Functional Medicine: Portland
Functional Medicine, Allopathic Medicine, and Naturopathic Medicine?
How to Reconnect the Dots and Put Humpty Dumpty Back Together Again
Thomas Kruzel, ND, and Zora DeGrandpre, ND
Functional Medicine, Portland: The Functional Medicine Approach
At an excellent functional medicine conference in Bellevue, Washington (April 28-30, 2011), “The Challenge of Emerging Infections in the 21st Century: Terrain, Tolerance, and Susceptibility,” several presenters made compelling scientific cases for the infectious root causes of certain diseases. Rheumatoid arthritis was described as being precipitated by a Proteus infection of the urinary tract. Ankylosing spondylitis was described as being caused by an infection of the bacteria Klebsiella in the colon. It was particularly striking to see the experimental and research data used to make the case for the development of autoimmune disease stemming from these infectious agents. Notable also was that, even in the face of significant scientific data supporting the premise of an infectious agent causing an autoimmune disease in humans, allopathic rheumatologists largely dismiss the data, preferring instead to continue to find drugs to mask symptoms rather than address the underlying cause.
What is Functional Medicine?
So, we began thinking: what is functional medicine and how might functional medical practitioners potentially be working toward clarifying or developing a more vitalist approach? (Vitalism is “the theory that the origin and phenomena of life are dependent on a force or principle distinct from purely chemical or physical forces” [http://oxforddictionaries.com/definition/vitalism].)
Does functional medicine provide areas for growth, development, and collaboration with naturopathic medicine, and does naturopathic medicine provide areas for growth, development, and collaboration with functional medicine? Indeed, do the naturopathic process of healing and the therapeutic order,1 early concepts by Lindlahr,2,3, and the principles of naturopathic medicine represent a synthesis of strengths from functional, allopathic, and naturopathic approaches? In this article, we explore the fundamental differences and the similarities that we perceive. These are worth exploring in the context of natural medicine’s important recognition of the terrain as the deepest underlying factor in illness. To further explore these ideas, we first must define functional medicine4:
The functional medicine approach is personalized medicine that deals with primary prevention and underlying causes instead of symptoms for serious chronic disease. It is a science-based field of health care that is grounded in the following principles:
Biochemical individuality describes the importance of individual variations in metabolic function that derive from genetic and environmental differences among individuals.
Patient-centered medicine emphasizes “patient care” rather than “disease care,” following Sir William Osler’s admonition that “It is more important to know what patient has the disease than to know what disease the patient has.”
Dynamic balance of internal and external factors.
Web-like interconnections of physiological factors…the human body functions as an orchestrated network of interconnected systems, rather than individual systems functioning autonomously and without effect on each other….
Health as a positive vitality—not merely the absence of disease.
Promotion of organ reserve as the means to enhance healthspan.
Functional medicine includes some of the important concepts of the vitalist approach, including recognition of biochemical individuality, a homeostatically based systems approach, and appreciation of the crucial interplay of the mind, body, and spirit. While some in allopathic medicine may be less appreciative, the use of different terminologies, such as biochemical individuality rather than genetic polymorphism, does not discredit the concept. Perhaps the most significant position of functional medicine, from the naturopathic point of view, is its appreciation of health as not merely the absence of disease but as a “positive vitality.” Vitalism also takes this view, although it is more broadly defined and applied within a naturopathic practice.
