Who has not heard of the famous writer, Art Buchwald? He has a story to tell the medical world. He is in a hospice now, having opted out of “life long” dialysis after the doctors amputated one of his legs. He was told that he would die in maximum two weeks time without dialysis. He opted out to live the rest of his life in a hospice. Medicare was prepared to pay for just two weeks of his treatment as, at the end of that period, he was supposed to meet his maker in heaven. Lo and behold, he is around after six weeks and is now back in circulation!



Art Buchwald

“When I got to the hospice, I was under the impression it would be a two- or three-week stay. But here I still am, six weeks later, and I've gotten so well Medicare won't pay for me anymore. Now this is what it's like for someone who is in the hospice: I sit in a beautiful living room where I can have anything I want and I can even send out to McDonald's for milkshakes and hamburgers. Most people who are not in hospice have to watch their diets. They can't believe I can eat anything I want. I keep checking with the nurses and doctors about when I'm supposed to pull out. No one has an answer. One doctor says, "It’s up to you." And I say, "That's a typical doctor's answer."

“So far things are going my way. I am known in the hospice as The Man Who Wouldn't Die. How long they allow me to stay here is another problem. I don’t know where I'd go now, or if people would still want to see me if I wasn't in a hospice. But in case you're wondering, I'm having a swell time -- the best time of my life.” Some studies have shown that patients who get admitted to for profit dialysis centres in the US do very badly as they do not even get a chance for transplant as the dialysis goes on as long as the patient can go on (and pay)!

From heart surgery to prostate care, the medical industry knows little about which common treatments really work. The signs are not very encouraging. David Eddy, a former professor of cardiovascular surgery at the Stanford, who left his job and got his PhD in mathematics from Duke’s university, has been struggling to get to the bottom of this uncertainty, without much success though. He has developed a computer model “Archimedes” that has given him an insight into our failings in this field. No body seemed to bother about my pleadings in the last forty years that doctors have been barking up the wrong tree and were taking patients up the garden path to the mirage of omnipotent treatment strategies. David’s strategy, using complicated computer models which common doctors don’t understand, seems to have woken up this slumbering dinosaur, the medical profession, at least in the west, to a certain extent.

With a groundbreaking computer simulation, Eddy showed that the conventional approach to treating diabetes, cholesterol, high blood pressure etc. did little to prevent the heart attacks and strokes that are the predicted complications. The same thing probably holds good in the field of asymptomatic hypertensives. David felt that if we doctors don’t pay heed, we might have to close shop soon. Eddy’s first half is very scientific and true but the second half is based on future predictions that never could come true in a dynamic human system. David’s message seems to be filtering through in the US. Kaiser Permanente, the largest HMO in the US, is trying to follow Eddy’s advice in a million patients.

Where has Eddy gone wrong so far? Not in correcting the past but in predicting the future. For Eddy, this is one small step toward solving the thorniest riddle in medicine -- a dark secret he has spent his career exposing. "The problem is that we don't know what we are doing," he says. Even today, with a high-tech medical-care system that costs the nation $2 trillion a year (in the US alone), there is little or no evidence that many widely used treatments and procedures actually work better than various cheaper alternatives,” feels David. Eddy liked to cite a figure that only 15% of what doctors did was backed by hard evidence.

A great many doctors and medical care quality experts have come to endorse Eddy's views. While there has been progress in recent years, we are still to know more than 80% of what we practice is only a myth. Clearly, there is a lot in medicine we don't have definitive answers to. My recent book, What Doctors don’t get to study in the Medical School, deals with all these and much more. This book, called the “Holy Text of Medicine” by Richard Smith, the famous editor of BMJ, had the following review in the amazon.com:

“Here, laid out clearly and concisely, are all the well-established potholes and pitfalls in current medical thinking and practice. It is a thought provoking challenge to modern medical practice and research and is intended to encourage us to consider the way medicine is taught. Modern medical practices are driven by science, technology and consumerism, with the cost of treatment weighted in favour of the doctor rather than to the benefit of the patient. Dr Hegde confronts the issue, and proposes an alternative humanistic attitude to education and treatment.”


Medicine is doing somewhat better in recognizing the problem, but in solving it, unfortunately, no. Because there are no definitive answers, patients are at the mercy of where they are and who they talk to. Take cancer for example. The choice of treatment may not matter very much. There really is no evidence to suggest that one treatment is better than another. Of course, there are areas of medicine, from antibiotics and vaccines to early detection of certain tumors, where the benefits are certain to a great extent, although some of them are questionable with newer evidence. The antibiotic resistance is a time bomb which could burst any moment. A lot of things we absolutely believe at the moment based on our intuition are ultimately absolutely wrong.

Large randomized controlled studies did not deliver the goods as expected because we have been treating the human body as a bio-medical electromechanical machine like a car engine. Human body is much more complicated and follows totally different rules of the game. We need to think afresh. So it's no surprise that up to one-third of clinical studies lead to conclusions that are later overturned, according to a recent paper in JAMA. Doctors have been predicting the unpredictable all through. Human body has two attractors, the chaotic dynamic attractor called health and the static attractor called death, in phase space. Disease is a state where the patient falls outside the healthy chaotic attractor. In the majority of situations s/he gets attracted back to the "healthy chaos" inspite of doctors’ interventions. Rarely, though, s/he can never ever be brought back to the healthy attractor despite all the hi-tech stuff that we boast of!

I can visualise the misunderstanding in the minds of the lay people, who have been brought up to believe that we doctors are omnipotent in the face of serious illnesses, but it is surprising that the medical profession is not aware of our inability to predict the future of the human organism under any circumstance with certainty. Uncertainty is the only certainty in human health and disease. To predict the future of the Universe one should know the position of each and every single particle in this world, which is impossible. How then do we predict human future using our limited knowledge of the human phenotype?

Let us educate the public that doctors are not capable of predicting the future in any disease set up and, therefore, doctors should have faith and hope even in the most desperate situations. Many of our interventions in emergency situations have not been audited at all and quite a few of them have been seen to do more harm than good. Doctors are fallible and they are not Gods. If we do not show ourselves as capable of saving people under any circumstance thus deifying ourselves, society would forgive us for our mistakes. We better remember the advice of Hippocrates to “cure rarely, comfort mostly but, to console always.” Otherwise, consumerism will change medicine for ever and make it prohibitively expensive. If this is understood then the question of lawyers coming into the picture does not arise. Empathetic transparent communication and good record keeping are the best insurance against malpractice suits.

Word Count: 1464 words exactly.