Both ends curve toward the same mistake — toward an outsourcing of agency (whether to the white coat or the wellness influencer, the hospital system or the biohacker podcast) and a hunger for certainty and control.
Thank you, this “horseshoe” framing really resonates! In clinic, the two extremes often start to look identical: high confidence + low quality evidence + strong identity/tribal signaling, just wrapped in different language (“natural” vs “standard of care”). The patient experience can end up the same too: a persuasive story, a promised certainty, and a plan that isn’t tethered to measurable outcomes.
The antidote on both sides is the same, and it’s very unglamorous: epistemic humility, clear priors (“what would change my mind?”), transparent tradeoffs, and shared decision-making that’s anchored to the patient’s goals and to follow-up data. I love when clinicians and patients can say: “Let’s try X, define success, watch for harm, and reassess.”
More of this kind of bridge-building is exactly what medicine needs; curious, compassionate, and evidence-literate without being evidence-rigid!
This essay bridges the divides among health/medicine perspectives better than any I've read. I may refer others to this piece as a great opening for better conversations in this realm. Remarkably, it also sheds light on many areas because the principle of the golden mean, the logic of proportion is present everywhere.
Excellent essay. As a cardiologist I see this every day. Some patients come in wanting a procedure to fix everything. Others are dragged in my family and refuse everything, convinced that western medicine is evil. To some extent, this is a situation that American medicine has brought on itself.
Nice article. For me, they sit side by side at the left side of a continuum of evidence. Neither over medicalisation nor wellness tests have evidence to support them. Moving to the right you gradually get more and more evidence of benefit being greater than harm.
Excellent! One addition to this part: "If the system can’t or won’t fix it, failure is chalked up to negligence, gaslighting, stingy insurers, or a heartless bureaucracy withholding the cure." The honest answer here from conventional medicine (my perspective) is to say, "We don't know." Important to acknowledge, and quite common.
"Toward an outsourcing of agency" is such a compelling way to name the mistake. When we're afraid we can't control our health, maybe we do wish there was something else in charge.
Great read. Interesting take. Very similar to the political far right and far left for which I like to say the only difference is on the far left we don’t have guns. With allopathic medicine, we have emergency rooms, oncologists, orthopedics trauma surgeons, and the PPI that healed that ulcer allowing you to stop taking it. The functional “ medicine“ side does not and can only exist because allopathic medicine is there when stuff hits the fan.
Exactly. And very well explained. As a former ICU and ER nurse, I know the ways modern medicine saves lives. I also know the ways it doesn’t.
Somewhere along the way, we forgot that herbs are medicine. That organic whole food is medicine. That sleep is medicine, the sun is life-giving, and sometimes the best prescription is a long walk in the woods or along the beach.
I can and do embrace both sides of medicine and natural healing depending on what needs healing.
Otherwise, lifestyle is ultimately the best medicine. What we do, how we move and what we eat and drink every day is what matters most.
Treat the cause. That is the essence of functional medicine as I understand it. Yes, often symptoms need to be addressed too, but that’s where most conventional doctors stop. I’ve often asked after they prescribe something for the symptom, “ok great. Now let’s treat the cause too.” I get blank stares, head tilts; eyes glaze. Huh?
THAT is what is wrong with western medicine that is run by profit-first pharmaceutical companies IMO. It didn’t used to be that way.
“Hunger for certainty and control”. I wish I had an operation/pill that cured that. That seems to be the most common ailment I see.
This essay made me think of the Amish/Mennonite community, we get a good bit where I work. I never had one ask me about getting a calcium score or what their LDL is, but they know to come to the hospital when they get chest pain that won’t go away.
As someone who claims to be a political scientist, I approve of this essay, which reminded me of two things:
I have never had a physician B ask me "Why did physician A prescribe this medication, and do you think it's helping?"
The human mind is a prediction machine. It seeks to identify patterns, even when none exist. While time is often the best medicine, a placebo sometimes also does wonders because it manifests in the mind as a pattern, as described in this Hidden Brain podcast episode: https://www.hiddenbrain.org/podcast/a-dramatic-cure/.