Vitalism and Reductionism at the Crossroads
So, where do functional medicine and naturopathic medicine meet at the crossroads of reductionist and vitalist medical approaches? Since the time of Hippocrates, there has been a long and somewhat arduous debate about the roles that vitalism and reductionism have in medicine. Certainly, Hippocrates, Paracelsus, Galen, and Hahnemann, as well as others, have contributed to the discussion over the centuries, with no clear-cut consensus emerging. Often, these discussions did nothing more than to maintain tension between the 2 views. While the resulting debate may have advanced many medical careers, this lack of consensus did not necessarily benefit the patient, who stands—or should stand—at the center of the ongoing debate. From a purely philosophical standpoint, these somewhat opposing positions may be viewed as the yin and the yang, locked in the dance of medicine as it developed over the centuries. This dance has certainly served to produce many of the great advances in medicine. Pharmacology can be regarded as the ultimate yang, or the ultimate in reductionist and mechanistic approaches, while public health advances may be better regarded as the yin or the ultimate in guarding the terrain in allopathic medicine.5 Flexner’s report in 1910, citing the need for a more robust science education and strict oversight for medical school admission and postgraduate education, also included recommendations for greater emphasis on disease prevention and social responsibility, as well as greater physician humility,6-8 arguably a more vitalist approach.
While allopathic medicine has largely embraced the reductionist method, recent developments in functional medicine may lead one to conclude that the single-faceted approach of the dominant reductionist paradigm may be nearing a bifurcation point. Naturopathic medicine—while clearly having roots in both the vitalist and reductionist traditions, as well as a conceptual and clinical history in alignment with concepts and a scientific body of knowledge in functional medicine—has as a result often found itself questioning its place in the dance of medicine. It has never been the most popular partner at the dance and has always continued to dance as if it needed no partner. However, one may wonder if that solitary role may be nearing its own bifurcation point and if there now is coming a time when a suitable partner may be found, if that partner is willing and able to make a serious commitment and if the rhythm is one we can dance to.
Functional Medicine: Reductionist Approach
Reductionist medicine follows several premises to logically address disease. Functional medicine has more recently begun to look more deeply into the causes of disease and to explore the interconnectedness—the network—of the organism’s attempts to restore homeostasis. However, functional medicine still may appear to view disease in terms of a cause-and-effect relationship within the framework of a reductionist model at times. This model may seem to convey—see the introductory comments herein about the April 2011 conference—that disease exists as discrete pathologic entities that can be specifically identified and eliminated through the application of evidence-based therapies, primarily drugs, and surgery or sometimes herbs and nutrients. However, functional medicine also recognizes that illness is associated with dysfunctional systems that allow pathologic conditions to develop.4 The main difference is the recognition by functional medicine practitioners that a patient is more than the sum of the parts. This recognition can be applauded but may not go far enough. Tolle causam, for instance, the naturopathic principle to identify and treat the underlying cause of disease, does not imply that finding the cause is simply treating the bacterium causing a patient’s infection but includes the full examination of the terrain.
Yet, the presentations at the April 2011 conference did not account for the premise of vitalist medicine. Seemingly, the thought is there, but it is not actively addressed. To NDs, it is the soil—the terrain—that is critical and not so much the specific organism. The presentations alluded to the naturopathic determinants of health but did not connect the dots of infection, cross-reactivity to self, and suppression of symptoms.
Functional Medicine: Vitalist Approach
The vitalist approach, by contrast, follows the view that health is a homeostatic or homeodynamic set point and a natural state that the organism is constantly attempting to achieve. Ill health is an adaptive response to a disturbance of the homeostatic balance of the organism, an attempt to rebalance the allosteric load.9-12 In the vitalist view, the balanced homeostatic or homeodynamic mechanism of optimal health follows the laws of the universe in that the mechanism’s process is ordered and dependent on a healthy environment. According to Paracelsus,13 health in the body relies on the harmony of man (the microcosm) and nature (macrocosm). Another way of thinking about this is to discuss terrain. In the naturopathic view, a fundamental construct is the terrain. It consists of the background genetics (or susceptibility) coupled with the epigenetic status (reflecting lifestyle), including socioeconomic status,14 constitution, and environmental factors. The lifestyle and environmental factors help form the allostatic load. The epigenetic mechanisms can provide for the reestablishment of homeostatic balance. This is why, in the vitalist view, some individuals get ill and others do not when exposed to the same perturbation. In a reductionist model, theoretically, everyone should become ill, or eventually will become ill when exposed. We know in practice that not everyone exposed to an infectious agent becomes ill; therefore, it seems likely that, at a minimum, the reductionist view is incomplete.
