What an interesting and thoughtful essay/interview. I have formal and informal education and experience in functional medicine. As a nurse educator, I see a definite educational gap. Nursing and medical education are pathogenic-focused. My passion is to balance pathogenesis with holistic health promotion. Chronic illness is a main driver of health expenditure, which I believe can be addressed by combining holistic health promotion with "sick care." However, just as there is a pharmaceutical for every "ill," there is a supplement or test "guaranteed to make you look and feel 20 years younger." Also, both conventional and complementary/functional medicine tend to make the same mistake: My view on health and illness is the "right" one, and the "other side" doesn't know what they are talking about. Patients would benefit from more collaboration between the two approaches to health and illness.
Brava Mo, for your insight and honesty. I’m a bit older than Dr. Cifu, but we both started in a time when I feel there was more of a focus on making a very intimate human connection with our patients. Both sides were rewarded. Now I feel medical training (a little), society (a little more) and corporate takeover of the exam room (way too much) have cleaved what once was more sacred. While during my 30+ years of teaching residents I actively supported preventative health and even researched/taught some alternative methods, BIG Supplement has affected the zeitgeist so much that society (at least American society) looks to be cured of everything. To abide with problems or the potential of not being uber-something is intolerable. Now we have a bed we’ve made and must lie in it.
I have a practical and a philosophical objection to the health maximizers:
1. "Come see your doctor when you feel healthy,” [Iyengar] says, “and it’s really easy and affordable to keep you healthy as opposed to waiting for something to break.”
There is obviously some sense in which this is true - when you are talking about sort of diseases of aging and metabolism - weight gain, glucose intolerance, sleep, diet, exercise, etc. There are many things one can do to maintain their health as they get older. But this also can sell the lie that your health is under your control. If you get hit by a car tomorrow, it doesn't really matter if your thyroid is well-tuned. These interventions do not prevent the vast majority of cancers. Yes, there are autoimmune disease that are not preventable or treatable through dietary changes. You will get older. There is no fountain of youth. This is not under your control. I have seen many patients - the health maximizers - who feel betrayed when, after a healthy and productive life, they come down with some ailment at age 70 - as if they don't deserve that, because they exercised daily and ate healthy. This is not how the world works. We all know the marathon runner who gets the heart attack, the young healthy person with cancer. And should you manage to maintain your physical health into very old age, it is very likely that instead you will increasingly have trouble with your mind.
2. I do agree that when we talk about health, we really ought to view the person holistically and think about their overall well-being, not just their physical health. How someone feels and how healthy they are as a human being goes well-beyond the numbers. I have a suspicion that those who are intensely focused on their own health and the details of their symptoms are being counterproductive. It reminds me of the theological idea of "incurvatus in se" - the turning in on oneself. This is associated with the sin of pride, but the real problem is that happiness - well-being - never comes from a focus on one's self. I sometimes wonder - what is more likely to make a person feel better - a peptide/cleanse/placebo or volunteering at a soup kitchen, or working at a museum, or helping a neighbor? Might that be better for one's overall well-being and sense of self?
Put me solidly in the Cifu camp. Medicine and Surgery are most valuable when there is an acute state of reversible disease. If your brain is about to herniate, you need a neurosurgeon. A liver transplant can radially transform a life. A knee replacement can prolong a period of active mobility. On the medicine side, antibiotics cure previously lethal infections, from cellulitis to endocarditis. Cancers can be put into remission. Type 1 diabetics can now live essentially normal lives. People who would have died form renal failure within weeks can live for decades on dialysis. The further we get from life-saving treatment to prevention of disease or to maintenance of health, the shakier ground we find ourselves on. This is a lot of the challenge in being a primary care doctor, pediatrician, or psychiatrist - trying to find the balance of compassion, listening, searching, reassuring, testing, cajoling, and treating. This takes significant interpersonal skill and clinical acumen, and in our productivity models, takes a significant hit.
