Now in my fourth year of blogging about the intersection of Endocrinology and quackery, the threshold for triggering my outrage meter is higher than at the beginning of this endeavor. I suppose my desensitization is a natural reaction to the research I do for my posts, which often requires me to help you ford rivers of alt med-inspired obfuscation – strewn with garbage and feces – to reach what I hope is clarity on the opposite bank.
That said, there’s still plenty of spark in my battery, which brings me to the recent stimulus that fired my action potential1.
Alicia, a podiatrist2, wrote me after receiving some mildly abnormal lab results from her primary physician. She had scheduled an appointment with a so-called functional medicine (FM) doctor to discuss the results in more detail, but then she started digging deeper into FM and developed misgivings:
I just started reading your blog and now I’m really second guessing my decision to go to a functional medicine doctor… I don’t know how to tell if they’re good or bad…and don’t know what to do.
What is Functional Medicine?
That’s an important question, but the answer will be different depending on one’s perspective. In my experience, FM is simply a marketing term – a rebranding, if you will – to make the usual approach to care favored by naturopaths and chiropractors3 appear legitimate.
The scary thing about FM is that the “field” is comprised of many healthcare professionals who hold an MD or DO degree – you know – actual doctors. Some of them, including the one Alicia ultimately saw, have even done an Integrative Medicine (IM) fellowship.
Wow, HD, a fellowship in Integrative Medicine? That sounds like a real thing… I mean, didn’t you do a fellowship in Endocrinology? Isn’t that kind of certification regulated by some sort of Medical Board?
About that…I can understand why you would perceive implied legitimacy here. While I’d be more than happy to spend a few thousand words on how Integrative Medicine came to be and what it is today, that work has already been done – comprehensively and to brilliant effect – by the good folks over at Science Based Medicine. I recommend starting with “Integrative Medicine:” A brand, not a specialty. If that introductory article piques your interest, then you can really dive down the IM rabbit hole with a huge number of posts spanning years at SBM. Here are just a few of my favorites:
- Integrative Medicine finally admits it’s attracting bad apples
- State Medical Boards should not recognize board certification in “Integrative Medicine”
- The Harm of Integrative Medicine: A Patient’s Perspective
- Functional medicine: The ultimate misnomer in the world of integrative medicine
If you don’t have the time or inclination to dig deep into IM, FM, or any of the other brands/iterations of alt med, here’s the TLDR version: IM offers the veneer of legitimacy by claiming to integrate evidence-based therapies from the alt med world into your conventional care plan. In large part, unfortunately, IM ropes in reiki, aromatherapy, acupuncture, homeopathy, and other theatrical placebos that have no solid evidence base, nor any scientifically plausible mechanism to work for the conditions they are intended to treat.
FM is a bit cagier. Ask an FM practitioner to show you the evidence for their recommendations, and they will respond that clinical trials aren’t that helpful. After all, a trial can’t account for the myriad ways in which one individual’s body will respond to a specific combination of herbals, vitamins, minerals, and medications – which, coincidentally, the FM practitioner will likely sell you from their shelf of goodies or infuse directly into your veins before you leave the office.
Alicia’s FM Experience
Alicia, a well-educated professional in the healthcare field herself, decided to go ahead with the visit to the Functional Medicine doctor, as she really wanted to explore all options. Happily for blog readers, she granted me permission to share it with you (edited for length, minor grammar, and identity protection):
When I walked in, I was warmly greeted, but immediately saw that she had advertisements for all sorts of supplements, red light therapies, a molekule air purifier, and piles of LifeExtension supplement magazines. I thought these were all red flags. But, I thought, give her the benefit of the doubt because I have yet to meet her.
When she came into the exam room, we covered my medical and social history extensively – more extensively than I have ever had. Of course, having a doc sit down with you and actually take the time to listen to your story and try to collect as much data to build a case and cause for your symptoms feels promising. It was really appreciated. Then after 45 minutes of discussion, she had me sit on the table and she listened to my heart, lungs and performed abdominal and neck palpations – all very normal for a routine checkup or new patient appointment.