This article resonated with me. Recently, for social studies, our twins had to compare Karl Marx and Adam Smith and the subsequent repercussions of their works. It was eye-opening to watch their expressions as we started from the center with each philosophy and then took it to its extreme. What a wonderful life lesson that was.
I was trained in the allopathic model, but always had a holistic philosophy. After becoming disillusioned with the bug-drug, cookbook approach, I ventured into holistic medicine and was board-certified in integrative holistic medicine for a time.
Like the author, I began to feel that not all was well in that community. Functional medicine made a lot of sense; however, there were loads of esoteric tests, and pharmaceuticals were traded in for nutraceuticals.
Soon, I found that my journey from the mechanistic planet of Trantor was veering off course and was drifting out towards the Isle of Woo-Woo. I let my board certification in integrative holistic medicine expire and went back to the “middle path”. The view is great, but there’s not much company. Why can’t we get excited about the middle?
The art and science are to stay centered on the dimensions of wellness and not to obsess too much about either extreme; otherwise, we find ourselves with either hypochondria or orthorexia nervosa. I’m eating blueberries this morning, not because they are high in anthocyanins, but because they’re blue and they taste fantastic!
I understand the limbic pull of the poles and that the logical middle can be boring. We need to return to a modicum of common sense and realize that we are scientists. Neither pole of this horseshoe magnet should sway us.
The glass is not half-full; the glass is not half-empty. It is simply an air-liquid interface at the midpoint of the glass.
I’m an MS4, trained as an allopath, preparing to enter family practice residency. Your comment and this article deeply resonate with me. I’ve often wondered why we can’t seem to gravitate to the middle instead of the poles, and I think you articulated it well. It’s funny to think how “boring” in public, personal, and institutional health is so often the most sustainable option.
I’ve personally never heard of the horseshoe theory but am better for it now. In reference to politics, I’ve come to find an analogy of a circle is more useful than a “spectrum” but the horseshoe just seems to fit better. And applying it to alternative and conventional medicine, wonderful.
In regard to my training, I think it is a sign of a healthy mind to seek options — particularly when exposed to perspectives that highlight the failings of conventional medicine, as in medical school. So naturally, we seek answers in alternative medicine.
I’ve found myself feel the pull of alternative medicine from time to time and each time I give it more and more agency. I recently found myself trending too far to the alternative side; I pulled myself back from the edge and reassessed. I think, as someone interested in the idea of holistic medicine, it is easy to let alternative extremes convince you that conventional medicine is too divided to integrate the whole. But if you consider the development in areas like endocrinology, immunology, rheumatology, and gut-brain connection you start to appreciate the capability actual, verifiable science has to understand the entire human body from mechanism to whole person.
But the conventional side can convince that it has ALL the evidence-based answers while there is still so much to discover.
Overall, I appreciate this article and this comment. I love seeing people use their heads to challenge their preconceived notions and help us all find the middle a bit easier! Fun read!
What a wonderful essay. I, too, was blown off by GI docs for a different serious health issue, which led to my foray into functional medicine. I, too, came to realize that it is easy to end up on the other side of the same coin, so to speak. My personal approach is "integrative". Why can't we integrate the best of conventional and lifestyle medicine? Both "sides" tend to have an all or nothing approach, which is very limiting. Thank you for such a thoughtful essay.
I’m a bit of a contrarian here. While Mo’s horseshoe analogy is elegant, too much reliance upon one’s own critical thinking is unwise. The real key to continuing good health is to find a PCP whose wisdom and commitment to shared control with the patient allows for balance.
This is a great point, Carl. I think I'm lucky that I do have a PCP like that. Still, I only see her once a year for my annual checkup. As a freelancer on an Obamacare plan, my deductible is $18K, so I go to the doctor as little as possible. That leaves a lot of the burden on me to do critical thinking of my own to determine what kind of care or tool will best suit any given issue (e.g., when it's something like a months-long, chronic eye twitch that seems obviously stress-related, I skip the MD and go straight to my acupuncturist).
...“Well, then I don’t know what to tell you,” he said, as he scribbled out a prescription for Prilosec."...and we are supposed to trust this as medical care and caring? No fricking way.