It is very clear in medical care that what "seems" like it must be true, what "makes sense" is often completely untrue. Spending lots of time, money, effort on "testing" to stay healthy apparently "makes sense" to many. the bottom line is you absolutely do NOT need a doctor to be or stay healthy! The keys to good health are completely free and available to all. You cannot outdo the benefits of healthy diet, modest exercise. Genetics lay a base. Then luck enters in. For those that accuse medical providers of focusing only on disease and treatments - it's not really true (we talk about root causes all the time: eating plan, exercise, habits). It also does not require a medical license to tell someone what a healthy diet is or how to exercise. I'm continuously amazed that functional medicine and the people who follow that somehow believe that it actually takes MORE tests (that cost money) and MORE pills/supplements/cleanses (that also cost money) to stay healthy. The analogy to preventive maintenance for an automobile does not apply to the human body - except the truth that the "maintenance" being exercise and diet, keeping weight down, avoiding toxins. In my practice I've spent inordinate amounts of time listening to, counseling, supporting patients. I have no idea if its truly helped (I'm certain it has for some). I have a very strong belief in adult human autonomy so that I don't begrudge the people that want to spend their time, money, and effort on functional medicine. The placebo effect is real. I never feel angry or irritated about what my patients decide to do for their health. There is an entire industry of "recreational medical testing" - people who like to get tests done so they can somehow feel better about things. wearable tech falls into this as well. I have so many people reporting their "sleep" per the ring or the watch or whatever. I guess I'm concluding that many people cannot accept that being healthy doesn't need a lot of testing or supplements. But it's their money.
Excellent article. I’ve worked as a traditional private practice dentist for 20 years and struggled with the industry’s revenue generating prevention and cosmetics more and more. I do believe we should have much more respect in regard to cutting tissue of any kind.
In recent years, I’ve battled my own health challenges and have sought both traditional and alternative healthcare modalities. I agree that traditional docs don’t have time or interest to listen. However, I found professionals on the functional side to be both prescriptive and restrictive in their “protocol.”
I have found my best results by doing my own research and experimentation. Less medicine is more. So on that regard, I would agree that when you feel good, enjoy it and be content.
Dr. Cifu draws the correct line between medical care and the wellness/longevity people. Medicine applies the methodology of science to determine the decisions that govern its practice. The task of medicine is to diagnose disease and recommend options for treatment or amelioration. Can an attentive and caring physician render additional benefits to their patients? Of course they can. We hardly know the true causes of most diseases and know even less about prevention. Most of the nostrums popular in the wellness/preventive field are scientifically unfalsifiable but often presented as truisms. It should also be pointed out that many widely accepted practices within the medical field have no more scientific backing than those of the wellness/longevity advocates.
In first year med school history taking course, one learns about the concept of “chief complaint”.
Yet for these prevention/ longevity hacks, the answer would be “well…nothing”. Pretty tough to investigate nothingness….which might explain their enthusiasm to instead investigate “everything”.
As for who should fund studies for the worried well? That’s easy. That guy you interviewed, should. If he is to contend that ANY of his interventions produce anything more than expensive urine, the burden of proof is on him. He’s the one who should go out and show that anything he does has any effect other than lightening your wallet.
There’s nothing wrong with mechanistic theory and biologic plausibility, per se. But the problem is those need to be burnished by outcome evidence. Otherwise it’s nothing more than navel gazing. Theory is the bedrock for those who lack evidence.
As someone who falls in the middle. I am not at the level of optimizer, however, I do try to live in a way to prevent/avoid/prolong illness. This piece was a nice example of the differences. I appreciate both physicians. I also think the relationship with your provider can make a huge difference in how well you feel/are.
I confess I was drawn to a well-regarded functional medicine provider here in my town, as I was looking into HRT for my osteoporosis, many years post-menopause. I did end up paying 3-4K for detailed bloodwork out of pocket. Some stuff would have been covered by insurance; other tests would not have been.
Turns out the nurse who worked with HRT patients left, so I couldn't have done that anyway. While I did learn some valuable things in the bloodwork, what they wanted me to pay to "cleanse" my body (for lack of a better word) for 4 months was way out of my league, and I didn't go back after the follow-up.
I love my doctors and surgeons, and I've had many of them due to random, unique problems (joint replacement, rotator cuff/biceps repair, gallbladder removal, ECRPs to remove stones after gallbladder removal, high LpA, and so on). My PCP, a DO, is pretty traditional, but she really listens to me and didn't criticize me when I got the other bloodwork done, since it did add value to my care management.
Nonetheless, I was disappointed in the advanced functional medicine practice overall. I felt they were trying to fix problems in me that were mild; it certainly wasn't worth the 10K they wanted me to pay.