Vitalism is a philosophy positing that the totality of an individual organism cannot be explained solely by the interplay of biochemistry but that there is an additional “spark,” an expression of energy that is essential to life. Furthermore, vitalism posits that the organism itself has a role in disease and that disease is not due primarily to exogenous organisms or factors but that it is the important interactions among the organism, the terrain, and the environment. Disease is viewed as a process rather than a discrete entity.1 A particular condition is the result of an organism’s response to a set of factors, and while there may be similar characteristics, the progress and the process of each individual’s condition are at least partly unique to the individual.
Functional Medicine: Enter Epigenetics
More recently, the field of epigenetics has emerged as a way to view the influence of the macrocosm on the microcosm through the activation (or deactivation) of genetic sequences that had previously been inactive (or active) via phosphorylation, methylation, and other mechanisms.15-18 Study in these areas clearly has the potential to identify the influence of the environment, mental and emotional status, and lifestyle choices on the development and progression of disease. It is not wishful thinking to believe that epigenetics will ultimately lend support to the vitalist view of health and disease, and both functional medicine and naturopathic medicine have incorporated this emerging discussion.
Because disease is viewed as a process rather than an entity, what are the factors that determine whether or not one becomes ill? Some of the factors thought to influence this are genetics, previous illness patterns, the effects of previous medications, one’s physical and mental and emotional state, toxic exposures, poor digestion and toxemia, hygienic factors, and poor-quality food and water. These are often not considered when the allopathic (non–public health) physician is faced with them simply because they are thought to be unquantifiable and not amenable to study.
Furthermore, it is often more difficult to view the patient as a unique individual influenced by a unique combination of factors, when perhaps the easier alternative is a label consisting of diagnostic and procedure codes.
Classic homeopathy, for example, can use entirely unique remedies for individual cases of chronic pharyngitis. The remedy for one case of pharyngitis may be Lachesis, while for another it may be Lycopodium. There is no convenient way to code for these differences because they are based on the individual symptoms and not the disease.
The functional medicine approach has strengthened aspects of naturopathic practice. It has added immense knowledge and a powerful and rigorous body of thought that scientifically explains the concept of tonifying weakened systems within the therapeutic order, for example. Thus, this article is less of an argument that functional medicine is not adequately approaching vitalism than a statement also applauding many of the concepts championed by functional medicine—and suggesting some concepts that, in our view, might enhance the impact of its approach. Key among those concepts is the consideration of patients’ biological and energetic terrain, which might help retain the clinician’s ability to recognize the integrity of Humpty Dumpty’s shell before it becomes weakened or broken by genetic predisposition or environmental onslaught. Functional medicine recognizes certain health determinants1 as a step in this direction.
In the process of medical education, the reductionist approach has many clear advantages, as evidenced by advances in surgery and the treatment of acute disease, for example. However, a problem arises clinically when the patient arrives at the office of the allopathically trained physician as a whole human being but (because of a reductionist education) is operationally regarded as a liver or a cardiovascular system. Humpty Dumpty is cracked. The question is, can we combine the best of functional, allopathic, and naturopathic medicine and begin to heal the cracks? The problem perhaps lies in the fact that, while Humpty Dumpty has been cracked, few medical professionals have received the entire scope of training and often cannot take the time or make the intensive intellectual effort needed to put him back together again.
