Welcome to the Evolution of Medicine podcast! This week, we sit down with Shalesh Kaushal, MD, PhD for Part 10 of our Group Visit Series. This episode looks at group visits from a different perspective—a much narrower one than we have previously shared, and I really love that. If you’ve been following our series or are familiar with group visits, you know that they are effective in so many areas of medicine, but in general, they affect the reversal of chronic diseases. In this episode, we’re talking about group visits in a very specific application: retina disease.
Dr. Kaushal is a pioneer on this front, bringing the power of group visits and community to super specific disease cases. His work exemplifies the broad range of application group visits can have, and how their positive impact can reach across the spectrum of medicine, from the general to the specific. If an ophthalmologist can run group visits, so can you! Highlights of this episode include:
- How Dr. Kaushal got his start in functional medicine
- When he realized he needed to deliver care in a group format
- What he has learned from his work as a medical specialist and group visit practitioner
- How he has used Group Visit Toolkits in practice
- And so much more!
James Maskell: Hello and welcome to the podcast! This week, we are continuing our Group Visit Series and we are talking with Dr. Shalesh Kaushal, who is a MD, PhD ophthalmologist and retina specialist. Now, if you’ve been following our series you know that group visits are super effective in so many areas, but in general, we’re talking about reversal of chronic illness. It can be quite a general thing. Well, here is a very specific thing: retina disease.
We’re going to hear today from Dr. Kaushal. One, how he got interested in functional medicine. Two, how he realized that he needs to deliver that through in a group. And three, what he’s learned from being a super subspecialist and using group visits.
If you’ve ever thought about retinal diseases or whether you’ve never thought about it, I think it’s a super exciting moment because ultimately it shows that the power of group visits can go all the way through medicine from the general to the specific; really, really interesting half an hour. I hope you enjoy it.
James Maskell: So a warm welcome to the podcast. Dr. Kaushal, welcome.
Dr. Kaushal: Thank you.
James Maskell: So Doc, it’s great to have you here. Through these last series, on the Group Visit Series, that we’ve done, we’ve really looked at all different areas where group visits and functional medicine can be valuable. I would say actually there’s been a range of topics that we’ve spoken about. But in general, the theme of the group visits as being quite general. It’s about recovering your health.
One of the reasons why I’m really excited to connect with you today as a retina specialist is because the work that you’re doing is very specific. So I guess just to start the conversation, maybe we could just start with how a MD, PhD retina specialist ophthalmologist gets interested in functional medicine in the first place.
Dr. Kaushal: Yeah. So mine is a slightly a different arrival as it were to functional and nutritional medicine, genomic medicine is. So just briefly, I was in academics most of my career except the last few years where I’ve transitioned to private practice. But some years ago we had discovered in our lab and subsequently thereafter that there’s a set of critical cellular pathways that control homeostasis or balance in the cell in the retina in particular, which we studied intensively. But it turns out those cellular pathways are canonically conserved. In other words, they’re conserved in all cell types in humans and for that matter from E. coli bacteria all the way to human cells as well. Those cellular pathways are interconnected with each other. And as I said, they control homeostasis. So you can think of them as springs connected to each other. If you jiggle one spring, all the other springs vibrate together.
That’s in some sense the intrinsic intelligence of itself. At the same time, it’s the response system when there is a stressor to a cell, be it in an external stressor, which is most often what we consume, right? What we eat and also internal stressors as I called them, our genetic makeup. Those genetic SNPs are single nucleotide polymorphisms present a certain stress in certain situations in certain cells over the lifetime or episodically for patients.
So given all that as our understanding started to deepen on these cellular pathways that are critical in not only homeostasis but also in the pathogenesis of various retinal diseases. It became clear to me as I read outside of my own field that these cellular pathways were being identified or had been completely identified to participate in other chronic diseases. Alzheimer’s, Parkinson’s, coronary artery disease, hypertension, diabetes, obesity and so on.