Then, she immediately jumped to testing. She took the time to review all of my labs from this past year, but never really discussed them. She said that she thinks Hashimoto’s is causing some of my symptoms but not all. She’s concerned about gut dysbiosis and mold toxicity. She suggested two tests – GI-MAP and a Mycotoxin urine test.
I’d honestly probably be interested to hear what the heck is living in my gut. I’ve had stomach problems for as long as I can remember. I’ve tried elimination diets, FODMAP diets, AIP diets, gluten free, dairy free, etc and haven’t seemed to ever completely crack the code. Plus, the gut does perform a lot of important functions and gives a lot of cues to the rest of the body on how to behave.
She recommended the Mycotoxin urine test because she was concerned with my living conditions – an old, historic apartment that’s been renovated. She said it could have mold. Again, she is not saying this is the cause of the Hashimoto’s, but maybe a multifactorial rationale for my symptoms (I’ve only been on levothyroxine for 8-10 weeks and haven’t dialed my TSH or FT4 to ideal levels quite yet, so having less frequent but still noticeable symptoms would make sense to me).
After researching the urine test, I saw a release from the CDC that these urine tests are highly unreliable and take advantage of the fact that our bodies almost constantly will have some level of mycotoxin present due to the foods we eat and the air/pollutants we unavoidably breathe. This test bragged about being highly sensitive. Personally, I wouldn’t want a highly sensitive test for a highly sensitive body…I’d want a test that tells me if I’ve reached a toxic level over just some low level. I don’t know.
She then suggested Lyme testing from Igenex, stating that the Western Blot I had performed back in December might not have been sufficient because Igenex uses humans to read the test while QuestDiagnostics uses a computer system to evaluated the bands. She said that some bands that are not black or white but rather gray could be positive markers that the computer is missing. Again, I’m not quite sure I buy that. But that test is $1300, so I get it.
She then suggested the possibility of a nutritional assay. Ok.
She then suggested sauna therapy in an infrared sauna 3x/week for 15 minutes at a time, then working my way up to 30 minutes at a time to detox.
She then suggested that NDT was superior to synthetic T4 or synthetic T3.
After all of this, I told her that $800 to spend on those first two labs was a little out of my reach. I told her, “You and I were both trained to be evidence-based first and foremost. Do you have any literature behind the theories, methods, and reliability of these tests you’re recommending? I trust you as a medical provider, but this could possibly be a big investment financially and I want to make sure that I fully understand the investment I’m making in my health.” She got slightly defensive and asked me what I thought the literature was going to solve. [HD: Bolding is mine.]
We then had an uncomfortable moment when she asked me about my approach, as a podiatrist, to certain foot and ankle issues. She scoffed at my answer, suggesting that many of my patients would be better served by something akin to chiropractic manipulation.
Finally, she did give me a lab order to send to my regular doctor’s office to get them to run the labs. She requested the following: Glutathione, Total GGT, Copper, Zinc, B1, Magnesium, Iron, TIBC, Ferritin, B6, Urine Iodine, B12, FT3, FT4, rT3, TSH, hsCRP, Homocysteine, Selenium, MMP-9, TGF-b1, HNK1 (CD57) Profile.
So, all that to be said…some interesting stuff that we talked about, but a lot of red flags. I think that this really kind of rubbed me the wrong way.
How to Know if your FM/IM Doc is a Quack
When I re-read Alicia’s email, the red flags for quackery leap off the page and bat me about the face. I feel like I should simply present the email to you and then mic drop like we used to at the end of a mathematical proof in my high school AP Calculus class: QED4. But, I realize that I live and breathe this stuff, while laypeople may not have picked up on all the red flags – demonstrated by both the FM doctor and Alicia.
I’m sure you noticed that the doc is advertising products in her office, which is an obvious red flag. But did you pick up on the fact that she recommended thousands of dollars worth of testing, most of which is well-known to have either no clinical validity or unproven validity? While this isn’t news to me, what I find compelling is that Alicia – despite knowing that gut microbiome testing is a mostly unproven diagnostic measure – still seems open to the concept of testing.