Functional medicine and naturopathic medicine have developed these skills and approaches collectively, in differing ways, on many fronts. From a naturopathic perspective, to connect the dots of reductionist facts and data, we must step back and think about how, for example, the thyroid actually interacts with the adrenals and the reproductive organs. It is insufficient to code for adrenal insufficiency coupled with hypothyroid function without realizing that the 2 are inextricably linked in ways that are often unique to each individual. The interactions of the mind and body are becoming more appreciated, but how do we treat or code for a patient whose epigastric pain is associated with the loss of a sibling, parent, or pet (diagnosis code 30000 [anxiety state, unspecified] or 78906 [abdominal pain, epigastric]? Neither is sufficient for description, yet the reductionist coding system (required in the United States for insurance purposes) forces physicians to do so. Physicians, of course, know the relationship, but the act of coding for billing purposes may blur the fact that physicians understand the patient’s disease, not the disease the patient has.
To fully put Humpty Dumpty back together again requires all the king’s medical men and women working together to redefine, rethink, and reconnect the dots of priorities within their various medical systems of thought—reductionism, functionalism, and vitalism—to one that embraces all that each has to offer while focusing on the health and well-being of the patients, who are at the center of the debate. It also requires that societies emphasize health and wellness rather than spending tremendous resources maintaining the status quo of illness. As long as we continue to maintain the model of disease as a normal state of being vs one of wellness and health, the vitalist-reductionist debate will undermine the health of communities and populations, with increasingly devastating consequences. Continuation of the debate will skirt the real issues that face entire communities and every patient who seeks medical attention for healing of the whole person—mind, body, and spirit.
Thomas A. Kruzel, ND is a naturopathic physician who is in private practice at the Rockwood Natural Medicine Clinic in Scottsdale, Arizona. He received a BA in Biology from the California State University at Northridge, and his Doctorate of Naturopathic Medicine degree from the National College of Naturopathic Medicine. Dr. Kruzel is also a board-certified Medical Technologist. He completed 2 years of Family Practice Medicine residency at the Portland Naturopathic Clinic where he was a chief resident prior to entering private practice. He also completed a fellowship in Geriatric Medicine through the Oregon Geriatric Education Center and the Portland VA hospital. Dr. Kruzel has been an Associate Professor of Medicine at the National College of Naturopathic Medicine where he has taught Clinical Laboratory Medicine, Geriatric Medicine, and Clinical Urology. He is the author of the Homeopathic Emergency Guide, A Quick Reference Handbook to Effective Homeopathic Care, published by North Atlantic Books and has published numerous articles in The Journal of Naturopathic Medicine as well as other publications. He is also the past president of the American Association of Naturopathic Physicians and was selected as Physician of the Year by the AANP in 2000 and Physician of the Year by the Arizona Naturopathic Medical Association in 2003.
Zora DeGrandpre, MS, ND is a practicing naturopathic physician with a background in clinical and basic science research. Her original training was as an organic chemist, specializing in drug design. Her BS is in Medicinal Chemistry. Dr. DeGrandpre received her Master’s degree from Roswell Park Cancer Institute where her research focused on cancer immunology, specifically examining the idiotypic relationships involved in the regulation of T-suppressor cells. Dr. DeGrandpre’s doctorate in natural medicine was awarded by the National College of Natural Medicine. She has served as a grant reviewer for the National Institutes of Health and the National Center for Complementary and Alternative Medicine (NIH/NCCAM). In addition, her expertise in natural medicine has been called upon in litigation matters, specifically on the properties of various herbal medicines and their interactions with pharmacologic agents. She is also the Scientific Review Editor for an upcoming foundational textbook in natural medicine. She has published textbooks in botanical medicine, drug-herb interactions, the treatment of alcoholism and addiction, homeopathy, and other topics. Dr. DeGrandpre is also a writer and editor for academia, writing scientific grants and curricula for Integrative Medicine programs. She writes for industry and the public, writing articles and monographs on various supplements, providing well-researched and documented information for both professionals and non-professionals on various herbal medicines and supplements. She also lectures on various topics, including diets to treat and prevent chronic disease, bio-identical hormones, mind-body medicine, naturopathic approaches to women’s health, and addictions.
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