Thank you, this “horseshoe” framing really resonates! In clinic, the two extremes often start to look identical: high confidence + low quality evidence + strong identity/tribal signaling, just wrapped in different language (“natural” vs “standard of care”). The patient experience can end up the same too: a persuasive story, a promised certainty, and a plan that isn’t tethered to measurable outcomes.
The antidote on both sides is the same, and it’s very unglamorous: epistemic humility, clear priors (“what would change my mind?”), transparent tradeoffs, and shared decision-making that’s anchored to the patient’s goals and to follow-up data. I love when clinicians and patients can say: “Let’s try X, define success, watch for harm, and reassess.”
More of this kind of bridge-building is exactly what medicine needs; curious, compassionate, and evidence-literate without being evidence-rigid!
This essay bridges the divides among health/medicine perspectives better than any I've read. I may refer others to this piece as a great opening for better conversations in this realm. Remarkably, it also sheds light on many areas because the principle of the golden mean, the logic of proportion is present everywhere.
Excellent essay. As a cardiologist I see this every day. Some patients come in wanting a procedure to fix everything. Others are dragged in my family and refuse everything, convinced that western medicine is evil. To some extent, this is a situation that American medicine has brought on itself.
Nice article. For me, they sit side by side at the left side of a continuum of evidence. Neither over medicalisation nor wellness tests have evidence to support them. Moving to the right you gradually get more and more evidence of benefit being greater than harm.
Excellent! One addition to this part: "If the system can’t or won’t fix it, failure is chalked up to negligence, gaslighting, stingy insurers, or a heartless bureaucracy withholding the cure." The honest answer here from conventional medicine (my perspective) is to say, "We don't know." Important to acknowledge, and quite common.
"Toward an outsourcing of agency" is such a compelling way to name the mistake. When we're afraid we can't control our health, maybe we do wish there was something else in charge.
Great read. Interesting take. Very similar to the political far right and far left for which I like to say the only difference is on the far left we don’t have guns. With allopathic medicine, we have emergency rooms, oncologists, orthopedics trauma surgeons, and the PPI that healed that ulcer allowing you to stop taking it. The functional “ medicine“ side does not and can only exist because allopathic medicine is there when stuff hits the fan.
Exactly. And very well explained. As a former ICU and ER nurse, I know the ways modern medicine saves lives. I also know the ways it doesn’t.
Somewhere along the way, we forgot that herbs are medicine. That organic whole food is medicine. That sleep is medicine, the sun is life-giving, and sometimes the best prescription is a long walk in the woods or along the beach.
I can and do embrace both sides of medicine and natural healing depending on what needs healing.
Otherwise, lifestyle is ultimately the best medicine. What we do, how we move and what we eat and drink every day is what matters most.
Treat the cause. That is the essence of functional medicine as I understand it. Yes, often symptoms need to be addressed too, but that’s where most conventional doctors stop. I’ve often asked after they prescribe something for the symptom, “ok great. Now let’s treat the cause too.” I get blank stares, head tilts; eyes glaze. Huh?
THAT is what is wrong with western medicine that is run by profit-first pharmaceutical companies IMO. It didn’t used to be that way.
“Hunger for certainty and control”. I wish I had an operation/pill that cured that. That seems to be the most common ailment I see.
This essay made me think of the Amish/Mennonite community, we get a good bit where I work. I never had one ask me about getting a calcium score or what their LDL is, but they know to come to the hospital when they get chest pain that won’t go away.
Great essay!
As someone who claims to be a political scientist, I approve of this essay, which reminded me of two things:
I have never had a physician B ask me "Why did physician A prescribe this medication, and do you think it's helping?"
The human mind is a prediction machine. It seeks to identify patterns, even when none exist. While time is often the best medicine, a placebo sometimes also does wonders because it manifests in the mind as a pattern, as described in this Hidden Brain podcast episode: https://www.hiddenbrain.org/podcast/a-dramatic-cure/.
