FROM DISEASE-CENTRED TO PATIENT-CENTRED MEDICAL EDUCATION.A PARADIGM SHIFT-PLEA FOR SANITY.
Posted by bmhegde on 1
“One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is CARING FOR the patient.”
Francis Weld Peabody.(1881-1927)
“If you listen to your patient long enough, he/she will tell you what is wrong with him/her,” wrote Lord Platt, a great British brain in clinical medicine, as far back as 1949. Recently, five of his students, who are now the medical Czars in Britain, studied the validity of this statement in the present era of scanners and scopes, in a computerized, prospective study that showed that all the examinations that the doctor does refines the final diagnosis only four per cent and all the tests, including the positron emission tomography, would only further refine it by eight per cent, while eighty per cent of the accurate final diagnosis and one hundred percent of the future management strategies could be arrived at, at the end of listening to the patient and reading the family physicians referral letter. Despite all these, the present medical education is purely disease centred, being run with money from the pharmaceutical companies, graphically brought out in two editorials in the two leading journals across the Atlantic, The Lancet in London and New England Journal of Medicine in Boston, in the same year 1997.
Even today medical thinking is based on the time-honoured linear mathematical science, which does not work in a dynamic human body. The latter is run continually by food and oxygen, controlled by the human mind and the environmental-genetic matrix. The science of medicine has been found to be wanting in many areas but, does not seem to make an impact on the leaders in the field. Medicine changed after the 1940s from the “art” that improved the quality of the patient’s day, to a pure “science,” since then. Much water has flowed down the river of pure sciences, especially quantum physics, since the turn of the last century, but medical science even today is mired in the old laws of Newtonian deterministic predictability and Cartesian reductionism. We have been predicting the unpredictable future of our patients, based solely on the very scanty initial knowledge of the patient’s body. Time evolution in any dynamic system depends on the whole knowledge of the initial state of the organism.
Earlier we make medical education holistic and patient-centred, the better for the suffering humanity, as also for the informed healthy people. The informed well people are the bread and butter of the drug and technology companies, since the advent of routine check up of the well to protect their health in the future is a big business for them. Man has never been happy since the advent of this screening industry. In a hard hitting signed editorial in the leading British Medical Journal, the dangers of screening apparently healthy people are highlighted. Statistical definition of health itself is fallacious. However, that helps the industry since it includes five per cent of the healthy individuals in society as ill, due to the inherent false positive errors. False positivity goes up to twenty-five per cent, when disease statistics are applied to healthy people. If all people in the world get checked up routinely, the industry would net nearly a billion healthy people as patients needing drug/technology interventions! Most of our “very scientific” studies are nothing but “Texas Sharp Shooters,” the term that describes what we do in our great studies, mostly funded by the industry. When you empty all your bullets on to a wall and then draw your target around the chance cluster of bullet marks, you could manipulate to get what you are looking for in research!
Many of the present day excellent studies, in the area of the role of human mind and spirituality being at the centre of illnesses and wellness, are being condemned as “sharpshooters” by the big bosses, led by Richard Sloan and others, despite the fact that many of the leading medical journals like the JAMA 2003; 290:215, Proc. Nat. Academy of Sci. 2003; 100: 9090 and 11148 The Lancet 2003;362:604, and Psychosomatic Med. 2003;65:636 have published well conducted peer reviewed articles on the role of mind, spirituality and, even, prayer on illness and wellness. The “thought leaders” of the medical field in the west, and their blind followers in India, declare all the conventional reductionist interventional studies as “pure” science. They consider other studies quoted above as Voodoo Science, after the discoverer of this word, Robert Park, president of the American Physical Society. Dr. Park probably does not know that there is a world beyond his myopic world view. In fact, a physicist does not know what an electron does when he is not observing the electron. He could describe the electron based on his consciousness! A recent meta-analysis of most, if not all, those pure scientific studies, when analysed by a super computer, turned out to be due to chance, the very thing that medical statisticians were trying to avoid! Data dredging is another big business in medical science.
After the data gets collected researchers dredge around the data to get what they want to get, shown elegantly in an article, Seeing What You Want to See in Research, by McCullough and Greenhalgh in the June 2000 issue of the British Medical Journal. Should they fail even there they club many studies, good, bad, and the ugly together and analyse them as a single study-the metanalysis. These “thought leaders” did not even raise a finger when a drug company bought four of their urological colleagues to “manufacture” a hitherto unknown “new disease”, the female impotence, to sell their wares! The beneficiaries were the four urologists, the drug company, of course, and the Cape Cod Hotel, where they were parked for this exercise. They have now planted these “pure science” studies in leading journals to show that there are four classes of female impotence needing urgent preventive treatment with sildenophil hydrochloride from menarche to menopause, a great business indeed. I did not see a whimper of protest from any quarters except an angry item in the British Medical Journal. The new disease has even been numbered and would appear in the medical texts soon.
Epidemiology, a science without sense, so described by a leading American epidemiologist, Steven Milloy, in a book by the same title, has been the cause of many an imaginary epidemic in the past. It is trying to repeat the same feat in predicting great epidemics of heart attacks, hypertension, diabetes and cancer in India in the near future-predicting the unpredictable, indeed. These are all illnesses of ageing and have to, per force, relatively increase as the population ages. Many a time it affects younger people if they age faster due to environmental causes, as happens with many of our able bodied young men who have the gene-food mismatch. While they were born with the thrifty genes of poor Indian parents, they start eating the rich junk food of the west very early in life. Naturally they age very fast, indeed. Their system would start degenerating when they are still chronologically young. This will not reverse by drugs and interventions but only by preventive education and change of mode of living. On the contrary, the Indian thought leaders are at the forefront of a war to get all healthy Indians screened for the above epidemics and start them on life long medications. Every one knows the outcome, but the common man will only be the “bakra”.
