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Functional Medicine isn't a protected title and a medical qualification isn't a prerequisite to practice. The result is an unregulated and disparate field, with medical doctors, nutritionists, naturopaths and homeopaths among the many practitioners.

Some other chronic illnesses the field claims to treat include heart disease, type 2 diabetes, irritable bowel syndrome, ulcerative colitis, depression, anxiety and arthritis

ll kinds of different reasons, some might have gluten issues, gut issues, others might have a deficiency causing neurological issues, MS is a symptom."

"There are components of Functional Medicine that absolutely lack an evidence base and there are practitioners of what they call Functional Medicine, they charge people for intravenous nutritional injections, they exaggerate claims, and that is professionally inappropriate, unethical and it lacks evidence.

On Dr Mark Hyman's view of MS he says, "there are a lot of terms put together there, all of which individually make a lot of sense, but put together in that way they do not.

"What does FM actually mean? It means nothing. It's a gift-gallop of words thrown together. It's criticised by advocates of evidence-based medicine because it's giving a veneer of scientific legitimacy to ideas that are considered pseudoscientific. For example, it'll take alternative medicine modalities like homeopathy and then call them 'bio-infusions' or something similar, rebranding it as something that works.

"It's a redundant name, real medicine is functional."

Next month the third annual Lifestyle and Functional Medical conference will take place in Salthill, Galway on November 3. Last year's event was attended by more than 500 people and featured a keynote address by honorary consultant cardiologist Dr Aseem Malhotra, author of bestselling The Pioppi Diet (which was named one of the top five worst celebrity diets to avoid in 2018 by the British Dietetic Foundation).

Dr David Robert Grimes is physicist and visiting fellow of Oxford and QUB. His research into cancer focuses on modelling tumour metabolism and radiation interactions. For Dr Grimes, the lack of definition, or "double-speak" as he puts it, in FM is troubling.

As well as the cost of appointments, FM practitioners commonly charge extra for tests. An omega finger prick test is around €100. A vitamin D test can cost upwards of €60, full thyroid panel more than €150 and a gut function test €400. Prices vary between practitioners.

"If I, as a GP, engaged in some of these behaviours I would be struck off." Specifically? "If I was recommending treatments that lacked an evidence base, or if I was promoting diagnostic tests which are expensive and lack an evidence base.

GPs engage every year in ongoing continuous professional development, I spend my evenings and my weekends outside of working hours attending educational events, small-group learning, large-group learning, engaging in research. This is an accusation that was levelled at the profession 30 years ago and then it was correct, but the profession has caught up…

"Obviously promoting wellness and healthy diet is very welcome but going beyond that and stating that certain aspects of 'functional medicine' can lead to reduced inflammation or prevent cancer, we have to be very careful about those claims.

Often the outcome of such tests are seemingly 'benign' prescriptions of vitamins or cleanses. However, dietitian Orla Walsh stresses that even these can have potentially harmful effects, especially on "vulnerable" patients, if not prescribed judiciously.

FM has five basic principles. 1. We are all genetically and biochemically unique so it treats the individual, not the disease. 2. It's science-based. 3. The body is intelligent and has the capacity for self-regulation. 4. The body has the ability to heal and prevent nearly all the diseases of ageing. 5. Health is not just the absence of disease, but a state of immense vitality.

She began her Functional Medicine career while training as a medical doctor and now travels the world working with high-profile clients. Dr McHale charges €425 for an initial consultation and €175 for follow-up appointments. Straightforward lab tests are €250 to €750, for complex cases testing fees can be up to €2,000.

"The term [Functional Medicine] tends to be bandied around quite a bit. Other things people say, such as 'functional nutritionist', can be misleading as a term. Many people are Functional Medicine practitioners but don't have any real medical background at all... I think regulation is always probably the best way forward."

"There's an awful lot to it in terms of biochemistry and physiology," she says. "You do need to have a very solid and well ingrained bio-chemistry background. A solely clinical background doesn't equip you with the knowledge to read a test.

"Evidence-base is the cornerstone of medicine and that has to be maintained. It becomes problematic in this area because you are looking at personalised medicine and that can be very difficult to evidence-base."

