THE FINE ART OF MEDICINE AND ITS OUTDATED “SCIENCE”.
Posted by bmhegde on 1
The art of medicine, that which makes the quality of the hapless patient’s day, should be the primary universal feature of medical care delivery systems in the world. Irrespective of which system is followed, doctors, in general, should cultivate the fine art of medical practice. Unfortunately, in the present day world of hi-tech modern medicine this aspect of patient care is not stressed in the medical schools, if ever mentioned during the trainees’ work there. In the rat race of medical practice where the doctors’ time with each patient is controlled by outside agencies, like the hospital managers, to improve the financial health of the hospitals, the patient’s health is relegated to the background! Philosophically, it is the art of medicine that impresses the immune system of the patient and works as a catalyst to enhance the immune guard. The latter eventually heals the patient, technology and interventions notwithstanding. Patient care is simply CARING for the patient. Many of the complementary systems score over modern medicine in this arena. We, in modern medicine, have been so much immersed in our interventions and the modern “scientific” methods, that we do not feel it is important to be kind to our patients. We feel so important ourselves, deluded by the array of scopes and scanners that we possess today, that we couldn’t care less for our patients joys and sorrows. While it is nice to feel important it is more important to be nice to our patients. Patients could live without doctors but doctors will not be able to survive without patients.
Time was when medicine was basically an art based on the patchy science that it followed those days. It was only after the twelfth Century AD when modern medicine was accepted as a science in the European Universities that the medical world lost track of its aims. Medicine began riding piggy back on the biological sciences and their attendant technological advances. The great physicians of yore, like William Osler, Lord Platt, Robert Hutchinson, Paul Wood, Richard Asher, Sir George Pickering, James Spence, Paul Dudley White, and Sam Levine and, even, some of the more recent ones like Walter Somerville, and Bernard Lown have spoken eloquently about the great role played by a placebo physician in the healing process. Talking Sense by Richard Asher and Talking with patients by Professor Calnan of Hammersmith Hospital are the two great books that students could read with profit in this field. While patients are getting disillusioned with modern medicine these days, it is time to remind the young medicos that their future depends on their bedside manners and their interest in their patients as suffering human beings and not as cases to be intervened.
The Present Science of Medicine:
The present science that we follow in medicine is called the reductionist science that was the basis of all the biological sciences up until the beginning of last century when physics deviated from this to go on the path of quantum mechanics, where reductionism counts very little. If medicine had followed the path taken by physics we would have done very well indeed. We still follow the linear mathematics in all our calculations. Whereas we believe that raised cholesterol, BP and sugar are all bad for the future of the organism (patient) the truth is that high cholesterol and low cholesterol are both bad for the organism as also BP and sugar levels. Another area we make patients suffer using this wrong science in our calculations is when we predict their futures. Predicting the future is always difficult. When we predict the future using linear mathematics and reductionism we are bound to go wrong. Doctors have been predicting the unpredictable futures of their patients wrote a noted physicist, Prof. William Firth, in a very good review article in the British Medical Journal in 1991.
A short note on this outdated science is in order here. Reductionism is the science where doctors study a cell of an organ and try to project that wisdom on to the organ and then on to the organism (human being). Unfortunately, what the organism does depends not necessarily on what a cell does. In practice the whole (Human being) need not (is not) be the sum total of the bits (cells). The future predictions based on this logic is sure to fail as time evolution in any dynamic system, like the human body, depends on the total initial state of the organism; i.e.: his genes, his mind (consciousness) and his body.
Our present science allows us to predict the future of our patients based on a few (not even the whole) of the phenotypic (body) features only. In addition, changing the initial state partially might not hold good as time evolves. To give a concrete example: to say that raised blood pressure will certainly harm the owner in due course is only a conjecture and not a scientific truth. So also to say that our lowering the patients’ blood pressures using powerful chemicals will hold good as time evolves to prevent complications is also a conjecture and not a scientific truth. It should now be clear to the reader how fallacious our science has been. Detailed note on all these aspects could be found elsewhere.
Reductionist science has left us in the lurch in our attempt to do good to patients. Most of our interventions, especially in the apparently healthy population (like routine screening for abnormalities) has been counter productive, to say the least. However, there is a huge big business in these methods and there are trillion dollar industries doling out drugs and technology to correct these “so called” phenotypic abnormalities these days. Doctors, who do not go deep into the working of this wonderful machine, the human body, are deluded to believe that our interventions are the best bet for man to survive on this planet. The business world uses doctors to get more returns for their tools, the scanners, the biochemical abnormalities, drugs, and surgical interventions. Whereas all these methods are useful in an emergency when a patient comes to seek our help in distress, despite the fact that the scientific basis of most of what we do is under a cloud, it is our duty to do our best to relieve the patient’s distress at that point in time. It would, however, be dangerous to use the same methods to correct the imaginary abnormalities in an otherwise well person. Many studies recently have pointed out these facts. A recent audit of our methods used extensively in the US could be obtained from the prestigious medical journal JAMA 2000; 284: 483-485.
Future Science in Medicine:
Quantum physics gives us an insight into the human mind. The latter resides in all the body cells at their sub-atomic (quantum) level. We have been successful in delineating the human genome to a great extent although that does not by itself mitigate our difficulty. The genes need the environment to penetrate to do what they are supposed to do. Future predictions using non-linear mathematical calculations using fractals (the science of CHAOS), would open a new era in the true science of medicine. We have just made a beginning and have a long way to go to achieve perfection. Knowledge advances, wrote Karl Popper, NOT by repeating known facts but by refuting false dogmas in any field. Medicine has so many dogmas woven around the present science that need to be demolished for medicine to come out of the cocoon. Earlier we do it the better. Medical students must be introduced to these methods for them to work and discover more truths in this area. Knowledge has to progress. “Never” say “I found the truth” wrote Kahlil Gibran, but rather “say,” “I have found a truth.”
Need for paradigm shift in teaching and learning in the medical schools:
Problem based learning, stressing the methodology rather than facts, should form the basis of the new pedagogy in medical schools. Facts change and they change so fast that what one learns at the medical school becomes redundant by the time the student graduates. The recent Medline figures have thrown up data to show that 7% new knowledge pours into the medical fields through more than forty thousand bio-medical journals every month. This should give us an idea as to what should be taught. Medical students should be taught how to access facts rather than store facts in their small heads in the present day hi-tech internet era. The methodology of patient care and the fine art of medicine should be ingrained to make them human and humane doctors, and not robotic technicians. Paternalism in medicine should give room to partnership in medical care where the patients participate in their care as well. Allowing the students to learn for themselves, providing them with all the necessary infrastructure, and trying to protect them from status quoists in the faculty should be the aim of the new paradigm shift in medical schools.