So as I kept reading more, it was clear that there was this rich biochemistry and also clinical work in these areas, these other chronic diseases and in the cellular pathways. That led to a serendipitous set of circumstances where I ran across some functional medicine literature. I didn’t know the name functional medicine five, six years ago. I just, as a biochemist, think in terms of biochemical pathways, and obviously most of the biochemical pathways that control homeostasis in a cell and in some sense in our bodies in total, are controlled by, not surprisingly, nutrition.
So in any case that’s, I sort of backed into a functional medicine. Not that I was looking for more clinical things to do or clinical approaches, it was because of our own research interest. But that’s blossomed over the years to also incorporate some of the principles, clinical principles of functional/nutritional medicine in my own practice.
James Maskell: Yeah, absolutely. Yeah. No, it’s clear that I think there’s so many specialties that sort of get drawn into it because I think many practitioners in the field and doctors who are really like thinking about why this is happening to their patients really have to end up taking a dive into understanding the why and you can see that something is macro is the sort of environment that we live in and the stress and the food and everything that goes into that can make a huge impact on even something as specific as the eye.
So tell me about your journey to actually start to implement these ideas into practice. Because obviously, it’s not like you have a lot of spare time anyway being specialists.
Dr. Kaushal: Yeah. Yeah. That’s a great question. It’s fun to share with people, the answer as well. Yeah, just to give a little perspective. So when patients come to a specialist like myself, and other people who are retina specialists or are in any specialty in medicine for that matter. They’ve usually been seen by other folks, in my own instance, they’ve seen an optometrist or general ophthalmologist, internist, often an endocrinologist or cardiologist.
So by the time they come to see us, we already have a sense of what may be the particular disease process that’s occurring in that patient. And then on the flip side is so we see because there’s such a…we all know that chronic diseases have literally exploded and not only the United States, but across the planet, right? We are incredibly busy. So a typical day for myself is seeing anywhere from 60 to 70 patients.
Now that sounds like a large number. Well, it is a large number, but there’s a whole group of staff people who work with me who are working up patients doing specialty testing and then who are in the room with me scribing. In other words, making all the entries into the electronic medical records. So I’m actually talking to the patient the whole time that I’m in the room.
Now, as you might imagine, if you’re seeing that many patients who can’t have an in depth discussion about nutritional/functional medicine with anyone. But what we did read or what I did recognize five, six years ago is that…see, the retina is a very sensitive barometer of health and nutrition. For two reasons. One, it’s extremely metabolically active, perhaps the most metabolically active tissue per unit weight in the body. And clearly it has the largest blood supply per unit weight.
So nearly every human disease has a retinal manifestation. That’s on one side. Given that, it was clear to me that if I really wanted to impact not only a patient’s vision, right? I had to impact their health, overall health. So what I call as foundational nutrition, we discuss that with every patient, every single time they come to clinic. It’s just by sheer repetition, we hope to, at least, begin to alter people’s behavior in terms of what they consume, their lifestyle and so on. Even those who are more interested, I tell them about the studies. For example, that macular degeneration is an age-related inflammatory disorder and there’s clear evidence that nutrition influences it in a very significant way. So we present that and that evolved over a couple of years. But to me that was still unsatisfying because I felt that I needed to make a bigger impact.
So that’s where the idea of doing a group visit for retina patients evolved from. Originally it was diabetic patients, patients with diabetic changes in their retina. It was a confluence of multiple things. One was my own desire to have a more detailed discussion with patients. And then second was a colleague of mine, he’s a retired professor from the University of Miami in The Villages, Florida. It’s the largest retirement community in the United States and where we have one of our clinics. He had been doing something like that for diabetic patients. He wasn’t a diabetic specialist or endocrinologist, but just as a retired person, how he had developed software for patients to follow their A1C levels.
So in any case, that coupled with the fact that I had seen what he had been doing and one of the…his group meetings, his own group meeting as it were over the last five to seven years in The Villages. I thought, geez, perhaps we could work together to do group meetings for our retina patients. So we did. We launched that about just about two years ago, almost two years ago now. That’s been fantastic.