This article resonated with me. Recently, for social studies, our twins had to compare Karl Marx and Adam Smith and the subsequent repercussions of their works. It was eye-opening to watch their expressions as we started from the center with each philosophy and then took it to its extreme. What a wonderful life lesson that was.
I was trained in the allopathic model, but always had a holistic philosophy. After becoming disillusioned with the bug-drug, cookbook approach, I ventured into holistic medicine and was board-certified in integrative holistic medicine for a time.
Like the author, I began to feel that not all was well in that community. Functional medicine made a lot of sense; however, there were loads of esoteric tests, and pharmaceuticals were traded in for nutraceuticals.
Soon, I found that my journey from the mechanistic planet of Trantor was veering off course and was drifting out towards the Isle of Woo-Woo. I let my board certification in integrative holistic medicine expire and went back to the “middle path”. The view is great, but there’s not much company. Why can’t we get excited about the middle?
The art and science are to stay centered on the dimensions of wellness and not to obsess too much about either extreme; otherwise, we find ourselves with either hypochondria or orthorexia nervosa. I’m eating blueberries this morning, not because they are high in anthocyanins, but because they’re blue and they taste fantastic!
I understand the limbic pull of the poles and that the logical middle can be boring. We need to return to a modicum of common sense and realize that we are scientists. Neither pole of this horseshoe magnet should sway us.
The glass is not half-full; the glass is not half-empty. It is simply an air-liquid interface at the midpoint of the glass.
I’m an MS4, trained as an allopath, preparing to enter family practice residency. Your comment and this article deeply resonate with me. I’ve often wondered why we can’t seem to gravitate to the middle instead of the poles, and I think you articulated it well. It’s funny to think how “boring” in public, personal, and institutional health is so often the most sustainable option.
I’ve personally never heard of the horseshoe theory but am better for it now. In reference to politics, I’ve come to find an analogy of a circle is more useful than a “spectrum” but the horseshoe just seems to fit better. And applying it to alternative and conventional medicine, wonderful.
In regard to my training, I think it is a sign of a healthy mind to seek options — particularly when exposed to perspectives that highlight the failings of conventional medicine, as in medical school. So naturally, we seek answers in alternative medicine.
I’ve found myself feel the pull of alternative medicine from time to time and each time I give it more and more agency. I recently found myself trending too far to the alternative side; I pulled myself back from the edge and reassessed. I think, as someone interested in the idea of holistic medicine, it is easy to let alternative extremes convince you that conventional medicine is too divided to integrate the whole. But if you consider the development in areas like endocrinology, immunology, rheumatology, and gut-brain connection you start to appreciate the capability actual, verifiable science has to understand the entire human body from mechanism to whole person.
But the conventional side can convince that it has ALL the evidence-based answers while there is still so much to discover.
Overall, I appreciate this article and this comment. I love seeing people use their heads to challenge their preconceived notions and help us all find the middle a bit easier! Fun read!
What a wonderful essay. I, too, was blown off by GI docs for a different serious health issue, which led to my foray into functional medicine. I, too, came to realize that it is easy to end up on the other side of the same coin, so to speak. My personal approach is "integrative". Why can't we integrate the best of conventional and lifestyle medicine? Both "sides" tend to have an all or nothing approach, which is very limiting. Thank you for such a thoughtful essay.
I’m a bit of a contrarian here. While Mo’s horseshoe analogy is elegant, too much reliance upon one’s own critical thinking is unwise. The real key to continuing good health is to find a PCP whose wisdom and commitment to shared control with the patient allows for balance.
This is a great point, Carl. I think I'm lucky that I do have a PCP like that. Still, I only see her once a year for my annual checkup. As a freelancer on an Obamacare plan, my deductible is $18K, so I go to the doctor as little as possible. That leaves a lot of the burden on me to do critical thinking of my own to determine what kind of care or tool will best suit any given issue (e.g., when it's something like a months-long, chronic eye twitch that seems obviously stress-related, I skip the MD and go straight to my acupuncturist).
Well said. Thank you for your thoughtful essay.
...“Well, then I don’t know what to tell you,” he said, as he scribbled out a prescription for Prilosec."...and we are supposed to trust this as medical care and caring? No fricking way.