Evidence based medicine in functional medicine

"First do no harm"

We rely on evidence-based-medicine (EBM) to determine safe and effective treatments for our patients.  This is ideal for pharmaceutical drugs that are potent and carry many side effects/risks, herbal medicines and supplements that are utilized in high or continuous dosing, and physical medical interventions such as IV treatments and procedures.

Over my years working in functional medicine, I've come to realize that there is a plethora of EBM that we do not use in conventional medicine.  I'd venture to say that maybe only 5% of the studies in circulation are used to determine medical treatments in our insurance-based medical system.  Most of these focus on pharmaceuticals and procedures.  It is a losing battle to try read everything in the literature, and unfortunately I don't know many colleagues that even have the time to read (so they end up going with "popular opinion" from colleagues and national organizations, and even outdated recommendations).  The amount of published studies is so extensive that we become paralyzed by the overwhelm!

I used to get very stressed trying to back up ALL my functional medicine treatment recommendations with studies in reputable journals.  Don't get me wrong - I still have hundreds of studies saved, but I don't try to back up EVERYTHING with evidence.  As an example, one of the lecturers at the IFM once mentioned that although double blinded placebo controlled studies are considered the gold standard for EBM, we cannot apply this to a parachute's ability to save lives.  No such trial will every be done on a parachute, yet we know that it will save a life in the right situation!  As an analogy, I'd have to say the same goes for eating vegetables - we know they provide essential nutrients and improve health, yet we will never be able to have a controlled study that proves this (vegetables are too complex, and often interact synergistically with the other ingredients in our food, to have components that can be applied to real world living).

Despite the thousands of hours of training, my confidence wavers - especially when a patient (or colleague) doubts my treatment decisions.  I know that no one - NO ONE - can be an expert in all areas of medicine.  We are still human, after all.  One trial that proves one treatment will likely disprove that treatment in another setting.  The world of science is not as black and white as we would hope.  So much information that we took as dogma in our medical education is now debunked - if we are stubborn and believe that the information we learn in school will always be true, we are greatly affecting the outcomes of our patients' health.

Last year (2017), I realized that my efforts to prove everything I do in functional medicine were mostly because I felt the need to defend functional medicine, particularly with colleagues.  But when I would discuss studies I use in treatment (even if these were from JAMA or NEJM), my colleagues in mainstream medicine would brush them off, saying "that's nice, but it's not what the [insert major organization] says".  Using this rebuttal is the "easy" way to practice medicine, since we unfortunately just don't have the time/energy to be be a skeptic or to be thoroughly informed.   Andrea Nakayama calls this the "Evidence Trap," which many practitioners face as they enter the mindset of functional medicine.  It's good to be evidence-informed, but we tend to become evidence enslaved.  We rely on national organizations to interpret the literature, but we fail to remember that many of these organizations are funded by companies that will profit off of the recommendations.  I had personal experiences with this when I worked at a company that partnered with the American Diabetes Association, who would provide lunch to local companies where my practice would give an informational talk on prediabetes and diabetes.  We were not allowed to tell any of the audiences about the role of sugar in diabetes, since a lot of companies that funded the ADA were based in the sugar industry!  I dare you to try to find any absolute sugar recommendations (in quantity, especially with studies that back this up) on the ADA website...they just aren't there!

The harsh reality is that it's easier to stay "within the box", and continue to treat chronic diseases in the current (failing) model.  Like I mentioned before, very few clinical practitioners actually read the research, and just like anything we read it is open to interpretation.  Don't get me wrong, I still follow the guidelines for medications and supplements - especially when "off label".  But now, I feel less inclined to seek studies on everything, especially when it pertains to food and lifestyle (the foundations of functional medicine).

When you start to utilize functional medicine, you become an innovator.  We've become so reliant on one-sided "evidence" for treatment that we're losing the "personalization" of practicing medicine.  We're losing our clinical intuition.  In functional medicine training, you realize that there is so much EBM that we are not aware of, and you may start to question the EBM used in mainstream medicine.  We don't want to believe that there are companies that fund our organizations that provide the scientifically-based recommendations by which we practice medicine, but we also can't be paralyzed by the need to find the "right" EBM that can be applied in functional/integrative medicine.  After all, the majority of treatments in this model are focused on nutrition, movement, stress management, and sleep, and we will never get the evidence we want to support the innate need to eat and live a healthy lifestyle.  It is just like the parachute analogy - we know that parachutes save lives, just like we know that we need to eat our vegetables, get good sleep, manage our stress, and stop being sedentary.  No studies will ever prove these.

 

Functional Medicine-Based Thinking vs Mainstream Medicine-Based Thinking

Instead of operating within the confines of a closed box, functional and integrative medicine practitioners honor the fact that studies don't reflect healing of individuals.  How can healing occur in a petri dish or in a controlled study?  No study can accurately reflect the complexity of any individual.  Healing is more than a single treatment.  People are complex, and when you really consider the goals of medical treatment, a patient only cares about the outcomes of a treatment and how we can help them achieve these.

 

Takeaways:

  • First do no harm
  • Be evidence informed (use the scientific evidence to be aware of the risks of drugs and medications/supplements, but always think about the biochemistry of how these pills actually work in the body), but don't become enslaved by it
  • We don't need to know everything - collect resources and referrals that you can provide to your patients for more information
  • Be aware that there really aren't a lot of long-term studies on pharmaceuticals or supplements.  In the world of pharmaceuticals, PPIs are a perfect example of this.  In the integrative medicine world, herbal remedies are the best example, since it's really only those trained in herbal medicine that are taught the pros/cons of herbal medicines.  As an example, I once met a practitioner who used artemisinin for a family member who travels to Africa, but used it continuously for weeks.  Artemisinin is one of many herbs that are supposed to be "pulsed" rather than used continuously.  The family member developed acute liver failure, which was attributed to the herb (and now the practitioner is hesitant to use this treatment, when it can help so many if used appropriately).
  • Honor the fact that studies don't reflect healing of individuals
  • There are very few studies in lifestyle medicine (nutrition, exercise, etc) that can effectively be used as "evidence" in clinical practice.  But this is where personalization comes into play, and where knowledge of nutrition is essential.  For example, kale and raw greens will not be good for someone with high oxalates (testing helps to find this), and avocados may be great but not for someone with high histamine levels or intolerance.

If you want to practice functional medicine, you have to look outside the box and honor the individuality and complexity of all patients.  It takes courage to question the authorities in our profession!

Wishing everyone great health, happiness, and a life at ease.

Meg