I’ll just share with you what we do. We get together once a month on a Saturday and initially, obviously, we talked about diabetes, diabetic retinopathy. But that, it was clear. We have a nice solid core group of people who come quite regularly, 15 to 20 folks that they were hungry and keen to learn more than just simply what may be impacting their diabetes. And of course, that’s a lot of it is nutritionally controlled and diabetes as well, particularly type 2 diabetes. So then I said, “Geez, this is interesting.” I was in touch with Dr. Shilpa Saxena and she told me about what the kinds of things or programs that she had developed.
What we did was we took that and we modified it. And what I do now, really our group visit is…or actually, I really looked forward to it because it’s a lot of fun. We just had one this past Saturday and we’ll touch on almost any topic, right? We covered things or begun discussions around genomics. We’ve talked about microvascular health, cardiovascular health. We’ve even got covered things like omega-3 fats, right? What should we be consuming? What’s the controversy? What is reasonable for someone to consume and what’s the role of omega-6 fats and so on.
So various topics like that. What I found is, well, first of all, it’s as I said, incredibly gratifying to share this with patients. But it’s changing behavior and that’s the fun part. They’re changing the way they think about their disease. They don’t think of it as an irreversible event as it were. They’ve come to appreciate that chronic diseases can be stopped and in some instances outrightly reversed.
James Maskell: Yeah. Yeah. That’s amazing. So I know obviously it’s a much more efficient way of delivering information, but what I’m really interested in is really the peer-to-peer delivery of value, right? How one patient adds value to another patient, independent of the practitioner. So what are some examples that you’ve seen from that of one person’s success leading to another person’s?
Dr. Kaushal: Absolutely. It’s so interesting you say that, James. So I’ve seen this. I see it when I’m…for example, before we start the people are sitting in our large waiting room, we sort of have a large circle of chairs at that point. They’re chitchatting and it’s a lot of fun. They’re reinforcing what they’ve learned in the past, what…so the first 15, 20 minutes really is, they talk about, “Oh, okay. When we met last time, this is what I implemented.” And then somebody will say, “Oh look, I tried this and I had some success with this.” Or “Where did you find these particular foods?” They share notes, emails, texts that way. So it’s really, that’s in some sense, that’s the most gratifying part is because it’s almost like a pyramid. They’re building off of each other.
James Maskell: Yeah, no, I love that. We definitely seen that occur across all of the groups. I guess, what are some of the challenges of delivering groups for such a targeted population? I mean, I imagine in a certain way it’s kind of easier because you can…when something’s a lot targeted, very targeted and you have a lot of those kinds of patients. It’s sort of a fit for them and they’re talking about exactly an issue that they have. But are there extra benefits or extra sort of drawbacks as far as you see it for having such a sort of a tight focus?
Dr. Kaushal: Not necessarily. Because as I mentioned to you, there are so many factors that influenced the development of retinal diseases that they overlap with so many other, if you’d like to call it, well, other specialties of medicine. Also, even other disease processes. For example, see macular degeneration in Alzheimer’s, they often co-migrate. In other words they can be present if a patient has Alzheimer’s, it’s important for them to be evaluated for possible macular degeneration and vice versa. Right?
So what I find is it’s a significant time commitment not only for myself. For example, our group visits aren’t…we’ve never had…I hear other people having a group visit for an hour. Our shortest group visit is two and a half hours, right? Sometimes they go for three hours. It’s until I’ve completed what I wanted to cover with them. And then there’s fairly intensive question and answer session and also comments.
There’s plenty of time for people to add comments and questions during the course of that time. So like I said, from my perspective, it is a very significant time, especially on a Saturday morning. We do it from nine to noon or so. That’s important. But I think if somebody is willing to make that type of commitment then not only as a care provider, via physician or anyone else, but also from the patient side. I think there’s a real chance to make an impact that’s more durable effect in a patient’s life or a person’s life. Then sort of episodic, you see them once a whatever, a couple months or whatever the case may be. You want it when there’s a certain discipline, in our own instance, getting together every month. Then there’s that group dynamic that you are alluding to that also continues to build and it creates a type of momentum.
