the what. And that’s one of the things that the health coaches do really well is they provide that how, and they make it achievable.

So, three weeks of no gluten, no dairy, no corn, no soy can be incredibly intimidating to people. But when you have someone who can break it down and guide you through the process, people will say, at the end of it, it’s not nearly as hard as I expected. And then at the end of it, they have that information, “Now I know what of my symptoms was triggered by food, because when I have gluten, it does this to me. And when I have eggs, it does this to me. And when I drink too much caffeine in the afternoon, this is how it impacts my sleep.” People get that feedback once they are able to tune into their body and do that elimination diet. And that ability to tune into your body and listen to what your body is telling you is so important for the other steps that we do later on down the line, that having a good experience through that elimination diet is really key. One of the key parts of our success is practice.

Dr. Sandi: You have been very successful because you go above and beyond for your patients. You’re a visionary. And this has been such a great conversation. Where can people find you?

Stefanie: So, people can find us online. The website is www.twotreehealth.com and that’s spelled out. I’m licensed in Maryland, Delaware, and D.C. So, I see patients from all three states. If you go on the website, you’ll see a button to click a 15-minute call. So, if you’d like to talk to us and learn more about our practice, that’s the easiest way to do it.

Dr. Sandi: Thank you for being our guest today. Wonderful conversation.

Stefanie: Thank you so much for having me. It was a pleasure.