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Medscape enables functional medicine quackery [Respectful Insolence]

Friday, October 14, 2016 3:49
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It’s no secret that I’m not exactly a fan of Dr. Mark Hyman he of the “Ultrawellness” medical empire and arguably the foremost promoter of the “subspecialty” (if you will) of “integrative medicine” known as functional medicine. Integrative medicine, as I’ve told you time and time again, is a specialty dedicated to “integrating” alternative medicine into conventional science-based medicine; i.e., integrating quackery into medicine. One very prominent, very common strain of integrative medicine is known as functional medicine, and Mark Hyman is, although not its originator, its current main guru. I first encountered him back when he was known primarily for his UltraWellness Center, which he still runs. Given his background, I was disappointed to see Medscape doing a three part interview with Dr. Hyman, “The New, Old World of Functional Medicine” (Part 1, Part 2, and Part 3). Reading Hyman’s blather, as you might imagine, can’t help but attract the attention of this blinky box of lights.

When I first encountered Hyman, lo those several years ago, it was because he had drawn my attention by busily mangling autism science, cancer biology, and systems biology in the service of woo and arguing that we should turn back the clock and rely on anecdote-based medicine instead of evidence-based medicine. These days, he’s head honcho at a new functional medicine clinic at the Cleveland Clinic, which, unfortunately, appears to be a wildly successful. He’s even been counseling Bill and Hillary Clinton about their health and, should Clinton be elected, be an influential advisor on health issues. Unfortunately, the alternative, Donald Trump, is far worse, given his hard core antivaccine beliefs and all his other baggage and vile behavior. Unfortunately, Hyman also shares some of those antivaccine views, having co-authored an antivaccine book with Robert F. Kennedy, Jr. and appeared on The Dr. Oz Show to help him promote it.

Functional medicine, of course, is quackery. It’s actually one of the harder forms of quackery to explain, for the simple reason that functional medicine practitioners sure sound science-y. They do lots of lab tests—lots of lab tests!—and act on them all, replenishing nutrients, trace elements, and vitamins whether it’s necessary or not and “personalizing” treatments based on the “biochemical individuality” of each individual. Of course, as I like to say, this appeal to “biochemical individuality” is functional medicine’s “get out of jail free” card for basically anything its practitioners want to do. They can always find ways to justify any form of treatment, be it science-based or quackery, simply by invoking the “biochemical individuality” of each human being. The problem is this. Human beings are individuals, and each human being is unique. There’s no denying that. However, we’re not so unique that our bodies don’t all work pretty much the same way. In other words, in terms of biology, physiology, and yes, systems biology, human beings are far more alike than they are different. If that weren’t the case, modern medicine, developed before we had the tools to probe our genetic individuality, wouldn’t work as well as it does. FM fetishizes “biochemical individuality,” not so much because humans are so incredibly different that each one absolutely has to have a markedly different treatment. We’re not. FM fetishizes “individuality” because it distinguishes FM as a brand from science-based medicine and, I suspect, because it makes FM practitioners feel good, like “total” doctors never at a loss for an explanation for a patient’s symptoms or clinical condition. As for the last bit about FM being a “science-using” profession, I like to say that FM “uses” science the same way that an illusionist or magician uses misdirection: So that the audience can’t see how he pulls off his trick. That’s the short version. The long version is that functional medicine is making it up as you go along.

Wo why was Medscape interviewing Dr. Hyman? Who knows what got into Dr Hansa Bhargava, medical editor for Medscape and WebMD? Whatever it was, he for some reason thought that a fawning interview with one of the foremost practitioners of quackademic medicine was a good idea, thus lowering Medscape still farther in my estimation. One thing I found interesting that I didn’t know about Hyman before was the circumstance of his conversion to functional medicine, which he relates in Part 1 of the interview. Basically, he started out as a family doctor in a small town in Idaho, after which he worked as an ER doc in Massachusetts for a while. Then he became medical director at Canyon Ranch in Lennox, which explains a lot, because Canyon Ranch is a resort and spa catering to well-off executives with wellness programs (at only $5,575 for a four day stay or $4,355 for a two day stay) and weight loss programs. Hyman’s evolution into an “integrative medicine” practitioner and the foremost practitioner of “functional medicine” is making a lot more sense in light of this revelation (to me, at least). This story also tells me a lot:

Right after I started at Canyon Ranch, I became quite ill. I had chronic fatigue syndrome. My whole system broke down: My muscle enzymes were elevated with creatine phosphokinase levels over 600. I had a positive anti-nuclear antibody, a low white blood cell count, elevated liver function tests, and severe cognitive dysfunction. I had myalgia, weakness, rashes, sores on my tongue, and severe diarrhea for years. My whole system just collapsed. I went from physician to physician, to Harvard and Columbia, and more. But I got no answers other than to take antidepressants or sleeping pills.