GP Christine Ritter travelled from England to attend the Galway conference last year with a view to integrating Functional Medicine into her practice.

"It was very motivating," she says. "Where it wasn't perhaps as strong was to find the evidence. The Functional Medicine people would say, 'we've done this study and this trial and we've used this supplement that was successful', but they can't show massive research data which might make it difficult to bring it into the mainstream.

"I also know the rigorous standard of trials we have in medicine they're not usually that great either, it's often driven by who's behind the trial and who's paying for it.

"Every approach that empowers patient to work on their destiny [is beneficial], but you'd have to be mindful that you're not missing any serious conditions."

Dr Hyman is working to grow the evidence-base for Functional Medicine worldwide. "The future is looking very bright," he says. "At the Cleveland Centre we're establishing a research base, building educational platforms, fellowships, residency programmes, rotations. We're advancing the field that's spreading across the world. We're seeing in China the development of a programme of Functional Medicine, South Africa, the UK, in London the Cleveland Clinic will hopefully have a Functional Medicine centre."

For Dr Mark Murphy regulation is a moot point as it can only apply once the field meets the standards of evidence-based medicine.

"Despite well intentioned calls for regulation, complementary and alternative medical therapies cannot be regulated," he says. "Only therapies that possess an evidence-base can enter our standard regulatory processes, including the Irish Medical Council, the Health Products Regulatory Authority and Irish advertising standards. In situations where complementary and alternative therapies develop an evidence base, they are no longer 'complementary and alternative', but in effect they become part of mainstream 'Medicine'.

l What are the principles?

"There's a huge variation between therapists, some are brilliant and some are okay, and some are ludicrous snake oil salesmen."

He is so concerned that patients' health and wealth are being put at risk by alternative therapies that earlier this year he joined Fine Gael TD Kate O'Connell and the Irish Cancer Society in introducing draft legislation earlier this year making it illegal to sell unproven treatments to cancer patients. Violators face jail and heavy fines.

Dr Grimes says criticism of variations in the standards of traditional medical research can be fair, however due to the weight of research it is ultimately self-correcting. He adds, "The reality is that good trials are transparent, independent and pre-registered.

"My involvement in shaping the Bill came from seeing first-hand the exploitation of patients and their families. Most patients undergoing treatment will take some alternative modalities in conjunction but a significant portion are talked out of their conventional medicine and seduced by false promises

The word for ‘philosophy’ in Korean is 철학, pronounced ch’ŏrhak. It literally means the ‘study of wisdom’ or, perhaps better, ‘how to become wise’, which reflects its more dynamic and proactive implications

At night, in the darkness of the cave, he drank water from a perfectly useful ‘bowl’. But when he could see properly, he found that there was no ‘bowl’ at all, only a disgusting human skull.

Our lives and minds are affected by others (and their actions), as others (and their minds) are affected by our actions. This is particularly true in the Korean application of Confucian and Buddhist ideas.

Wŏnhyo understood that how we think about things shapes their very existence – and in turn our own existence, which is constructed according to our thoughts.

In the Korean tradition of philosophy, human beings are social beings, therefore knowing how to interact with others is an essential part of living a good life – indeed, living well with others is our real contribution to human life

he realised that there isn’t a difference between the ‘bowl’ and the skull: the only difference lies with us and our perceptions. We interpret our lives through a continual stream of thoughts, and so we become what we think, or rather how we think

As our daily lives are shaped by our thoughts, so our experience of this reality is good or bad – depending on our thoughts – which make things ‘appear’ good or bad because, in ‘reality’, things in and of themselves are devoid of their own independent nature

We can take from Wŏnhyo the idea that, if you change the patterns that have become engrained in how you think, you will begin to live differently. To do this, you need to change your mental habits, which is why meditation and mindful awareness can help. And this needs to be practised every day

Wŏnhyo’s most important work is titled Awaken your Mind and Practice (in Korean, Palsim suhaeng-jang). It is an explicit call to younger adherents to put Buddhist ideas into practice, and an indirect warning not to get lost in contemplation or in the study of text