Excellent article. You briefly touch upon what I feel is the most impactful influence related to the placebo effect: "relationship based care." I have been teaching clinician patient communication for years, and from my evaluation of the literature, observation, and personal experience it is the power of "connection" is our most powerful tool as health care providers. Sadly, this is vastly under appreciated, and as interaction time shortens and care becomes more depersonalized we are losing a very large part of our effectiveness. I am all about connecting with the patient whether it be one visit or ongoing care. I feel this is a big part of integrative medicine that is not appreciated as well. Caring providers with more time is its biggest secret. As Sensible Medicine teaches, we all greatly over credit the power of a specific medical treatment for the individual patient. As I teach: "Connecting with the other person" is the answer to world peace!
Dr. Cifu is obviously correct. The other person would have been a snake oil salesman 150 years ago. You don’t have to pay outrageous concierge fees to eat healthy, exercise, and curb your appetite. By the way, disease all too often trumps the best intentions. Then see Dr. Cifu and certainly avoid the faith healer. He’ll hasten your decline with nostrums.
It's ironic that Dr Iyengar would compare the human body to the preventative care of an automobile. Sounds convincing until you reflect that humans are not machines, --a point he would surely agree. And then doing lots of tests to measure 'markers', in the absence of data to support their use. A good example of the more-is-better bias. Add in services such as botox and nutritional IVs and I'd classify Dr Iyengar's approach as a religion.
There are plenty of perverse and harmful incentives to go around. But this is hardly a sound argument that integrative medicine is beneficial. I'll line up much more strongly with Dr Cifu's approach.
Thank you for a great and thoughtful essay. I think one of the most important things a practitioner can do (medical or functional) is to listen, show compassion, and offer hope. There definitely needs to be trust between patient and practitioner.
Stephen Trzeciak, MD, MPH has been studying compassion and hope and these have been shown to be integral to decreasing pain and increasing survival. (https://www.researchgate.net/profile/Stephen-Trzeciak) Our minds are so important to our physical health.
I see patients in a free clinic; many of our patients are recent immigrants. They have suffered greatly in their travels. These patients have many complaints that can't necessarily be attributed to something physical. For far too long we have ignored the state of someone's mind (emotions) and it's influence on physical health.
What an interesting and thoughtful essay/interview. I have formal and informal education and experience in functional medicine. As a nurse educator, I see a definite educational gap. Nursing and medical education are pathogenic-focused. My passion is to balance pathogenesis with holistic health promotion. Chronic illness is a main driver of health expenditure, which I believe can be addressed by combining holistic health promotion with "sick care." However, just as there is a pharmaceutical for every "ill," there is a supplement or test "guaranteed to make you look and feel 20 years younger." Also, both conventional and complementary/functional medicine tend to make the same mistake: My view on health and illness is the "right" one, and the "other side" doesn't know what they are talking about. Patients would benefit from more collaboration between the two approaches to health and illness.
Brava Mo, for your insight and honesty. I’m a bit older than Dr. Cifu, but we both started in a time when I feel there was more of a focus on making a very intimate human connection with our patients. Both sides were rewarded. Now I feel medical training (a little), society (a little more) and corporate takeover of the exam room (way too much) have cleaved what once was more sacred. While during my 30+ years of teaching residents I actively supported preventative health and even researched/taught some alternative methods, BIG Supplement has affected the zeitgeist so much that society (at least American society) looks to be cured of everything. To abide with problems or the potential of not being uber-something is intolerable. Now we have a bed we’ve made and must lie in it.
I have a practical and a philosophical objection to the health maximizers:
1. "Come see your doctor when you feel healthy,” [Iyengar] says, “and it’s really easy and affordable to keep you healthy as opposed to waiting for something to break.”
There is obviously some sense in which this is true - when you are talking about sort of diseases of aging and metabolism - weight gain, glucose intolerance, sleep, diet, exercise, etc. There are many things one can do to maintain their health as they get older. But this also can sell the lie that your health is under your control. If you get hit by a car tomorrow, it doesn't really matter if your thyroid is well-tuned. These interventions do not prevent the vast majority of cancers. Yes, there are autoimmune disease that are not preventable or treatable through dietary changes. You will get older. There is no fountain of youth. This is not under your control. I have seen many patients - the health maximizers - who feel betrayed when, after a healthy and productive life, they come down with some ailment at age 70 - as if they don't deserve that, because they exercised daily and ate healthy. This is not how the world works. We all know the marathon runner who gets the heart attack, the young healthy person with cancer. And should you manage to maintain your physical health into very old age, it is very likely that instead you will increasingly have trouble with your mind.