I began to search for other ways to understand what was happening. I knew it wasn’t in my head. I finally discovered that after living in China for a year I had gotten mercury poisoning.

I learned through this process that there was a whole new field of thinking that had a systems-biology view of medicine. It addressed the root causes of disease—not just symptoms but also etiology. It’s medicine by cause, not just symptoms. It’s medicine by understanding mechanisms, not just geography, or where the symptom or pathology exists. It was a whole new operating system for understanding how to diagnose and treat chronic disease.

So I started practicing functional medicine at Canyon Ranch and healing myself. I started seeing extraordinary results with patients and myself. I joined the faculty and eventually became the chairman of the board of the Institute for Functional Medicine, which trains physicians and other healthcare providers in functional medicine, a powerful systems-based model that takes our observations of the root causes of disease and our biological networks, and integrates them into a framework for clinical application.

Systems biology. You keep using that term. I do not think it means what you think it means. Hyman has already shown that his understanding of systems biology is what I would consider less than optimal. Particularly annoying is how Hyman seems to think that, before functional medicine, no one ever thought of cancer as a systemic disease or wondered about the microenvironment of the tissues in which cancers form and grow. He is also very sloppy about citing studies to support his point of view.

Be that as it may, Hyman had some sort of mysterious illness that may or may not have been fibromyalgia, and it changed him, activating a latent tendency towards embracing pseudomedicine. Obviously that tendency was already there, or he probably wouldn’t have taken the position of medical director of a spa for executives. Characteristic of functional medicine is a rather large dollop of arrogance, as though functional medicine were something amazingly new and different that we hidebound physicians could never have thought of and only enlightened innovators like Dr. Hyman can appreciate. It’s utter nonsense, of course, but get a load of Part 2 of the interview if you want to see more annoying stuff. Dr. Bhargava basically launches a really slow pitch softball question with a huge high arc right over the plate. Not surprisingly, Hyman easily hits it deep. What’s really irritating is how he does that. As usual, he denigrates conventional medicine as not looking at the whole picture and, in contrast, paints functional medicine as considering things that conventional medicine fail to consider. Of course, there’s a reason why evidence-based medicine doesn’t do what functional medicine does; it’s because it’s not evidence-based. None of this stops Hyman, of course:

But in conventional thinking, the end stop is the differential diagnosis, which we all learned in medical school. That’s usually the end of our thinking. Once we’ve made the differential diagnosis and we have the diagnosis, we know what to do. We pick up the Washington Manual of Medical Therapeutics for residents. We have the standard of care. It’s not that complicated. Once you make the diagnosis, you know what the treatment is, right?

In functional medicine, the diagnosis is the place where we start to think. It’s not the end of our thinking. In traditional medicine, it’s the naming and blaming game. We name the disease and blame the name for the problem, and then we tame it with a drug. Let’s take depression, for example. Someone comes in, and they’re hopeless and helpless. They’re sad. They have no interest in life. They have no appetite. They’re not sleeping. They have thoughts of suicide. You say, “I know what’s wrong with you. You have depression.” Depression isn’t the cause of those symptoms. It’s the name of those symptoms. Then, we ask, “What’s the cause of those symptoms?”

Arrgh!

Hyman no more knows the cause of depression any better than his portrait of conventional medicine’s understanding. Don’t believe me? See what he says next:

Well, there may be dozens of causes of depression, right? It could be psychosocial trauma, early life experiences, or Hashimoto thyroiditis, an autoimmune disease that leads to low thyroid function and is caused by eating gluten, which creates an autoimmune thyroid disease. The depression could be because you have been taking a proton-pump inhibitor for 10 years and you have vitamin B12 deficiency, or because you live in the Northeast and you have vitamin D deficiency, or because you have taken antibiotics that altered your gut flora, or because you love sushi and you’re eating sushi all the time and you have mercury poisoning, or maybe you hate fish and have omega-3 fatty acid deficiency, or maybe you’re insulin resistant and love cinnamon buns and have prediabetes. All of those can cause depression. So it’s a methodology for sorting through the root causes and the things that are driving it and then addressing those.