While Wŏnhyo had emphasised the mind and the need to ‘practise’ Buddhism, a later Korean monk, Chinul (1158-1210), spearheaded Sŏn, the meditational tradition in Korea that espoused the idea of ‘sudden enlightenment’ that alerts the mind, accompanied by ‘gradual cultivation’

we still need to practise meditation, for if not we can easily fall into our old ways even if our minds have been awakened

his greatest contribution to Sŏn is Secrets on Cultivating the Mind (Susim kyŏl). This text outlines in detail his teachings on sudden awakening followed by the need for gradual cultivation

hinul’s approach recognises the mind as the ‘essence’ of one’s Buddha nature (contained in the mind, which is inherently good), while continual practice and cultivation aids in refining its ‘function’ – this is the origin of the ‘essence-function’ concept that has since become central to Korean philosophy.

These ideas also influenced the reformed view of Confucianism that became linked with the mind and other metaphysical ideas, finally becoming known as Neo-Confucianism.

During the Chosŏn dynasty (1392-1910), the longest lasting in East Asian history, Neo-Confucianism became integrated into society at all levels through rituals for marriage, funerals and ancestors

Neo-Confucianism recognises that we as individuals exist through plural relationships with responsibilities to others (as a child, brother/sister, lover, husband/wife, parent, teacher/student and so on), an idea nicely captured in 2000 by the French philosopher Jean-Luc Nancy when he described our ‘being’ as ‘singular plural’

Corrupt interpretations of Confucianism by heteronormative men have historically championed these ideas in terms of vertical relationships rather than as a reciprocal set of benevolent social interactions, meaning that women have suffered greatly as a result.

Setting aside these sexist and self-serving interpretations, Confucianism emphasises that society works as an interconnected set of complementary reciprocal relationships that should be beneficial to all parties within a social system

Confucian relationships have the potential to offer us an example of effective citizenship, similar to that outlined by Cicero, where the good of the republic or state is at the centre of being a good citizen

There is a general consensus in Korean philosophy that we have an innate sociability and therefore should have a sense of duty to each other and to practise virtue.

The main virtue of Confucianism is the idea of ‘humanity’, coming from the Chinese character 仁, often left untranslated and written as ren and pronounced in Korean as in.

It is a combination of the character for a human being and the number two. In other words, it signifies what (inter)connects two people, or rather how they should interact in a humane or benevolent manner to each other. This character therefore highlights the link between people while emphasising that the most basic thing that makes us ‘human’ is our interaction with others.

Neo-Confucianism adopted a turn towards a more mind-centred view in the writings of the Korean scholar Yi Hwang, known by his pen name T’oegye (1501-70), who appears on the 1,000-won note. He greatly influenced Neo-Confucianism in Japan through his formidable text, Ten Diagrams on Sage Learning (Sŏnghak sipto), composed in 1568, which was one of the most-reproduced texts of the entire Chosŏn dynasty and represents the synthesis of Neo-Confucian thought in Korea

with commentaries that elucidate the moral principles of Confucianism, related to the cardinal relationships and education. It also embodies T’oegye’s own development of moral psychology through his focus on the mind, and illuminates the importance of teaching and the practice of self-cultivation.

He writes that we ourselves can transform the unrestrained mind and its desires, and achieve sagehood, if we take the arduous, gradual path of self-cultivation centred on the mind.

Confucians had generally accepted the Mencian idea that human nature was embodied in the unaroused state of the mind, before it was shaped by its environment. The mind in its unaroused state was taken to be theoretically good. However, this inborn tendency for goodness is always in danger of being reduced to passivity, unless you cultivate yourself as a person of ‘humanity’ (in the Confucian sense mentioned above).