I saw an elderly lady, Kaveri, yesterday who became a psychological wreck after seeing a young cardiologist on a routine check up. She is usually very tense, having suffered some of the great tragedies of human life that teems with ills of all kinds, and naturally was anxious while going for the check up. For that hapless soul the cardiologist in question was like the tiger for a cave dweller forefather of ours. He proclaimed “loudly” that her blood pressure was very high, her heart not so strong, and could fail anytime in the near future and, that she runs the risk of eye damage with blindness, kidney damage, strokes and/or heart attacks et cetera. She had all the available machines let loose on her after this initial judgment. While he was screening her, he was giving a running commentary of the hazards of her very existence. She was curtly told that she needs to take the drugs religiously for the rest of her life. She was also given one of the most recent ACE inhibitors and another drug to take. It is surprising that she was alive at the end of the encounter. Now she is a total mental wreck that I could not undo the damage easily. I have taken the help of one of our good clinical psychologists to assist me in this gigantic task. To cap it, she lives with her children in the US. This label and the drugs will ruin them also economically as in that country even if one has Medicare A, B, and C one needs to supplement that with money for the drugs, the new drugs being at least twenty-five times costlier than the best old drugs for lowering blood pressure. All that Kaveri needed was compassion, understanding and, may be, a small dose of the inexpensive medication only if stress relief measures, diet change and life style change does not bring down the imagined “white-coat hypertension”. None of them were even suggested, leave alone discussing.
Here again medical science has failed the common man. Despite the fact that one of the largest and best carried out studies in this field, the ALLHAT Study did show that the oldest and the cheapest thiazides with some potassium supplements was the best and the safest drug except in the rare cases where there are contra-indications for thiazides. ALLHAT came out in 2003 and has been done over a long period of time and on a very large sample of patients. The practising doctor, however, gets a different message through the doctored, sexed up medical literature, that the earlier studies, which all have been shown to be badly flawed scientifically, The HOT study and the HOPE (HOPELESS) study, were the best. These studies showed the most recent, very expensive drugs to be the first drugs of choice. Both these studies have so many flaws but did not stir the conscience of the thought leaders who keep rubbishing many of the good studies in the field of change of mode of living. One of the old studies, but done on a very large sample, eighty thousand patient years of experience to its credit, The MRC study, published in 1995 also showed thiazides in very good light. The MRC study also showed that to save one stroke death in the community one will have to treat with drugs unnecessarily 850 apparently healthy human beings for as long as five years! The drugs themselves would have, in the meantime, sent some of those hapless individuals to meet their maker in heaven. The Australasian study, done much earlier, showed that in people with mild to moderate hypertension, diagnosed in the hospital, nearly half became normal on repeated observations and reassurance. They were in no way different from those that had the drugs de novo.
The earlier we change the medical education from this kind of Cartesian reductionist, disease-centred and oragn-based education to the holistic patient centred but community-based education, the better for mankind. Be warned, as otherwise, what happened recently in Israel when doctors went on strike would be universally happening! It would be a futile drain on the economy of a country like India, although it might control our population burden a lot. Let us learn from others’ experience. When doctors went on strike in Israel recently, in Los Angeles county years ago and in Saskatchewan decades ago, death and disability rates significantly came down only to go up when doctors came back to work in full strength. Even our misconception that better doctor-patient ratio would make society healthier, has been proven wrong in a six country study in Europe and Asia. Up until recently I was under the impression that acute emergencies like trauma, our modern quick-fixes are wonderful. This was changed after I had a look at the audit of per capita death in seriously wounded soldiers in the Vietnam and Falklands wars. Whereas the Americans had the best five-star hospital in Saigon minutes away from the war theatre, the British did not have that luxury. Some of the wounded soldiers were left in snow(thank God for that) for as long as twelve to twenty-four hours, in Falklands. The audit shows that the per capita death in Falklands was almost half that in Vietnam. There are good physiological reasons for this but space does not permit me to go into the subtleties. I have written about the heroic surgeons elsewhere. The hero in the drama was the poor patient who offered himself for such adventure!
Things are changing for the better in the west. Many medical schools in the US and a good many in other European countries teach spirituality and stress management as a part of the curriculum. Problem based community learning is also in order there. Complementary systems are taught in many of those schools, while in India, its birth place, the king of medical sciences, Ayurveda, can not be legally taught in a conventional medical school even today. We are deep down in the license Raj even in medical education. Naturally, corruption rules the roost in any control Raj. When America had strict prohibition, powerful crafty people used to supply the best European whisky all over the country, controlled from the central Stork Club in Washington DC, where on one side, the who is who of America dined, while at the rear side the underworld empire ran bootlegging from Buffalo to New Mexico! Human beings, whether in the Castle or cottage, are governed by the same emotions and passions. Modern technological quick-fixes can not work in a dynamic human system. H.L.Mencken wrote years ago: “For every complex problem there is a solution that is simple, neat and wrong.”
How true?
“…. but they (physicians) cure the body with the mind, and the mind which has become and is sick can cure nothing.”
PLATO in The Republic. (c. 427-347 B.C.)