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Internal medicine physician Sally Daganzo discusses her article “How functional medicine fills the gaps left by conventional care.” Sally explains how a systems-based, evidence-informed approach can uncover root causes of complex conditions like fatigue, brain fog, anxiety, digestive issues, and eating disorders, especially when standard lab tests and specialist visits fail to provide answers. She highlights how functional medicine complements conventional care by considering factors such as nutrition, sleep, inflammation, microbiome health, and environmental stressors. Listeners will gain practical insights into how functional medicine reconnects doctors with clinical reasoning, expands treatment tools, and helps patients find healing when traditional approaches leave them feeling dismissed or “treatment-resistant.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Sally Daganzo. She’s an internal medicine physician. Today’s KevinMD article is “How functional medicine fills the gaps left by conventional care.” Sally, welcome to the show.
Sally Daganzo: Thank you. Glad to be here.
Kevin Pho: Let’s start by briefly sharing your story and journey.
Sally Daganzo: My journey into medicine was a bit circuitous. I grew up with a sick older sister, so medicine was always in the back of my mind. She passed away at about age 10. I initially did grad school in physics, and then I did management consulting. Medicine kept pulling me back because I liked the science aspect but also the complexity of always learning something new and getting to apply it to the real world, versus physics, which is very esoteric, at least in my opinion.
I ended up at UCSF in San Francisco doing medicine, and I bounced around from every single specialty, thinking I might do neurosurgery or transplant surgery. You name it, I thought it might be a good fit. I ended up in internal medicine because I couldn’t decide, and that was a way of punting down the road, and I just stayed in there. I didn’t really want to specialize because I really like everything. I’ve done various things along the way with internal medicine, from Hawaii back to California.
Kevin Pho: Before we talk about your article, tell us what functional medicine is and how you first got interested in it.
Sally Daganzo: I was thinking before I came on today, there’s this term that most of your audience probably knows, like functional neurologic disorder or functional dyspepsia. I don’t know if the term came from that, but that’s a lot of what I think functional medicine physicians treat: something where we don’t have a lab test that tells us, for example, “You’re anemic, and therefore it’s iron deficiency anemia.” We look more at the root cause.
That’s the buzzword: what’s underlying it? Is it your genetics? Is it the environment? Is it trauma? A blend of all of those things. To me, it’s going back to the basics of the first two years of medical school, which I don’t know that many of us really think that we’re using on a day-to-day basis in our busy practices.
That’s what drew me to it, was the scientific aspect of really getting to the root cause of a particular person’s situation. It’s personalized medicine, I would say, where your chronic fatigue versus your next door neighbor’s chronic fatigue might have the same phenotype, but they’re not the same story to get there. In busy practices, it’s really hard to do that. That’s what drew me into functional medicine: this root cause approach of getting to think more deeply, getting to go to PubMed and look for articles that are case reports and what might be going on with this person. More challenging cases, which is what I’ve always enjoyed.
Kevin Pho: Your KevinMD article talks about how functional medicine fills the gaps left by conventional care. For those that didn’t get a chance to read your article, just tell us more about it.
Sally Daganzo: Part of why I wrote it is I think there’s this notion out there that functional medicine is more complementary. There is that term “complementary alternative medicine,” but it’s integrative and it’s basics. In the article, I was trying to dispel the myth that functional medicine is this other thing that is a mystery. It’s actually what all internists, or anybody who went to medical school, are well-equipped to practice. There’s nothing new or groundbreaking that you learn. The learning is fantastic if you go through a rigorous training program like the one I did, but it’s going back to, “How does the mitochondria work, and what things are toxic to the mitochondria, and why might that lead to this person having illness?”
That’s not something that when I’m meeting somebody with type 2 diabetes at my last job and I’m treating it, we’re not thinking about that. Conventional medicine has gotten down to sort of algorithms for the most part, at least in primary care, where it’s like, “You had a heart attack, you need an aspirin and a statin.” That’s one example. To me, that’s so boring, and there had to be more to it. I was just trying to dispel the myth that functional medicine is this out-there, magical thinking. It’s really not. It’s really scientific, and that’s what drew me to it. My background in physics, you know, I’m open-minded, but I’m still scientific, and I think that’s important for people to recognize. It’s not just some made-up science or “woo woo” medicine, as we might call it. It’s actually very rigorous and difficult. You have to remember all the basic science.
