After a storm hit central Florida in late fall 2020, a 27-year-old female front-line healthcare worker went out to the backyard on a Sunday afternoon to clear debris from a fallen tree that had graciously missed her house. While carrying broken branches to the backwoods, she slashed her left anterior shin on a branch that ripped through her pants and a layer of skin in this unfortunate area with poor blood supply. The wound was cleaned and dressed, and she continued working the next day and through another long week on her feet. At this stage in her life, she was overworking as a Physician Associate (PA) in a busy primary care clinic that had also been converted into an urgent care center during the COVID-19 pandemic. Working tirelessly and feeling underappreciated and undervalued became part of a formula for compassion fatigue and burnout. About 10 days after the injury, she developed wound cellulitis. A colleague evaluated her, ordered blood tests, administered a shot of Ancef, and started her on a week-long course of Bactrim, without much awareness of how this would affect an antibiotic-naïve individual like herself. The patient reacted poorly to the course of Bactrim, developing urticarial wheals that eventually disappeared several weeks later. However, her labs also revealed elevated liver enzymes, prompting a full workup for hepatitis. She continued to work full-time during this period, pending additional labs.

Winter 2020 arrived, and while scarring of the skin took place, another type of rash started appearing, which was diagnosed as guttate psoriasis, with a presumed post-infectious etiology. Additionally, she was faced with the confirmation of chronic hepatitis B status. At this point in her life, it felt as if she had been given a new, shocking identity. This patient was born in an indigenous part of South Vietnam when HBV vaccines were not yet implemented in the early 1990s. Although she received the series later in life before immigrating to the U.S. and was fully vaccinated with other childhood vaccines at the age of 10, it did not matter. Her HBV had remained dormant until an opportunistic infection wreaked havoc on her skin. By early 2021, she was diagnosed with erythrodermic psoriasis and chronic HBV, and shortly thereafter, eczema, which runs in her family. Red scaly skin patches layered with itchy excoriations continuously moved to different parts of her body. Her first dermatologist initially suggested that the condition would eventually improve as her immune system healed from the post-inflammatory effects of the skin infection. Yet, almost four years later, by the time this story is published, the rashes and flares still wax and wane. She was unable to take oral immunosuppressants during major flares because that would activate the HBV, requiring lifelong treatment for hepatitis B. Therefore, she chose to stick only to topical treatments during flares as needed. There were flares that lingered for months due to chronic stressors, lack of self-care, and in late summer 2021, she contracted the COVID-19 Delta strain. Her autoimmune rashes were at their worst during that period.

By then, she had been training with the Institute for Functional Medicine (IFM) for nearly four years and began implementing the Elimination Diet to remove potential triggers and attempt to heal the gut lining. She then reintroduced most of the foods. Through self-experimentation and evidence-based research on the microbiome, she became more attuned to triggers from lifestyle choices, including dietary intake, exercise routine, sleep quality, stress resilience, social connections, and more. At the end of 2021, the patient relocated, hoping for a better chapter in her life. Each lifestyle choice has had a direct impact on her microbiota, both skin and gut, leaving imprints on her skin via scars from the rashes. Her microbiome is still not the same as before the yard work injury or the treatments for that initial infection. Each time her immune system encountered a new antigen—whether an allergen, virus, or bacterium—the psoriasis-eczema combo would flare up again, affecting all parts of her body. Each flare lasted longer, impacting her quality of life increasingly. Finding balance in food choices, exercise routine, sleep quality, stress management, and healthy relationships—while avoiding risky substances—can either calm or trigger the immune system. 

How she supports her microbiome through lifestyle choices is as crucial as its ability to heal from within. This patient is embarking on a lifelong journey to heal her leaky gut and subsequently her leaky skin. The patient in this story is me. 

My name is Nhi (pronounced like ‘Knee,’ and it means ‘Little’), and I am Vietnamese-American. I now have a name for this rash of mine: ‘The Quiet Extrovert.’ I am learning to completely accept it while remaining as loud an introvert and as true to myself as possible. I believe in a root-cause approach to resolve, if not reverse, a multitude of medical conditions. Currently, I am a triple-board-certified PA, trained in Functional Medicine and Lifestyle Medicine. I have been researching opportunities to enhance my clinical practice as I continue to pursue my personal and professional goals. I enjoy spending quality time with family, practicing power yoga, blogging about healthful resources, meal-prepping, traveling, and being in nature. My resource blog is www.nhimado.org; for anyone interested, check it out and share it! This is my way, as a loud introvert, to share with the world.

