Clinical MedicineHealth PolicyPA Practice

‘Dys’functional Medicine: A Risky Departure from Evidence-Based Practice

Functional medicine has garnered increasing attention in recent years, presenting itself as a holistic, personalized approach to healthcare that aims to address the root causes of diseases rather than merely treating symptoms. However, this alleged paradigm shift reeks of psuedoscience under the facade of progress.  

Despite its appeal to patients seeking individualized care, functional medicine often diverges significantly from the principles of evidence-based medicine (EBM). So significantly, in fact, that it’s barely recognizable. This article exposes how functional medicine tries to borrow the vocabulary of biology, chemistry, and medicine while completely departing from their precepts.

The Principles of Evidence-Based Medicine

Evidence-based medicine is the gold standard in healthcare. Full stop. Or at least it ought to be. It integrates clinical expertise with the best available research evidence to inform decision-making. 

Evidence-based medicine (EBM) relies on rigorous scientific methodologies, including randomized controlled trials (RCTs), systematic reviews, and meta-analyses, to ensure that treatments are both safe and effective. This approach minimizes bias and maximizes the likelihood of achieving positive and predictable patient outcomes.

Defining Functional Medicine

Functional medicine purports to offer a more individualized and holistic approach by identifying and addressing the underlying causes of disease. Acolytes seem to tout this as a novel concept as if practitioners of EBM were somehow uninterested in anything but superficial symptoms. 

Functional medicine supposedly emphasizes the interconnectedness of body systems and the impact of lifestyle factors such as diet, exercise, and stress (which is actually great and not a new concept). Proponents argue that this model provides a comprehensive, patient-centered approach to health. But that’s where anything worthwhile in functional medicine ends.

The Departure from Evidence-Based Medicine

A Foundation on Shaky Ground

One of the fundamental critiques of functional medicine is its heavy reliance on tradition, Eastern philosophy, scientific-sounding jargon, and good old-fashioned anecdotes. “I’ve seen this work for other patients, so surely it will work for you.”

In functional medicine, clinical decisions are often guided by theories that may sound sophisticated but aren’t backed by real-life evidence. While herbal supplements, vitamins, and dietary restrictions can be valuable tools, their use must still be based on credible evidence. 

Reflexology, craniosacral therapy, homeopathy, reiki, therapeutic touch, chiropractic, and energy healing are all examples of mystical practices that not only have no hard evidence but have actually been disproven in the research. Functional medicine is right at home here.

Sure, sometimes people who utilize these therapies improve. While that’s certainly a reason to celebrate, without a plain understanding of how or why these things work and the ability to reproduce results with some degree of certainty, it equates to selling the patient a costly experiment and may provide false hope.

The placebo effect, regression to the mean, and spontaneous remission can all contribute to perceived improvements, making it difficult to ascertain the true efficacy of a given intervention without rigorous clinical trials.

Lack of Rigorous Scientific Validation and Magical Thinking

Many treatments and diagnostic tools used in functional medicine lack rigorous scientific validation, and frankly, don’t make any sense at all. For instance, functional medicine practitioners often employ comprehensive stool analyses, hormone tests, and micronutrient assays. These tests, however, frequently lack standardization and have not been proven to correlate with clinical outcomes. Functional med practitioners also like to talk about “optimal” levels versus “normal”.

Take Vitamin D, for example. It’s a popular one to check and treat. But are low levels of Vitamin D in the blood the cause of or the result of a particular malady? And is a patient with 30 ng/mL really any worse off than a patient with a Vitamin D level of 80 ng/mL? Where’s the proof?

The use of dietary supplements and nutraceuticals is all too prevalent in functional medicine despite the clear warning that these “products are not intended to diagnose, treat, cure or prevent any disease.”

While some natural supplements have been studied and shown to be beneficial, most others lack sufficient evidence to support their use. And ironically, when given in supratherapeutic doses, these supplements no longer act as dietary supplements but as drugs. If only someone had mentioned that to 30-year-old woman who died after an IV infusion of turmeric or the 64-year-old man who died after an IV vitamin infusion.

This isn’t to say that people don’t die from medication interactions, reactions, and overdoses because they do. But it’s likely that few of those harmed by unregulated supplements saw it coming.