2. I do agree that when we talk about health, we really ought to view the person holistically and think about their overall well-being, not just their physical health. How someone feels and how healthy they are as a human being goes well-beyond the numbers. I have a suspicion that those who are intensely focused on their own health and the details of their symptoms are being counterproductive. It reminds me of the theological idea of "incurvatus in se" - the turning in on oneself. This is associated with the sin of pride, but the real problem is that happiness - well-being - never comes from a focus on one's self. I sometimes wonder - what is more likely to make a person feel better - a peptide/cleanse/placebo or volunteering at a soup kitchen, or working at a museum, or helping a neighbor? Might that be better for one's overall well-being and sense of self?
Put me solidly in the Cifu camp. Medicine and Surgery are most valuable when there is an acute state of reversible disease. If your brain is about to herniate, you need a neurosurgeon. A liver transplant can radially transform a life. A knee replacement can prolong a period of active mobility. On the medicine side, antibiotics cure previously lethal infections, from cellulitis to endocarditis. Cancers can be put into remission. Type 1 diabetics can now live essentially normal lives. People who would have died form renal failure within weeks can live for decades on dialysis. The further we get from life-saving treatment to prevention of disease or to maintenance of health, the shakier ground we find ourselves on. This is a lot of the challenge in being a primary care doctor, pediatrician, or psychiatrist - trying to find the balance of compassion, listening, searching, reassuring, testing, cajoling, and treating. This takes significant interpersonal skill and clinical acumen, and in our productivity models, takes a significant hit.
It is very clear in medical care that what "seems" like it must be true, what "makes sense" is often completely untrue. Spending lots of time, money, effort on "testing" to stay healthy apparently "makes sense" to many. the bottom line is you absolutely do NOT need a doctor to be or stay healthy! The keys to good health are completely free and available to all. You cannot outdo the benefits of healthy diet, modest exercise. Genetics lay a base. Then luck enters in. For those that accuse medical providers of focusing only on disease and treatments - it's not really true (we talk about root causes all the time: eating plan, exercise, habits). It also does not require a medical license to tell someone what a healthy diet is or how to exercise. I'm continuously amazed that functional medicine and the people who follow that somehow believe that it actually takes MORE tests (that cost money) and MORE pills/supplements/cleanses (that also cost money) to stay healthy. The analogy to preventive maintenance for an automobile does not apply to the human body - except the truth that the "maintenance" being exercise and diet, keeping weight down, avoiding toxins. In my practice I've spent inordinate amounts of time listening to, counseling, supporting patients. I have no idea if its truly helped (I'm certain it has for some). I have a very strong belief in adult human autonomy so that I don't begrudge the people that want to spend their time, money, and effort on functional medicine. The placebo effect is real. I never feel angry or irritated about what my patients decide to do for their health. There is an entire industry of "recreational medical testing" - people who like to get tests done so they can somehow feel better about things. wearable tech falls into this as well. I have so many people reporting their "sleep" per the ring or the watch or whatever. I guess I'm concluding that many people cannot accept that being healthy doesn't need a lot of testing or supplements. But it's their money.
I would much prefer a well trained, compassionate physician caring for me than someone who has perfected the art of a “wallet biopsy“
Ben Hourani MBA
Excellent article. I’ve worked as a traditional private practice dentist for 20 years and struggled with the industry’s revenue generating prevention and cosmetics more and more. I do believe we should have much more respect in regard to cutting tissue of any kind.
In recent years, I’ve battled my own health challenges and have sought both traditional and alternative healthcare modalities. I agree that traditional docs don’t have time or interest to listen. However, I found professionals on the functional side to be both prescriptive and restrictive in their “protocol.”
I have found my best results by doing my own research and experimentation. Less medicine is more. So on that regard, I would agree that when you feel good, enjoy it and be content.
Dr. Cifu draws the correct line between medical care and the wellness/longevity people. Medicine applies the methodology of science to determine the decisions that govern its practice. The task of medicine is to diagnose disease and recommend options for treatment or amelioration. Can an attentive and caring physician render additional benefits to their patients? Of course they can. We hardly know the true causes of most diseases and know even less about prevention. Most of the nostrums popular in the wellness/preventive field are scientifically unfalsifiable but often presented as truisms. It should also be pointed out that many widely accepted practices within the medical field have no more scientific backing than those of the wellness/longevity advocates.