Kevin Pho: You’re an internal medicine physician. Give us some examples of how you would incorporate functional medicine in your practice, the types of patients you would receive, and the type of conditions that you would treat that would require a functional medicine approach. What exactly would that look like?
Sally Daganzo: That’s a great question. I actually primarily treat eating disorders, which is not always best for a functional medicine approach. A lot of functional medicine is lifestyle and nutrition interventions that are not medications, what we call “a pill for an ill” medicine. It’s more like getting a person’s history. A couple of the tools that we use are a timeline, which is really just a good history that we all know how to do when we do an H&P. One of the big things is asking, “When did you last feel well?” So it might be somebody coming in with fatigue.
Initially, what I started with was things like long COVID, which lends itself pretty well to functional medicine. I think most of us have seen the post-acute sequelae of COVID, or long COVID patients, or POTS. Those people might have been to different specialists who say, “Oh, if it’s POTS, just take propranolol,” or if it’s fatigue, “take a stimulant or go see a therapist.” There are these prescriptive answers without looking a bit more holistically. If you get more of a timeline, going back to, to be extreme, in functional medicine, we ask, “Were you breastfed or bottle-fed, and how does that affect your microbiome?”
It’s a lot, but if you go back to what all the things in this person’s life are that led up to them feeling this way with a complex illness. I would say POTS might be a classic one, or long COVID, or myalgic encephalomyelitis/chronic fatigue syndrome is another one that a lot of doctors can’t stand. Fibromyalgia, all of those, there usually is a pattern of dysfunction. We use the word “systems biology.” Instead of mapping it to the heart or the lymphatic system or the brain or the GI tract, we’re mapping it to systems like energy production and communication, and that’s how the whole body coordinates itself.
For example, if it’s energy production, it would be everything from, “What are you eating? How is it digested? How is your body taking it up?” And then, “How do your cells process it, and how does your mitochondria work?” That’s a whole different thing. It’s something that all of us have learned and we’re all familiar with, but it’s not something that on a day-to-day basis, at least for me in my former practice, I was able to utilize or implement. I just wasn’t thinking about it.
The typical person that would need a functional medicine approach is anybody with a complex illness that maybe they were told is “functional.” I think we know that term, “it’s in their head.” It’s not just a surgical issue or a gallstone pancreatitis or whatever. It’s more the nervous system, more complex. But it’s something that takes more time, which we’re not given, and that’s my struggle with how to fit it in. That’s the next step: how to fit it into a busy practice and how to still take some of the tools that we learn in functional medicine and in medical school and integrate them little by little. A lot of it’s lifestyle medicine and dietary medicine, but it’s also really partnering with your patient and believing them and trying to help them get to wellness, which sounds just like primary care.
Kevin Pho: That leads me to my next question because it sounds like functional medicine is a lot of the preventative medicine things that we do or we’re supposed to do in the exam room. I’m an internal medicine physician myself. I do primary care, but like you said, a lot of this stuff takes time, especially taking a holistic approach to a patient’s problems. In a typical 15-minute visit, it’s very difficult to do that. You said earlier that you want to take some functional medicine tools and try to incorporate that into a conventional primary care practice. How do those two models intermeld if they can be combined at all?
Sally Daganzo: I definitely think they can, and I think where I used to work, in retrospect, they’re actually using some of it. Getting a relationship with your patient is the first thing, and you can do that in 15 minutes if you preface it in the right way. “We’ve got 15 minutes, let’s get to know each other in these ways, and here’s why I am going to ask you if you had a c-section or if you were a vaginal birth,” or whatever thing you’re going to ask them. I think part of primary care is you actually have a longitudinal relationship, so I think in primary care, it lends itself very well to that.
