Prof. B. M. Hegde,
“I wish to say what I think and
feel today,
with the proviso that tomorrow
probably,
I shall contradict it all.”
Ralph Waldo Emerson.
Doctor
sees a patient to give him/her therapeutic advice as well as prognosis. Would
you be surprised if I told you that both these activities are unscientific, to
say the least? Both these are based on the fallacious linear mathematics that
medicine has been following since the time that medicine was accepted as a
science by the European Universities in the twelfth century. This used to be
the case with other natural sciences up until the time of the early part of the
last century when physics, supposed to be the king of sciences, realized the
mistake and ventured to have a quantum jump into the hitherto fore unknown
world of the sub-atomic particles, where the rules of the game were totally
different.
Soon
did the physicists realize that the observer in any experiment is as important
as the observed? In other words, it is all in the eye of the beholder. This was
the beginning of science recognizing the importance of human consciousness for
the first time. The sub-atomic world taught physicists one more fundamental
lesson that the unseeable sub-atomic particles behave the way they do only when
we observe them, but what they do when they are not observed is known only to God.
Of course, God does not exist for a hard core physicist. Medical scientists,
however, can not be that hard on God as recent research has revealed that even
prayer works wonders in patient care. Believers are known to have longer life
spans and better health status compared to the non-believers! This new world of
particle physics is hereinafter called quantum physics for convenience- a
quantum jump indeed!
On
the lighter side, father JJ Thomson, of the Cavendish Institute, got the Nobel
Prize in the year 1907 for showing that the electrons were waves. His son, JG
Thomson, got the Nobel thirty years later, from the same institute, for showing
that the electrons were particles. Both were right and both were wrong, as both
did not know what the electrons did when they were not observing them. When you
go In Search of the Schrödinger’s Cat in
a book by that name you will meet many a quantum cook who could get new
particles out of his quantum kitchen with considerable ease. Today we have more
than two hundred sub-atomic particles and more would be out in the future.
However, the greatest truth for all times, this has a bearing on modern
medicine, was the Uncertainty Principle of
Werner Heisenberg. Uncertainty is the only certainty in the human body or, for
that matter, in any other aspect of this dynamic universe.
When
the doctor predicts the future of a given patient based on some of the
parameters of his body (phenotype) he/she has only a very limited knowledge of
the patient as a whole (his genotype and his consciousness). The future time
evolution of any dynamic organism depends on the total initial state of
that organism. Now you have understood the statement made in the beginning of
this article that doctors’ predictions are all unscientific. More serious is
the next truth. Partially changing the initial state of the organism, as we do in
medical care set up now, may not hold good as time evolves or might even change
for the worse as time evolves.
One would realize the reason why many of the interventional long term
studies have given unexpected results. Most of the drugs used in the treatment
of chronic ailments have, in the long run, been more damaging. Screening the
apparently healthy population and detecting innocent changes in body parameters
and trying to set them to our preconceived “normal” levels have not borne fruit
so far. When doctor interventions were reduced (when doctors went on strike) in
the apparently healthy population, mortality and morbidity showed a downward
trend. This is not surprising. Rather, it should be the rule.
Be
that as it may, the rules of the game change when one has a suffering human
being on hand. Here even the wrong scientific basis should not deter us from
intervening because it is our law that we comfort mostly but console always.
Although we cure rarely we could heal always. Healing is holistic and needs the
help of a placebo doctor who is human and humane. In an emergency situation we
have to do all that we could even though knowledge in that field is not
adequate and complete. The outcome is not in our hands but in the hands of the
body’s repair mechanism. This mechanism is so elaborate and efficient that a
little help from the medical profession might goad that system into full gear.