James Maskell: Yeah, absolutely. Yeah. I mean that’s super interesting. It seems. What has been when you speak to other people who are in your field particularly? Do they look at you like you have two heads? I mean, how far out of the conventional practice of ophthalmology is this and do you see your colleagues sort of coming around to starting to really understand that they need to take a whole body approach to such a specific issue?
Dr. Kaushal: So that’s a challenge. I am not aware of any other ophthalmologists or general ophthalmologist doing what we’re doing, even though I’ve given talks about this both nationally and internationally. I do it in the context of our own discoveries, right? But I would say my ophthalmologist and retina colleagues, they’re not looking to do more than they already are doing because they’re busy enough. But like I said, for me it’s a passion because of our own, as I said, the way I came to it was from our own research. So it has a different meaning.
But I will say this, for those of you who may be thinking about it. I mean there, there’s some practical implications of it too. Because I will tell you our patient, it’s our group visit. It’s very interesting. They will go talk to their friends and say, “Hey look you might want to consider coming to the group visit.” Or be seen by me as a patient, right? As an eye patient. Almost invariably unsolicited for me is what I hear from these folks is that geez, this is a different dimension that none of their other doctors talks about. What was very clear is there’s a tremendous desire on patients or I would just say the lay person in general, right, about learning about this. But it’s a question of access to the information and I’m sure you faced the same thing.
James Maskell: Yeah. I’ve seen it for sure. And I think it’s really exciting and I could imagine that if there are some practical benefits to it, I marketing for the practice, the word getting out there that you’re doing things differently, then that could be extremely beneficial to the next generation of ophthalmologists that are looking for ways to differentiate their practice and possibly, ophthalmologist working with health coaches or dieticians or nutrition to form these kinds of teams.
One of the things I’ve been thinking about is oftentimes in order to communicate what we’re trying to communicate to patients, we’re sort of looking for an opening where patients are sort of sick enough to go and do something about it, especially with men, right? Where with women that are a little bit more proactive and I guess I’m just thinking that perhaps this is kind of like a stealth way to get people because I’m sure there’s a lot of people in your groups who don’t really have any other health issues, but their vision is going and this is kind of the first thing that happens. It may be a first time that they even hear about lifestyle or functional medicine because their labs are normal range and they’re just so generally healthy and here’s an opportunity to sort of engage them.
Dr. Kaushal: Yes, exactly. That’s exactly right. We have a whole set of folks who are like that. Exactly as you described.
James Maskell: Yeah, that’s really, really wonderful. So what advice would you have for other specialists and areas, people who may have sort of got an inkling already, maybe that behavior change is hard or the functional medicine doesn’t scale or that this is not affordable for most people. What sort of advice would you have for other people that other specialists who may have considered those issues, but I’ve never tried a group visit?
Dr. Kaushal: It’s one of those things you got to jump in with both feet, right? You have to, obviously, you want to prepare yourself. I remember the first couple of group visits I did. I was anxious about it frankly because I wasn’t sure how it would be received, but when it was clear after even the first or second one how engaged people were. That made me feel that I was doing something that was meaningful for them. Perhaps even more meaningful than my eye exam to be honest, right? Because if I can impact their overall health, that’s going to help their vision, but it’s also going to help all their other organ systems as well.
So it’s one of the things, yes, you need to prepare yourself well. There’s lots of tools and lots of presentations and information on the web and otherwise that you can read and prepare. For example, I prepare my own PowerPoint presentations when you get together. It’s kind of fun to do it and it’s a chance to review the literature at the same time too. So that the information that I share is not only up-to-date but as accurate as I can possibly be to reflect current thinking. And then after that you just go for it.
It’s one of those situations if the desire, and it boils down to desire as does almost everything in life, right? If the desire is really to try to stop the or stem the tide of chronic diseases by either stopping the disease progression or slowing the disease progression or in the most, in the best of circumstances reversing the disease progression, then it seems to me it’s a group is that is absolutely an essential tool in doing that.