Functional medicine also seems to be uniquely capable of finding a host of alleged fungal or bacterial infections (of course missed by mainstream medicine) that often require long, potentially dangerous antibiotic regimens.

Let’s just get this out of the way, too… It’s not fair to say that EBM providers don’t already take a holistic approach and strive to identify the root cause of disease. No doctor or PA treats a cough without considering what might be causing the cough, what exposures might the patient have had, and what other health conditions, medications, and lifestyle factors might be contributing. 

Integration of Pseudoscientific Concepts

Functional medicine openly accepts unscientific ideas. For example, the idea of “detoxification” is a common theme in functional medicine, where various treatments are purported to cleanse the body of toxins. However, the concept of detoxification is quite silly really as the body has its own highly efficient systems for eliminating toxins (i.e. the liver, kidneys, skin, and lungs). 

Then there are the functional medicine diagnoses that most doctors and PAs recognize as spurious and completely unfounded in the world of facts and data: adrenal fatigue, leaky gut, chronic Lyme disease, candida/yeast infections, MTHFR mutation, and heavy metal toxicity to name a few.  

Overemphasis on Individualization

While personalized care is a laudable goal, functional medicine overemphasizes individualization to the detriment of evidence-based guidelines. While we are all unique in some way, we are more alike than not. You may like your coffee just so but you still need oxygen as the end electron acceptor in order to create an electrochemical gradient for hydrogen to create ATP.

This well-meaning approach does sound nice. Who wouldn’t want to be recognized and treated as unique and special? 

The Allure of Functional Medicine

Despite its departure from EBM, functional medicine appeals to many patients and practitioners. This appeal can be attributed to several factors:

  • Holistic Approach: Functional medicine’s holistic approach resonates with patients seeking comprehensive care that addresses physical, emotional, and lifestyle factors. We all recognize that our modern lifestyles are unhealthy but we’re not quite sure what to do about it. 
  • Personalized Care: The emphasis on personalized, patient-centered care (and longer consultation times) allows for a more in-depth exploration of patient concerns and fosters a strong therapeutic relationship, something traditional medicine just can’t afford to do.
  • Frustration with Conventional Medicine: Some patients turn to functional medicine after feeling dissatisfied with conventional medicine’s supposed focus on symptom management rather than addressing underlying causes. 10-minute appointments, fighting insurance companies at every step, and the over-compartmentalization of medical specialties don’t help. 
  • Marketing and Misinformation: The effective marketing of functional medicine, often bolstered by testimonials and anecdotal success stories, can create a perception of efficacy that is not supported by scientific evidence.

Medicine vs Alternative Medicine

Patients should understand that, truthfully, there is no such thing as functional or alternative medicine. Any effective method of diagnosis and treatment becomes a part of good medical practice. There is no such thing as alternative science or “alternative facts”. Science is science and anything else is… not.

This fact was made quite clear in a 1998 JAMA article:

There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is “Eastern” or “Western,” is unconventional or mainstream, or involves mind-body techniques or molecular genetics is largely irrelevant except for historical purposes and cultural interest.

Alternative Medicine or an Alternative Lifestyle?

Psuedoscience might just be the symptom of a greater ill, however. There seems to be a growing body of people that reject the well traveled path in favor of forging their own way. It’s almost like a way of life. A middle finger to authority.

The COVID-19 pandemic drew a line in the sand between those who understand and appreciate science and those that do not, for example. The anti-vax crowd seemed quite at home promoting unproven therapies for the coronavirus. They were often the same people who already prefered natural remedies and essential oils and distrusted Big Pharma. As noted by Stephen Barrett, MD “The ‘alternative movement’ is part of a general societal trend toward rejection of science as a method of determining truths.” It’s a post-truth era.

The Ethical Implications of Frontier Medicine

The ethical implications of functional medicine’s departure from EBM are significant. The potential for harm exists when unproven treatments are used in place of evidence-based interventions. It’s not okay to add morphine to children’s cough syrup. Additionally, the financial burden on patients who pursue expensive tests and treatments that lack validation is a major concern. Healthcare is already too expensive. Functional medicine needless adds to those costs.