During some of my previous experiences, whether as a student or an employee, I often asked, “Where is the joy in this?” Nowadays, I simply state, “The journey I am on has joy in it.” There will be sorrow and challenges too, but joy is always a part of this current journey. We are creatures of habit, and sometimes those habits override our judgment over time. As a result, the medical system has become more reactive than ever! There is a pill for every ill. Where did we go wrong, and how was joy lost? I am speaking on behalf of many medical practitioners who have become more jaded over the course of practicing medicine. But practicing itself is part of the joy! Sometimes we do not have all the answers, and the beauty of the journey lies in working with our patients to reveal the root cause(s) of their conditions that led to their diseases in the first place. That is the real joy in the medical field, which I still believe in!

While in my first four years practicing as a PA, I began and completed my intensive training with IFM and received my Board Certification in December 2021. I then found my way to the American College of Lifestyle Medicine (ACLM) in early 2022, as I felt its root-cause approach and pillars of health foundation complemented the Modifiable Lifestyle Factors under the IFM Matrix very well. At this time, I am also Board Certified in Lifestyle Medicine through the American Board of Lifestyle Medicine as of December 2023. I love utilizing the tools from both organizations to help my patients and loved ones, provide educational seminars, and offer actionable take-home points and handouts. I became a member of ACLM shortly after I started working full-time with my current employer at the beginning of 2022. Since then, I have become more involved with ACLM Member Interest Groups (MIGs), particularly the PA MIG, the Primary Care MIG, and the Cancer MIG, with their ongoing lifestyle-driven projects. I have been fortunate to lead an incredible project in creating and publishing the first Lifestyle Medicine for Cancer Risk Reduction and Survivorship Toolkit through ACLM with a five-member task force. I was thrilled to discover more like-minded health professionals!

While practicing full-time as a PA since 2017, I also enjoy creating lectures and hosting free classes for my patients and community members. I focus on different pillars of health in each interactive lecture and always remind my audience of the foundation of whole-person health, which aligns with Dr. A.T. Still’s practice philosophy. As I advance in my career and as a true learner, I have been pursuing a Doctor of Medical Science degree with A.T. Still University since March 2024. I am learning not only about medical writing and research methods but also about integrating evidence-based data into clinical practice.

In December 2014, I graduated from the University of Florida (UF) with a Bachelor’s in Nutritional Sciences and a Minor in Health Disparities in Society. Since then, I have learned a great deal more about nutrition and wellness beyond the textbooks. I returned to UF for my Master of PA Studies from 2015-2017 and have always been drawn to lifestyle as medicine. All in all, I love presenting a diverse collection of lifestyle topics and providing much-needed resources to all walks of life, along with simple tips and tricks. During patient encounters, I often use a health-coaching approach to inspire action, such as designing S.M.A.R.T. goals! This acronym describes how to create goals that are Smart, Measurable, Achievable, Relevant, and Time-bound. My patients often share their most vulnerable stories with me, and translating those stories into medical records and care plans helps them understand that I am genuinely trying to meet them where they are and guide them toward better health and happiness. We create S.M.A.R.T. goals together to empower one another toward a therapeutic relationship between practitioner and patient. I am grateful to have learned this skill over the years in practice and during my pursuit of lifestyle medicine. Most importantly, it has been empowering to see the excitement in my patients’ eyes, whether during one-on-one appointments or group lectures, when they too are empowered to nurture their well-being journey!

From time to time, I reflect on my unique post-PA training experience at the True North Health Center as an intern immersed in a community of patients healing from water fasting. I recall how my psoriasis-eczema-combo rashes occurred during the middle of my training in functional medicine and how I utilized the tools to reset my gut from IFM. I then applied ACLM’s lifestyle medicine pillars and have been implementing the principles of eating plant-predominant foods and more. Having the knowledge and know-how without an environment that allows me to fully flourish would not align me for success with my rashes. Therefore, I am still embracing the waves of flares that wax and wane. Almost as if these urticarial rashes are trying to tell a story and a message that my body wants to give me. So, here goes the question again: ‘Where is the joy?’ Is it still on this journey?! Am I going to be alright? I find the joy in this journey that I walk, with my supporters—those who believe in me and give me the benefit of the doubt. As a saying reminds me: the world is my Petri dish; this time, I am the experiment on that Petri dish. And until I find the root causes and complete resolutions, I shall continue to find joy in my journey. Please recognize the joy in your journey too. Thank you for reading my story!