At What Point Are We Overutilizing Laboratory Testing?

I attended the Emerson Ecologics IGNITE conference in mid-November in lovely Carlsbad, California. The OMNI La Costa is one of those plush getaways that you imagine hosts meetings for executives of a Fortune 500 company, and the bedroom-deep bath with marble flooring did not disappoint. Jeffrey Bland, PhD, who has played a pivotal role in introducing and educating me (and most of you) on functional medicine, gave the keynote. After an early workshop on nutritional intervention in treating diabetes, the talks focused on the business of medicine. Among the speakers instructing us on tips to build our practice was Peter Osborne, DC, founder of Gluten Free Society, and author of the soon-to-be published book No Grain, No Pain. Osborne’s work has focused on the deleterious role that gluten plays in people’s health; his book reviews his clinical experience working with patients over the past 15 years. He promises that his book will expand upon Perlmutter’s Grain Brain and Davis’s Wheat Belly. Emerson Ecologics is to be congratulated for catering the weekend events with highly palatable – in fact, delicious – gluten-free, dairy-free fare.

Osborne’s talk, however, was not focused on reviewing his rationale for counseling patients on being gluten free. He outlined his multipronged strategy for practitioners to substantially increase their incomes. Osborne is charismatic and persuasive and very steadfast on his message. He thinks that practitioners of functional medicine, spearheading the medicine of the future, deserve to be financially rewarded for offering patients the best diagnosis and treatment. Osborne has developed “protocols” for diagnosing patients that require extensive functional medicine testing. Without that testing, Osborne contends, a practitioner will miss key biochemical and physiological abnormalities that are not diagnosed by most MDs. Osborne considers that all incoming patients need extensive laboratory testing including genomic analysis, toxic metal evaluation, comprehensive vitamin and mineral testing, screening for fungal toxins and candida, food allergy evaluation, comprehensive stool analysis with parasitology, and other assessments. Such laboratory testing is routinely done with all new patients. Based on the lab results, protocols are created requiring nutritional and diet changes, and costly supplementation orders are implemented. Due to difficulties with insurance company authorization, his laboratory services are directly billed to the patient, not insurance or Medicare.

The question is, is this functional medicine? Is functional medicine a diagnosis based on an array of out-of-range laboratory tests that are flagged and then automatically treated? How do the physical exam, history, imaging studies, and pathology factor into the functional-medicine diagnosis? If the patient is receiving prescription treatment, do the laboratory abnormalities alone provide the basis for modifying the medical treatment? What about legitimate concerns about erroneous laboratory testing?

Elsewhere Alan Gaby, MD, has argued that less testing is better; we should use our clinical acumen to diagnose and treat the patient. Horror stories abound about patients becoming alarmed after being informed of a diagnosis based on incorrect pathology and imaging reports. While erroneous functional medicine testing is unlikely to cause alarm, for example, a wrong vitamin B12 level, generating a massive compilation of out-of-range test scores that may not be fully understood, does not yield a “true” medical diagnosis. From a medical legal basis, the lab abnormalities will not counter malpractice based on failing to provide usual and customary care.

Practitioners may generate fabulous incomes based on ordering extensive lab testing leading to protocols requiring purchase of quantities of supplements, but this is income-based medicine, not functional medicine.