Functional medicine practitioners love to order extensive laboratory panels that can cost the patient thousands of dollars. The worst part about these expensive analyses is that they’re mostly useless. Here are some functional medicine favorites: metabolism panels, methylation profiles, micronutrient reports, and food allergy tests. 

Functional medicine folks also love gut permeability studies, hormone levels, tests of inflammation, and genetic profiles. When ordering dozens of labs, the odds of finding something slightly outside of the “optimal” range are pretty high. That way there’s always something to treat!

Some functional medicine practitioners don’t take insurance and charge hundreds and even thousands of dollars for consultations that can last several hours. No wonder it attracts burnt-out clinicians who are tired of prior authorizations, peer-to-peer reviews, and denials (so, so many denials). These clinicians may have forgotten the Hippocratic oath, however: primum non nocere which is to say first, do no harm.  

Medical professionals have an ethical duty to provide care that is grounded in the best available evidence and to inform patients of the limitations and potential risks associated with every treatment. Not only does this seem to be lacking in functional medicine but it’s apparently a feature. Nothing that’s natural could possibly be dangerous, right? Right?!

Moving Forward: Integrating EBM with Holistic Care

The challenges posed by functional medicine highlight the need for a new approach within conventional medicine. By adopting certain positive aspects of functional medicine—such as a holistic view of patient health and a focus on preventive care—without compromising on scientific rigor, healthcare can evolve to better meet patient needs. 

There’s so much we just don’t know about the human body. We only recently discovered that there are lymphatic vessels in the brain, for example. We are still learning about the gut microbiome, sleep, and mental health. We don’t need to make it worse by guessing at what treatments are worth our time and money.

But it should be clear to everyone, medically trained or not, that we eat terribly, don’t get enough exercise, stress too much, sleep too little, and are addicted to screens, social media, and politics. That’s not adrenal fatigue, it’s living the American dream.

Enhancing Patient-Provider Relationships

Improving patient-provider relationships within conventional medicine is likely part of the solution. Longer consultation times, empathetic communication, and a thorough exploration of patient concerns can enhance patient satisfaction and adherence to evidence-based treatments.

For too long, paternalistic doctors had the final say. We now recognize patient autonomy but what we still lack is patient responsibility. Clinicians need to partner with their patients and help them make better decisions regarding their health. The days of treating uneducated patients are gone. Doctors shouldn’t dictate and patients shouldn’t expect miracles without putting forth the effort.

Integrating Lifestyle Medicine is not Integrative Medicine

Incorporating lifestyle medicine into conventional practice can address some of the gaps that functional medicine seeks to fill. Emphasizing the role of diet, exercise, sleep, and stress management in disease prevention and management is supported by a growing body of evidence. For example, lifestyle interventions have been shown to be effective in managing chronic conditions such as diabetes, hypertension, and cardiovascular disease.

What’s not helpful is Integrative Medicine which tries to bridge the gap between alternative and mainstream medicine. While there may be some useful parts of traditional Chinese medicine, acupuncture, chiropractic, and the like, trying to integrate science with nonscience makes no sense. You end up with the worst of both worlds. 

There is a need for rigorous research on integrative approaches to health that combine conventional and alternative practices. This research should adhere to the same standards of scientific rigor applied to conventional treatments, including randomized controlled trials and systematic reviews.

As Dr. Harriet Hall once said, “What’s good about functional medicine is not unique, and what’s unique about it is not good.”

Educating Patients

Educating patients about the principles of evidence-based medicine and the importance of relying on scientifically validated treatments is essential. Doctors are teachers at heart. Or at least they should be–it’s literally what doctor means. Healthcare providers should strive to empower patients with accurate information, helping them make informed decisions about their care.

For now, functional medicine represents an ill-considered departure from evidence-based medicine, the only type of medicine that ought to be practiced. While it claims to offer a holistic and patient-centered approach, the lack of scientific validation poses ethical and practical concerns. 

By enhancing the patient-centered aspects of conventional medicine and integrating evidence-based lifestyle interventions, healthcare can evolve to better meet the needs of patients without compromising on scientific integrity. The medical community must continue to advocate for treatments grounded in rigorous evidence to ensure the best outcomes for patients.

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