You should constantly try to activate your humanity to allow the unhampered operation of the original mind to manifest itself through socially responsible and moral character in action

Humanity is the realisation of what I describe as our ‘optimum level of perfection’ that exists in an inherent stage of potentiality due our innate good nature

This, in a sense, is like the Buddha nature of the Buddhists, which suggests we are already enlightened and just need to recover our innate mental state. Both philosophies are hopeful: humans are born good with the potential to correct their own flaws and failures

this could hardly contrast any more greatly with the Christian doctrine of original sin

The seventh diagram in T’oegye’s text is entitled ‘The Diagram of the Explanation of Humanity’ (Insŏl-to). Here he warns how one’s good inborn nature may become impaired, hampering the operation of the original mind and negatively impacting our character in action. Humanity embodies the gradual realisation of our optimum level of perfection that already exists in our mind but that depends on how we think about things and how we relate that to others in a social context

For T’oegye, the key to maintaining our capacity to remain level-headed, and to control our impulses and emotions, was kyŏng. This term is often translated as ‘seriousness’, occasionally ‘mindfulness’, and it identifies the serious need for constant effort to control one’s mind in order to go about one’s life in a healthy manner

For T’oegye, mindfulness is as serious as meditation is for the Buddhists. In fact, the Neo-Confucians had their own meditational practice of ‘quiet-sitting’ (chŏngjwa), which focused on recovering the calm and not agitated ‘original mind’, before putting our daily plans into action

These diagrams reinforce this need for a daily practice of Confucian mindfulness, because practice leads to the ‘good habit’ of creating (and maintaining) routines. There is no short-cut provided, no weekend intro to this practice: it is life-long, and that is what makes it transformative, leading us to become better versions of who were in the beginning. This is consolation of Korean philosophy.

Seeing the world as it is can steer us away from making unnecessary mistakes, while highlighting what is good and how to maintain that good while also reducing anxiety from an agitated mind and harmful desires. This is why Korean philosophy can provide us with consolation; it recognises the bad, but prioritises the good, providing several moral pathways that are referred to in the East Asian traditions (Confucianism, Buddhism and Daoism) as modes of ‘self-cultivation’

As social beings, we penetrate the consciousness of others, and so humans are linked externally through conduct but also internally through thought. Humanity is a unifying approach that holds the potential to solve human problems, internally and externally, as well as help people realise the perfection that is innately theirs

The internet stripped institutions of their gatekeeping powers, thus making it possible for anyone to publish—and making it inevitable that many writers would create audiences independent of media institutions.

The internet destroyed the apprenticeship system that had dominated American journalism for generations. Under the old system, an aspiring writer took a low-level job at a media institution and worked her way up the ladder until she was trusted enough to write.

Under the new system, people started their careers writing outside of institutions—on personal blogs—and then were hired by institutions on the strength of their work.

In practice, these outsiders were primarily hired not on the merits of their work, but because of the size of their audience.

what it really did was transform the nature of audiences. Once the internet existed it became inevitable that institutions would see their power to hold audiences wane while individual writers would have their power to build personal audiences explode.

this meant that institutions would begin to hire based on the size of a writer’s audience. Which meant that writers’ overriding professional imperative was to build an audience, since that was the key to advancement.

Twitter killed the blog and lowered the barrier to entry for new writers from “Must have a laptop, the ability to navigate WordPress, and the capacity to write paragraphs” to “Do you have an iPhone and the ability to string 20 words together? With or without punctuation?”

If you were able to build a big enough audience on Twitter, then media institutions fell all over themselves trying to hire you—because they believed that you would then bring your audience to them.2

If you were a writer for the Washington Post, or Wired, or the Saginaw Express, you had to build your own audience not to advance, but to avoid being replaced.

For journalists, audience wasn’t just status—it was professional capital. In fact, it was the most valuable professional capital.

Everything we just talked about was driven by the advertising model of media, which prized pageviews and unique users above all else. About a decade ago, that model started to fray around the edges,3 which caused a shift to the subscription model.

Today, if you’re a subscription publication, what Twitter gives you is growth opportunity. Twitter’s not the only channel for growth—there are lots of others, from TikTok to LinkedIn to YouTube to podcasts to search. But it’s an important one.

Twitter’s attack on Substack was an attack on the subscription model of journalism itself.

since media has already seen the ad-based model fall apart, it’s not clear what the alternative will be if the subscription model dies, too.

All of which is why having a major social media platform run by a capricious bad actor is suboptimal.

And why I think anyone else who’s concerned about the future of media ought to start hedging against Twitter. None of the direct hedges—Post, Mastodon, etc.—are viable yet. But tech history shows that these shifts can happen fairly quickly.