This, my friends, is the kind of mindset on which alt med preys and of which it takes advantage. Alicia has had years of unresolved gut symptoms but no answers, so of course she’s open to new ideas. It makes perfect sense, and I’m not knocking her. However, the argument in favor of this unproven testing is a straw man argument: “Nothing else has led to a solution, so why not test the gut microbiome, which hasn’t yet been done?” Sure, that would make sense if we knew what to make of the test results. Unfortunately, there is no accepted, standard reference range for the number and type of various bacteria that comprise one’s gut microbiome. If you’re “low” in one strain and “high” in another, does that mean that you need raise the low one? Lower the high one? Both? Is balanced better, or is it beneficial to have greater numbers of certain types of bacteria? Is it possible to dial in “treatment” with expensive probiotic/prebiotic pills sold by the doctor, or would you have just as much luck eating more fermented foods and taking an over-the-counter probiotic/prebiotic from a reputable manufacturer?
Spoiler alert: I don’t know the answers to these questions, and neither does your FM physician. Is the gut microbiome important? Yes. Is it a fascinating new frontier that we need to research extensively? Absolutely. Is it ethical to order this test for patients and present the results as clearly indicative of a treatment plan that is going to help? Hell, no. If the FM doc really wants to sell some fancy probiotics out of her office, she can do that without the expensive gut tests.
The other concept I’d like to highlight is that a visit to an FM practitioner will typically result in a concussion from having the kitchen sink thrown at your head. Did you see the breadth of recommendations for testing and treatment? I realize that many people will view this as the doctor being thorough. I know this because I have had countless people come to my office for a “third opinion,” openly wondering why “nobody has ever checked these things before?” People get upset when they think their regular doctors have been negligent in exploring every avenue to attempt diagnosis and treatment of their health concerns. I have written entire posts about this issue, including Dear Alternative Medicine – Stop Testing! and Top 5 Reasons Why You Shouldn’t Order Your Own Blood Tests. Suffice it to say, competent physicians don’t order tests unless there is a solid evidence base for them and we know what to do with the results. Not only can we not interpret the results of nonstandard testing, but it is often expensive and billed directly to you. I’m not sure I can communicate the inadvisability of this testing any more clearly.
Ethics, or Lack Thereof
Shortly after Alicia regaled me with the details of her visit, she forwarded me an email that the FM doc sent to her patients, at the beginning of the coronavirus crisis. Read this excerpt, and see if you can spot the questionable ethics:
If you are looking to get tested for COVID-19, please contact our office so that we can assist you.
There is value in knowing if you are positive because there can be treatment measures taken… We are staying up on cutting edge research that has proven helpful for treating this virus in other countries. We will also be getting a specific herbal kit directed towards COVID-19. Please call us for further details if you would like to purchase (these have been on backorder and we are hopeful to have these ASAP, we suspect they won’t stay on the shelf long!).
Please don’t panic! All of you that are patients at [redacted] are already supporting your immune system, which is key to help fight COVID-19. Eat clean, have clean air, clean water, and a calm mind. Wash your hands frequently, with soap and warm water for at least 20 seconds. Use an alcohol based non-toxic hand sanitizer to clean your hands if soap and water are not available. In general, to support your immune system, make sure you are taking your vitamin C, vitamin A, zinc, vitamin D3 and monolaurin which are all good for immune support and addressing viruses. If you haven’t already, make an appointment for a Myer’s cocktail which has vitamin C in it and is great to fight viruses (we are also running a March special on infusions!), please call for an appointment.
Does anyone else need a shower after reading that? Look, I realize that many readers of this blog have had terrible experiences with their mainstream medical providers; that isn’t lost on me. But getting your care from a “functional medicine” doctor who preys on pandemic-induced fear to sell you placebos in the form of herbal kits and IV vitamin C – that is not a sensible alternative.
By reading this site and interacting with me and others in the Comments, you agree to abide by my Disclaimer.
- Pretty sure I’ve drained multiple metaphor-cows of every last drop of milk!
- Not her real name or profession.
- I’m referring only to chiropractors who foray outside their realm of training in musculoskeletal manipulation.
- Quad Erat Demonstrandum, roughly translated as “thus it has been proven.”