THE SCIENCE OF MEDICINE NEEDS A QUANTUM JUMP.
Posted by bmhegde on 1
Mankind has been here for well over 500,000 years in about fifty thousand generations. Medical men must also have been there for that length of time. Pain had always been man’s greatest enemy; it is so today and, shall be so for all times to come. The real role of a good doctor is to allay anxiety and relieve pain. The medical profession, in different places and at all times, has lived up to this expectation of man, mainly because of the art of medicine. “Art” wrote Henry David Thoreau “is that which makes the quality of another man’s day.” The fine art of medicine aims at making the day for the hapless patient. Bedside medicine still is based very much on the fine art of doctoring. So far so good. However, the euboxic evidence based medicine is a far cry from this.
Times were such in the distant past that only the art of medicine had do make do for all the problems. Lately the science of medicine seems to be making inroads into that territory of the sacrosanct doctor-patient relationship. In the name of the science of medicine and the much abused word “evidence based medicine” we have been taking the patients for a jolly ride although they end up paying for all the fun from their pockets! We have now reached a stage where modern “scientific” medicine is beyond the reach of nearly eighty per cent of the world population despite the fact that there is a big business in the field of modern medicine.
Science is change. Anything that does not change can never be called good science. The truth of today could be the folly of tomorrow in science, as our knowledge keeps expanding. Unfortunately, most of us are very sure of what we are doing for the patient as we seem to know very little about the complex human machine. We divide the human body into organ based defects and try and set the damaged organs right like the car mechanic setting the parts of the car engine right. Unfortunately, the similarity between the motor car and man ends just there. The two behave totally differently. With more knowledge and wisdom doubts will have to creep in. Modern medicine today stands at the threshold of a major change just as physics did at the beginning of the last century. Having been the captive of the reductionist laws of deterministic predictability of Isaac Newton and Rene Descartes, physics was not making much headway up until the time when Werner Heisenberg, a young student at the Zurich Polytechnic, who in the year 1927 at the age of 25 years, came up with “transcendental algebra” to decipher the mystery of the sub-atomic world.
Heisenberg’s “Uncertainty Principle” about the sub-atomic world took the hallowed world of the “greats” in the field of physics like Albert Einstein, Neils Bohr, Paul Dirac, and Erwin Schrödinger, by a heavy storm. They all cried foul and condemned the young man. He had to fight his lone battle till the end and eventually in 1956 he got his Nobel for his all time great discovery. The only certainty in this world is uncertainty. Without going into the minutiae of physics and Heisenberg’s hypothesis, all that I would like to convey to the reader is that we are in the same state today in medicine. Modern medicine has been the prisoner of the reductionist thoughts since it was accepted as a science by the European Universities in the 12th century.
Our reductionist science in medicine has resulted in drugs and interventions (intervene=go in between with malice) which have made life miserable for patients, as shown by the Institute of Medicine report in the US in 2000. Doctors and hospitals have been the third important cause of death in that country. Adverse drug reactions the fourth cause of death. ADRs accounted for nearly quarter of the hospital admissions there. If one takes the out-patient adverse drug reactions also into consideration it amounted to 77 million prescriptions for correcting ADRs in one year with the total bill for all that amounting to $ 79 billion with an additional 140000 deaths in one year due to ADR alone! Other countries would have similar experiences although they have not been highlighted.
All these happen despite the “so called” evidence based medicine. In fact, we practice “evidence burdened” medicine. To cite one example there are well over six guidelines for hypertension treatment in the world. If one computes all of them together they account for just 39% of hypertensive patients as per their inclusion criteria. Rest of the 61% will have to be treated based on the wise guess of the doctors. Most of those mild to moderate hypertensives will have to be drugged for very long times in the fond hope of saving them from major catastrophes. But in reality the MRC study published in 1985 of mild to moderate hypertension showed that to save one stroke in society doctors have to treat 850 apparently normal individuals with anti-hypertensive drugs for five years! One could only imagine the ADR story here, not reported though. The evidence is reductionist while human body works holistically. No two human beings behave identically for us to club them as cohorts for our controlled studies.
Time evolution in the human body depends on the total initial state of the organism. Our today’s science does not allow us to know the total initial state of the human being. Hence the reductionist interventions might (do) result in catastrophic end results many a time. That said, I must hasten to add that just as in physics where the deterministic predictability models did help to build bridges, construct buildings and fly aero planes etcetera, we have been able to help patients in distress using the reductionist interventions with drugs and surgery in many emergency situations. Things seem to work reasonably well in the short term. The curse of reductionist evidence based medicine has been in the field of trying to change the initial state in the apparently healthy population in the fond hope of avoiding “statistically presumed” complications in the distant future for that person. There are so many imponderables in that area to make deterministic predictability model dangerous. Here doctors have been “predicting the unpredictable” in the words of a physicist, Professor Firth, in the Xmas issue of the 1991 BMJ.
Routine screening of the apparently healthy population could be very dangerous, declared the BMJ in one of its editorials. “How to avoid Modern Medicine” was an article written by Lord Platt decades ago. Early coronary bypass surgery resulted in four fold increase in stroke deaths. Doctors’ strike brought down death and disability in Israel. With the total body scanner coming into to common use (God forbid) it would declare all human beings as abnormal because of the inbuilt false positives. There will be no well human being left in the world if we stick to the evidence based reductionist science of today. Earlier we change to the holistic science of non-linearity and chaos, the better for mankind. It is unscientific to think that the consciousness (the mind) of the patient and the treating doctor does not come to play a significant role in the healing process. In fact, the placebo doctors and the healers of yore did make use of their “lepto-quarks” to stimulate the immune repair mechanisms in their patients. But for that in the centuries gone by when the so called evidence based medicine was missing, mankind would have become extinct long before the dinosaurs. Long live doctor-patient relationship.