The Root Cause of the Beef Between Functional and Conventional Medicine

This year I tried looking outside my established comfort zone to learn a different way of practicing medicine — and not just in how I structured my employment, with a foray into entrepreneurship, but with a leap in clinical scope outside the house that residency, insurance, and the system built.

I can't remember when I first heard the term "functional medicine." Or when a patient first handed me a list of labs and told me they'd been requested by a doctor she was seeing outside my system — because my system wasn't helping her meet her health goals — and could I please order them?

I reacted with no small amount of indignation. Why should I order, and then be stuck interpreting, a panel of labs I had no idea how to read? How could these possibly be important if I'd taken care of so many people without ever ordering them? I'm not sure I accommodated that request the first time it came.

A Phenomenon Worth Noticing

But the requests kept coming — not often, but often enough to notice. Something was evolving inside the structure of conventional medicine.

Terms like "root cause" started coming up. And I noticed that many of my patients were paying out of pocket to see these providers — as often nurse practitioners, chiropractors, or pharmacists as independent physicians — to investigate things that had been dismissed by the doctors I worked alongside. Hormone therapy. Thyroid treatment. Supplement management. Nutritional deficiencies. For the fatigue, hair loss, and chronic pain that so often have no clean diagnosis in the traditional system.

The Problem I've Always Had With My Own Field

Here's something that has long bothered me about Western medicine: we are so driven by the search for a solution that we'll adopt and repeat a pharmaceutical protocol the moment we learn it works.

Diabetes? Metformin. Heart disease? Statin. High blood pressure? Losartan. For every nameable malady, a drug at the ready, ordered with a click, with a follow-up plan we run through again and again. Twenty patients a day — that's the goal.

There's comfort in having a solution. There's real discomfort in failing to diagnose. Unexplained fatigue, hair loss, chronic pain — these are the ones we groan about when they appear on the schedule. With no solution, what are we supposed to do? Listen? What would be the point? Who has the time?

Why Functional Medicine Made Me Suspicious

At first, the functional answer seemed suspect to me. It looked like naming a hundred conditions I'd never named before — mostly based on labs outside anything I'd been taught — and then assigning a hundred new solutions in the form of supplements.

That was the opposite of where I wanted to go. For all the prescriptions I've written, I've long believed in "less is more" with medication: the body can heal itself, so the fewer pills the better. I wasn't about to start recommending supplements left and right. It made me uncomfortable — you never really know what's in them, given how thinly stretched the FDA is on regulating them.

But Two Things Stood Out

Still, a couple of things functional providers were doing caught my attention.

First, more of them had access to compounded GLP-1 medications — which, used in the right clinical context with proper support and lifestyle change, I've found to be nothing short of life-changing. Compounded medicines generally (FDA-approved ingredients, regulated pharmacies, but unregulated formulations) were something I had no experience with until Ozempic's shortage status made them "okay" to prescribe according to the institution I worked for.

Second, functional doctors had fluency in the language of midlife. They were working with estrogen, progesterone, and testosterone in ways that felt taboo — nearly forbidden — when I presented those cases to colleagues.

The Studies That Built the Fear

I just spent a weekend at an advanced masterclass in hormone dosing, and here's what struck me: much of the fear dominating mainstream medicine around hormone therapy traces back to studies with serious flaws.

The Women's Health Initiative is the big one. When its estrogen-plus-progestin arm was halted in July 2002, millions of women lost access to hormone therapy nearly overnight. What got lost in the headlines: the average participant was 63 years old — a population at higher baseline cardiovascular risk — and the absolute risk increase for breast cancer in the combined-therapy group was roughly eight additional cases per 10,000 women per year. A number almost nobody heard.

The moratorium that followed has been substantially reexamined since. Where I've landed, informed by the work being done in functional and longevity medicine, is that symptom relief is the wrong target to organize around. The more compelling case for hormone therapy is prevention — protecting bone density against osteoporosis and supporting cardiovascular health over the long run. From that vantage point, the more useful question isn't how many years a woman is out from menopause, but what her actual cardiovascular status is right now. A coronary artery calcium score can answer that directly, and it's a far better tool for deciding whether and how to proceed than a number on a calendar.

I'll be straightforward that this is not where the major guidelines currently sit — mainstream recommendations still lean heavily on timing and symptom burden. But it's a serious position held by serious clinicians, and I'd rather have that conversation openly with a patient than pretend the question is closed.

For men, the parallel is the Vigen study, published in JAMA in November 2013 — the year before I graduated medical school. It reported increased cardiovascular events with testosterone therapy and triggered an FDA safety bulletin. It also underwent two published corrections, and reviewers eventually discovered that nearly 10% of the supposedly all-male dataset were women. Twenty-nine medical societies petitioned JAMA to retract it, citing "gross data mismanagement and contamination" that rendered it "no longer credible."

The moratorium these studies created has been substantially reexamined. And thyroid belongs in this conversation too — with attention to how common Hashimoto's thyroiditis actually is, and the recognition that causes of fatigue and malaise may be hiding inside labs my colleagues would call "normal."

So Where Does the Fighting Come From?

Which brings me to what I've really been chewing on: what's the root cause of the beef between functional and conventional medicine?

One camp criticizes the other for lack of evidence. The other criticizes the first for rigidity and poor evidence. Fingers point, blame gets assigned, and patients are left confused. Somewhere in the middle of it, physicians are dismissive of the work nurse practitioners do, and nurse practitioners resent having the gate to independent clinical practice kept by physicians.

Here's a thought. Our nature as human beings may prevent us from judging a behavior in someone else unless we've also expressed it ourselves. You can't recognize a thing well enough to judge it unless it lives in you somewhere.

And what all of us are really judging in each other is the thing we fear most: that we don't know enough. That the work of caring for other human beings is endless, all-encompassing, Sisyphean — and that we're messing it up all over the place. It's so much easier to call that out when you suspect it in someone else than to admit you're the one working with a crucial knowledge deficit.

So we recognize our own lack of information and name it in others. Meanwhile the fact persists: no matter what we know, we don't know everything. And the day we do is no closer now than it was a century ago — even though, by one widely-cited estimate, the doubling time of medical knowledge has collapsed from about 50 years in 1950 to a projected 73 days as of 2020.

What I'm Going to Do About It

My solution, for now: keep learning. Keep practicing. Keep building Metronome Family Medicine to provide collaboration and creativity in care like I found for myself and want for others.

And keep remembering that there's no way I advance this alone. We're going to need hundreds more — MDs, DOs, NPs, and PAs could open a hundred direct primary care or functional practices every day this month and we still wouldn't have enough to care for everyone who needs one.

One thing is certain: this isn't happening inside the system. It's a revolution, and it will only thrive in the hands of revolutionaries.

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