James Maskell: Absolutely. That’s wonderful. I guess the last question I want to ask doc is obviously this podcast is sponsored by the Lifestyle Matrix Resource Center. Shilpa was a real inspiration for me six years ago when I heard her lecture at a conference and I just kind of…I just had an intuitive hit that this was really with the way things had to happen, if we really wanted it to get this to all people. How much easier was it to feel confident in doing that first visit with all of those materials in the Group Visit Toolkit?
Dr. Kaushal: Oh, absolutely. I was alluding to it earlier and I wasn’t sure if it was appropriate for me to discuss it. But yes. I, in fact, had multiple conversations with Shilpa and the Lifestyle Matrix resources, at least for the initial couple group visits was wonderful. I even took those presentations and I added more slides into my own, right, to flesh it out further. As I said, after the first a couple, I just make my own slide presentations now for our…depending on the subject that we’re going to cover.
James Maskell: Absolutely. Well, Doc, look, I really appreciate you coming here onto the podcast and I hope more than anything that anyone who’s listening to this really realizes that we, everyone, almost everyone in medicine has to be bringing people back to the principles of lifestyle medicine and functional medicine if we’re really going to stem the tide and we’re really serious about behavior change. That can only really be done effectively in a group. So whatever type of whatever play…whatever role you’re playing in healthcare. If there is a behavioral element to the patient’s health and there’s this sort of like way of thinking about it. We need to get on board. I really appreciate you sharing it because I think that if I was to ask a practitioner or just a generalist like, “Oh, can you think of a profession that wouldn’t benefit from this?” They might say like, “Retina specialists because it’s so specific.” And yet, the way you’ve described it is so obvious. I know even in my own family, certainly the macular degeneration was a function of…had lifestyle component to it.
Dr. Kaushal: Absolutely.
James Maskell: Yeah, I’m excited to make that connection. So share this with your local ophthalmologist. If you’re a health coach or nutritionist, maybe go in and meet an ophthalmologist and send them this podcast or give them my upcoming book and maybe that’s a way that you could make a difference in the patients in your community.
Doc, thanks so much for leading the charge. It’s not easy to be the first person to do things.
Dr. Kaushal: You bet. This was fun though.
James Maskell: But it is a lot of fun, I’m sure.
Dr. Kaushal: James, if you don’t mind, if I could just share one other thing and perhaps you and your audience would be interested. We’ve run an annual meeting here in Florida. It’s called Reversal of Chronic Diseases. We’re having our fourth one coming up in February, February 14th and 15th here just a little North of Tampa at a beautiful resort, Innisbrook Golf Resort.
What we do is invite really outstanding clinicians and scientists, colleagues and friends of mine in the past from MIT, Duke, Harvard, Yale and NIH and so on. A Case Western. The idea is to bring people who are doing cutting-edge science or have contributed significantly to both basic and clinical science in the area of reversing, just outrightly reversing, chronic diseases.
We’d love for people to attend where this is really a labor of love more than anything else. We want to provide information not only for people in health care, but even the curious lay person. In fact, I would say over the last three meetings, the most incisive questions came from the curious lay people versus the physicians or even the PhDs in the audience. So if any of your audience members might be interested, we’d love to have you come. We have a wonderful set of speakers this coming year as well. You could call our number 352-775-1010 if you’d like to attend.
James Maskell: Wonderful. Yeah. Well, I’ll put all the details in the show notes about the conference. Yeah, I’m excited to hear that that kind of thing is happening. Yeah, doc, again, really appreciate for you being part of the evolution of medicine podcast. This had been our group visit series. This is the first session that you’ve heard. You can go back through the other nine sessions that we’ve done. Check out my book out January 14th it’s called The Community Cure where we’re talking about group visits. But in the meantime we’d be with Dr. Shalesh Kaushal.
I’m your host, James Maskell. Thanks so much for listening and we’ll see you next time.
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