Interesting perspective.
In first year med school history taking course, one learns about the concept of “chief complaint”.
Yet for these prevention/ longevity hacks, the answer would be “well…nothing”. Pretty tough to investigate nothingness….which might explain their enthusiasm to instead investigate “everything”.
As for who should fund studies for the worried well? That’s easy. That guy you interviewed, should. If he is to contend that ANY of his interventions produce anything more than expensive urine, the burden of proof is on him. He’s the one who should go out and show that anything he does has any effect other than lightening your wallet.
There’s nothing wrong with mechanistic theory and biologic plausibility, per se. But the problem is those need to be burnished by outcome evidence. Otherwise it’s nothing more than navel gazing. Theory is the bedrock for those who lack evidence.
As someone who falls in the middle. I am not at the level of optimizer, however, I do try to live in a way to prevent/avoid/prolong illness. This piece was a nice example of the differences. I appreciate both physicians. I also think the relationship with your provider can make a huge difference in how well you feel/are.
I confess I was drawn to a well-regarded functional medicine provider here in my town, as I was looking into HRT for my osteoporosis, many years post-menopause. I did end up paying 3-4K for detailed bloodwork out of pocket. Some stuff would have been covered by insurance; other tests would not have been.
Turns out the nurse who worked with HRT patients left, so I couldn't have done that anyway. While I did learn some valuable things in the bloodwork, what they wanted me to pay to "cleanse" my body (for lack of a better word) for 4 months was way out of my league, and I didn't go back after the follow-up.
I love my doctors and surgeons, and I've had many of them due to random, unique problems (joint replacement, rotator cuff/biceps repair, gallbladder removal, ECRPs to remove stones after gallbladder removal, high LpA, and so on). My PCP, a DO, is pretty traditional, but she really listens to me and didn't criticize me when I got the other bloodwork done, since it did add value to my care management.
Nonetheless, I was disappointed in the advanced functional medicine practice overall. I felt they were trying to fix problems in me that were mild; it certainly wasn't worth the 10K they wanted me to pay.
Excellent article. You briefly touch upon what I feel is the most impactful influence related to the placebo effect: "relationship based care." I have been teaching clinician patient communication for years, and from my evaluation of the literature, observation, and personal experience it is the power of "connection" is our most powerful tool as health care providers. Sadly, this is vastly under appreciated, and as interaction time shortens and care becomes more depersonalized we are losing a very large part of our effectiveness. I am all about connecting with the patient whether it be one visit or ongoing care. I feel this is a big part of integrative medicine that is not appreciated as well. Caring providers with more time is its biggest secret. As Sensible Medicine teaches, we all greatly over credit the power of a specific medical treatment for the individual patient. As I teach: "Connecting with the other person" is the answer to world peace!
Dr. Cifu is obviously correct. The other person would have been a snake oil salesman 150 years ago. You don’t have to pay outrageous concierge fees to eat healthy, exercise, and curb your appetite. By the way, disease all too often trumps the best intentions. Then see Dr. Cifu and certainly avoid the faith healer. He’ll hasten your decline with nostrums.
It's ironic that Dr Iyengar would compare the human body to the preventative care of an automobile. Sounds convincing until you reflect that humans are not machines, --a point he would surely agree. And then doing lots of tests to measure 'markers', in the absence of data to support their use. A good example of the more-is-better bias. Add in services such as botox and nutritional IVs and I'd classify Dr Iyengar's approach as a religion.
There are plenty of perverse and harmful incentives to go around. But this is hardly a sound argument that integrative medicine is beneficial. I'll line up much more strongly with Dr Cifu's approach.
Great article. Very thoughtful. Thanks for all your time.
Thank you for a great and thoughtful essay. I think one of the most important things a practitioner can do (medical or functional) is to listen, show compassion, and offer hope. There definitely needs to be trust between patient and practitioner.
Stephen Trzeciak, MD, MPH has been studying compassion and hope and these have been shown to be integral to decreasing pain and increasing survival. (https://www.researchgate.net/profile/Stephen-Trzeciak) Our minds are so important to our physical health.
I see patients in a free clinic; many of our patients are recent immigrants. They have suffered greatly in their travels. These patients have many complaints that can't necessarily be attributed to something physical. For far too long we have ignored the state of someone's mind (emotions) and it's influence on physical health.