A few folks have asked me what I think of “functional medicine”, which led me down a bit of a rabbit hole. I explored what it means to be a doctor, and what the doctor-patient relationship means, and I noted that knowledge without compassion is a waste.

But compassion without knowledge is worse than wasteful—it’s dangerous, and this is where I split from functional medicine. Medicine—my profession—is based on science. As our knowledge changes and grows, so do our practices. Many of the practices we used to think were right have long since been abandoned. We used to think fevers should be treated by blood-letting. We used to think that lidocaine after a heart attack saved lives. We used to think that malaria was literally caused by “bad air”. But medical knowledge grows and changes, and practices follow. What seemed obvious before now seems like a mistake. As an internist I have to actually know how to interpret new science and how to safely make changes to how I do things. I’m not sure functional medicine really does this. Part of the problem is that no one really knows what functional medicine is.

As you may have guessed, for a variety of reasons, I am not a fan.

Functional medicine doesn’t have a single definition or a defined set of practices but there are some commonalities. According to The Institute for Functional Medicine:

The language may differ a little but this doesn’t sound all that different from what I do as an internist. Internal medicine strives to treat “the whole person”, their uniqueness, their emotional needs. We bring together an array of scientific tools. As when it comes to a “deep understanding” of science, well, we have that covered. After four years of university, four years of medical school, and three years of residency, not to mention continuing medical education, my colleagues and I have a pretty deep background in what we do. We certainly understand that physical and mental well-being are inseparable (or as my dad used to say, “show me a mind without a brain and body”).

Since functional medicine and regular medicine seem to share these characteristics we’ll have to dig a little deeper. First, “functional medicine” isn’t a recognized medical specialty like, for instance, internal medicine, general surgery, or dermatology. The medical specialties you’re used to hearing about are part of the American Board of Medical Specialties (ABMS) which sets shared standards that doctors must meet in order to be “board certified”.

The Institute for Functional Medicine (not part of the ABMS) has, it seems, two types of certificates, one for doctors, and one for everyone else. The “Functional Medicine Certified Professionals” (FMCPs) can be just about anyone—nurses, chiropractors, optometrists, acupuncturists. There are no rigorous standards of education, experience, or ethics. They just have to have an undergrad degree, a license in their profession and one hundred hours of training.

Folks, as a medical resident I easily did 100 hours of training in a week—for three years. And in order to maintain my board certification I have to continue my “maintenance of certification” to ensure I’m up to date on my profession. Not only does an internist have more learning and experience in a week of training than an FMCP, we must keep up with the ever-changing science of our profession.

Now, the IFM also offers a Functional Medicine Certification for medical professionals like MDs, DOs, NPs, and PAs. Still, there are only 100 required hours of training in this “specialty”. So, an MD with no other training in primary care medicine could be treating you for your blood pressure problem based on 100 hours of classes.

But maybe FMCPs have something additional to offer, something my colleagues and I can’t. Thankfully, the IFM publishes a list of “core competencies”. The outline is pretty long so it might be helpful to pick something out of it to look at more closely.

The largest section of their core competencies is called “patient evaluation”. This section is, in my opinion, quite alarming. For the sake of comparison, let’s look at what doctors like me learn. During medical school we learn about biochemistry (the ridiculous number of interdependent chemical reactions that run our body); anatomy; physiology (how the body works); pathophysiology (how it goes wrong); pathology (disease states, their causes, etc); histology, histopathology, pharmacology, etc, etc, etc. This takes us about two years. Then we spend another two years applying this to real people. And that’s all before our actual practical training in residency. These are all “hard” sciences that have been built up for literally centuries, and are ever-growing and changing.

The functional medicine side of things uses a different language but let’s look briefly at one term they use a lot: root causes. Supposedly, FM focuses on root causes of disease, which I suppose implies that we don’t. But their “root causes” don’t really go into those two years of actual learning I did. In fact, a lot of it reads as near-nonsense to someone who is actually trained in science-based medicine. You can’t understand the root causes of disease without a deep background in how the healthy body works and how it breaks down. This takes a lot more than 100 hours of training.

Let’s look at a specific condition, a common and deadly one: high blood pressure. I googled “functional medicine” and “hypertension” and given that unlike real medicine there’s no standards to work with, I picked the top search result. It starts out with a pretty accurate explanation of high blood pressure, and even gives a case study.

But here’s the problem. First, the things that FM claims to do differently or better than what I do are, frankly, untrue. When it comes to treatment of high blood pressure, we always look for modifiable causes, such as sleep apnea, obesity, and diet. We always recommend exercise and evidence-based dietary changes, such as the DASH diet. And we use proven medications when these fail or when the blood pressure is too high or dangerous to wait for lifestyle changes to work.

What I don’t do is order expensive and useless tests like stool analysis or heavy metal levels (unless there is a very compelling reason to do so). The reason I don’t order all the tests the FM folks do is that they aren’t supported by the medical literature. And as we’ve seen, treating people without good science-based evidence can kill people.

So, no, I don’t support functional medicine. It is often practiced by unqualified people; they order unnecessary tests; they often recommend and/or sell unproven supplements; they can delay real, evidence-based care leading to death and debility. And they do not offer anything of value that normal doctors don’t.

So why would anyone go to a functional medicine practitioner?

There are many reasons, but as I noted in part 1, it’s often because we’ve failed them. We haven’t spent enough time, we haven’t made them feel heard; and we haven’t made them feel better.

Unfortunately, our failure leads people to seek out even worse care. The solution is for us to do better, to give our patients a good reason to stick with the science. If we do a better job, patients might trust us more.

We’ve got a ways to go.¹