Wait, what? Hyman is basically saying that conventional doctors who treat depression, like primary care doctors and psychiatrists, don’t look at thyroid function and psychosocial trauma. (Hint: They do.) In fact, what Dr. Hyman is doing is touting how functional medicine does what medicine does. Basically, he’s constructing a differential diagnosis. Let’s say a patient comes into your office with symptoms of depression. You evaluate him, and he fits the DSM-V criteria for depression. Now what? You have to see if this patient has any known causes of depression, such as, yes, thyroid disease, psychosocial trauma, genetics, nutritional deficiencies, endocrine disorders, lupus, and several others. Unfortunately, Hyman doesn’t stop there. Functional medicine considers all the known science-based causes of depression and then adds pseudoscience, such as the “mercury poisoning” from sushi, plus the usual panoply of lab abnormalities from the extensive lab panels that functional medicine demands. The other problem is that, while a lot of conditions are associated with depression, the causative relationship is not always clear. For instance, diabetes and prediabetes are indeed associated with depression, with diabetics being at a higher risk of depression, but that doesn’t mean that diabetes necessarily causes depression. Basically, Hyman exhibits a whole lot of hubris by asserting that functional medicine does so much better than conventional medicine in examining the causes of depression.

It’s a hubris that extends into Part 3:

I studied Chinese in medical school and learned about Chinese traditional healing systems. I’ve had much acupuncture in my life. In fact, it cured me of chronic pain that I had from back surgery. I do use other alternative modalities all the time as an adjunct to support my health.

But, when you use other modalities, how do you use them? When do you use the modalities? What is the diagnostic map? If you have migraines and you go to a group of integrative medicine doctors, one might say that you have a dosha imbalance, that maybe your vata/pitta is out of balance. An acupuncturist might say that your kidney chi is not right. The psychologist is going to say that maybe you’re stressed and you should get therapy. The biofeedback person will say you need biofeedback. The herbalist is going to tell you to take feverfew.

In functional medicine, we don’t do that. We ask, “Why are you having a migraine? What’s the cause of your migraine?” If the cause of your migraine is that you’re eating gluten, all these modalities are not going to help. We have a simple rule: If you’re standing on a tack, it takes a lot of aspirin to feel better. You need to take out the tack. If you’re standing on two tacks, taking one out isn’t going to make you 50% better. You need to get rid of all the causes.

Give me a friggin’ break. This is nothing but more hubris. Basically, what functional medicine really does is to run every lab test under the sun and try to correct abnormal values. This is what Hyman refers to elsewhere in his interview as “the original precision medicine,” an assertion that made me want to head to our liquor cabinet and open up a bottle of scotch. Fortunately, I resisted. It was, after all, a work night when I wrote this. Otherwise, I might have had a more violent reaction to this:

I think the concept of precision medicine is fantastic. It is in alignment with functional medicine. In fact, functional medicine is the first application of precision medicine.

I get concerned about this getting coopted by pharma as being about pharmacogenomics. Precision medicine is how we match the drugs to the person. We know that if you have a 2C19 polymorphism, then maybe you should be adjusting your warfarin differently. Fertility doctors will check methylated SNPs, MTHFR. If you have a methylated SNP, you might need methylated folate or a higher dose. These are more personalized drug therapies as opposed to a holistic systems approach.

I think we have to be careful with it. It’s really looking at more of a Leroy Hood model in systems biology, what he calls P4 medicine: personalized, preventive, predictive, and participatory. That’s essentially what we do in functional medicine.

I do so find a lot of amusement in how Hyman loves to invoke systems biology without having the slightest clue what systems biology actually is or entails. Oh, and I have observed Leroy Hood for many years. Mark Hyman is no Leroy Hood. he’s also rather obvious:

Dr Bhargava: Now I’m going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I’ve seen them all. Have you looked at their credentials? They’re usually shills for pharma. I’m saying things that are not popular.

Ah, yes. The pharma shill gambit. If there’s one thing I know, it’s this. Whenever someone tries to dismiss his critics as “pharma shills,” I know that that person has nothing else. The same is true here. Notice how Hyman just dismisses his critics as “pharma shills.” There are no details. There’s no actual evidence presented that any of them are, in fact, in the pay of big pharma. He just seems to think that saying “pharma shill” is enough. To his incredible shame, Dr Bhargava lets Hyman’s use of the “pharma shill gambit” pass unchallenged. Pathetic. Even if Dr. Bhargava were sympathetic to the quackery that Hyman was laying down, it’s an utter, shameful failure in his role as medical editor for Medscape and WebMD to have allowed Hyman to make such statements completely unchallenged.

What this interview tells me, more than anything else, is that the medical editor of Medscape and WebMD is not only clueless about what “functional medicine” is but that he is more than willing to let someone like Dr. Hyman spout self-aggrandizing pseudoscientific bullshit unchallenged. That is the deficiency among those of us who are ostensibly defending evidence- and science-based medicine. We are not willing to call quackery when we see it. Quacks who can talk the talk and seem to be practicing evidence-based medicine are the beneficiaries of this reluctance.

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