That needs a compassionate doctor. Hence no robot could replace a doctor for
all times to come. Our aim should be to produce good doctors that care for
their patients, patient care.! Intervening in healthy people should be reduced
or stopped until we are on firmer grounds about future predictions. As of now
we are like the weather predictors where the “butterfly effect”
The
new science of wholism, where the human organism is viewed in its totality for
intervention, is based on non-linear mathematics of fractals. It is also called
the science of CHAOS. This word is not an acronym nor does it convey the
conventional English dictionary meaning of confusion. The human body works as a
whole and in tune with the environment around it. The most important part of
the human physiology is the human mind (consciousness) that oversees the
functioning as well as the malfunctioning at all times. To give the reader an
inkling into the difference between the linear laws that we follow today and
the new non-linear fractal rules, I could cite the example of the heart. The
heart is not a square, rectangle, triangle or even a circle. Therefore it can
never be measured by integer measures like one border or three sides. It does have
non-integer measures like 1.2345 or some such thing. Each cell of the body
could have a fractal measure but not an integer measure. Simple estimate of the
ejection
fraction today is fallacious. Ejection fraction can not be the
indicator of the left ventricular function alone as the ejection depends to a
great extent on the pre-load and the after-load, both of which depend on the
heart rate. The latter depends on one’s mind to a great extent! So ejection
fractions of two patients with identical left ventricular functions might not
be the same in reality.
The
new science is in its infancy. Lot of work has to be done in this field. Until
such time, I am afraid; our patients will have to put up with the linear
science and its ravages in medicine. One example would be enough here. Blood
pressure is not the product of cardiac output and peripheral resistance! The
original view was based on the Ohm’s law of fluid flow which states that in a
straight tube flow pressure is the product of flow volume and flow resistance.
Where is the straight tube in the human body? The whole vascular tree is a
continuous branching bend and is a closed circuit. The branching also is based
on a simple genetic code that is followed by all branchings in the body, the
villai, the nephrons, the neurons etc. The largest part of the vasculature is
the enormous capillary bed. This is totally ignored in our linear calculations.
Mean capillary pressure is the vital measure that we do not do and we base all
our interventions on arterial pressure where the arteries do not even form a
millionth part of the vascular tree. Even fluid replacement based on arterial
pressure could be fallacious. The “dry theory” did proclaim long ago that the
replacement need not be drop per drop of the fluid lost, but the “wet
theorists” carried the day. There is big business in the wet theory of fluid
replacement!
Further,
beta-blockers that increase peripheral resistance also decrease arterial
pressure. Strange are the ways of the world. An audit did show that most blood
pressure studies were flawed. The MRFIT screenees’ study did show that the
linear relation between blood pressure and mortality, taken to its extreme,
shows that the lower the pressure the better. Could one, then, wholistically,
survive with the blood pressure of 60/30? Will there be coronary filling at
that pressure?
Here
again reductionism fails to live up to scrutiny. Most drugs that lower blood
pressure, in the long run, have done more harm than good, as shown in a recent
survey. Even the HOT study, much talked about and sold, has shown that while
most of the powerful drugs did lower box blood pressure effectively while
sending a marginally higher than expected people to meet their maker
prematurely. Brings to my mind the great saying of Richard Asher in his bookTalking Sense that ‘Riva Roci would
grieve indeed in his grave for the patients who have been at the receiving end
of the misuse and abuse of the box that he discovered.”
Time
only would show that we have been barking up the wrong tree. I do not think it
makes sense to most readers at this point in time. Knowledge advances not by
repeating known things but by refuting false dogmas. Medicine is full of such
false dogmas that need to be demolished but the dirty job of doing that is a
thankless job. People would think that the person who points out the wrong path
himself is deluded. May be-may be not but think one must. If the medical
profession is humble enough to accept that all humans are fallible doctors can
not be an exception. It is because we do not teach our students that doctors
could make mistakes that they try and sweep their mistakes, when they do occur,
under the carpet and get into the consumerism muddle. Honest admission of one’s
fallibility and sincere concern for the patient’s welfare would keep the
medical profession on a very high pedestal for all times to come. I, for one,
would be glad to be made known of my foibles. Let us start thinking for a
change.
“Science is always wrong. It never
solves a problem
without creating ten more…….!”
George Bernard Shaw.