But the other things that they use, at least in the Institute for Functional Medicine, which is where I did my training, there’s a big emphasis on a team-based model where there are health coaches or a multidisciplinary approach. It’s not just the physician. It may be that I’m taking the history or I’m making something prescriptive about their lifestyle or how to improve sleep or how to alter their dietary intake or other things like that. But then I may pass that along, and maybe it’s a group visit with a health coach and other people are learning something similar.
There are ways to do it like that. That’s one way that works really well. A lot of my colleagues that have been doing functional medicine for a long time require that all of their patients work with their health coach because they get better results to implement some of these changes that require motivational interviewing or other habit changes. It’s hard for a patient to see us every week, so that’s one way that is effective that I think is easy to expand on.
Kevin Pho: You said earlier that sometimes functional medicine gets classified or misunderstood as fringe or unscientific, despite what you said is a rigorous, evidence-based foundation. Why do you think functional medicine gets that bad reputation?
Sally Daganzo: I guess I might blame social media, which I’m not totally on all the time, but there are a lot of people that can go and just… there’s not a board. Well, there will be a board certification for it starting next year, actually, to help remedy that, but anybody can be a functional medicine practitioner. There’s nobody saying you can or can’t. So I think part of it is just anybody can say it. They could be doing quantum water or, I don’t know, there are so many things out there that are very dubious. I think that’s where it’s just watered down. It’s not like, “Oh, I’m a cardiothoracic surgeon.” Everybody kind of knows my neighbor can’t say that. Well, maybe he could, but I don’t think so. I think that’s where it comes from, and people see it as fringe.
But it’s really not. It’s just basic science, and I’m trying to apply it. It’s evidence-informed rather than evidence-based, I guess. It’s evidence-based, but then it’s a little bit more inclusive because my patients that are sick don’t want to wait 20 years for Lilly to do a randomized controlled trial on low-dose naltrexone for long COVID or whatever it is. There is this partnership of, “Do you want to try this thing that’s not FDA-approved or whatever? Do you want to try it now, or do you want to wait 20 years?” There’s this risk-benefit, and you have to go to PubMed, open evidence, whatever, and look for data and partner with your patients to do that. But I think a lot of people practicing out there just say it because it’s a buzzword, which is part of why I wanted to write the article, just to lend some legitimacy to it, that it’s a real thing, and for people to ask good questions when they’re seeing somebody who says that they offer it to make sure they know what they’re getting into also.
Kevin Pho: Now for the patients who are listening to you and are interested in a functional medicine approach to their conditions, what are some things that you should watch out for or look for when searching for a functional medicine clinician?
Sally Daganzo: I’m a bit biased. I think that it’s a red flag if somebody’s practicing functional medicine that is not also trained in what we would call conventional or traditional medicine because I think in order to practice functional medicine, you need to know all the guidelines and everything else. I feel strongly it should be a blend and not one or the other. It should be holistic and inclusive.
If you’re going to go see an acupuncturist or something, acupuncture does have a role in medicine. I don’t think too many people disagree with that. For a lot of people, it helps with different conditions. But if they’re going to be prescribing you medications, which would be supplements, right? They would be vitamins. That worries me. I include vitamins and supplements as pharmaceuticals. I put them all in the same category, whether I write a prescription that requires my license or not. For me personally, that’s a red flag because if this person doesn’t really know when you would use atorvastatin or semaglutide or what have you, then how can they know that they’re giving you the best care? I think you have to use all of the tools. For patients, I think that it’s best to have somebody who is equipped with all of that, which may be hard to find, but it’s getting easier, or to at least have somebody who’s open-minded to that and to work with their primary care on being collaborative.
Kevin Pho: We’re talking to Sally Daganzo. She’s an internal medicine physician. Today’s KevinMD article is “How Functional Medicine Fills the Gaps Left by Conventional Care.” Sally, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Sally Daganzo: For people to be their own self-advocate and not be afraid to ask questions to their primary care or another doctor. Now with AI and everything, patients can be even more of their own advocates. I love it when people bring questions, so I think if they’re not sure, just ask. And if you feel gaslit by your doctor, just look for another one. There are still so many great clinicians out there. It’s worth partnering with one that is somebody you can feel comfortable with. I think that’s the biggest thing in wellness to get well.
Kevin Pho: Sally, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.