Statue of Asclepius
Somewhere along the road we came across a fork. On one side was the conventional medicine climbing the slow and arduous ladder of scientific discovery and thoughtful action. To continue along that path was the considered opinions of the “experts;” that innovation would be slow and the potential to achieve huge dividends would be even slower in patient care. They advocated the other path; the one with faster methodology, quicker results and the hope of scaled returns. That was the chosen path. It was a brilliant piece of deductive understanding at the time to obtain huge dividends. As the rewards poured in, the entrenchment got deeper. Life was now being lived in the fast lane of “cause and effect.” The “cause” was arbitrarily determined as long as it fit the overall paradigm. The “effect” was glorified if it fit the causal premise. However if in contradistinction to the anticipated result, it was rendered, as craftily as possible, for overall impact to the reading physician in a mercenary statistical overtones, to confuse and obfuscate
From the many vagaries of numerical manipulations to the observed beliefs of a rigid scientific thought the forest of this data was massaged to render a fait accompli. Who could argue when the end result was an “improvement” in the wellbeing of patients? And yet as steadily as the beat of positive studies emerged from this abundance of derived literature, a slow drumbeat of contrary opinions began to surface. A clash of the contrarians and the protagonists was about to take place. But it did not.
What happened? Why did the fight vaporize? These are the questions worth exploring. Somewhere in that realm the protagonists realized that the fight would be lost. They came up with a formula to save and bolster the cache of their determinations. They came up with “Guidelines.” What were these “guidelines” and who determined them to be such? It turns out that these “Guidelines” were the considered determinations of the fast-lane society. They crafted a terminology called “Evidence Based Medicine.” What was the evidence and how did it serve medicine? This last question remains unanswered. But let me suggest that since medicine is a constantly evolving science and circumventing its practice to the simplicity of antiquated “evidence” is tantamount to making robots of the physicians and rendering their expertise and knowledge as moot. The “Art” that lies at the very heart of good medicine and practiced by the physician based on his or her judgment was rendered unworthy of any weight. Thus “Guidelines” were used to make consistent delivery of healthcare to the sick and remedy any possible weaknesses in the system. Did theses guidelines serve their purpose? That question may have been answered in many a mind as “no” yet it will take moving a mountain for the officials to declare it ineffective. For the present though there are many physicians who have bought into these crafty words and use it to echo their opinions under the “guidelines” scenario. So much so that the “Guidelines” are being used unfortunately as “mandates” by some. The luster and reach of this new magical beast is evaporating just as easily as driving a new car out of the parking lot. As surely as the pendulum swings one way, the other side pulls and tugs at it.
Freeze Dried Roses
So in this robotic world of “Guidelines” and “Mandates” where does medicine fit in? Are the physicians simply there to quote the "evidentiary" statements from the proscribed “Guidelines” and express the percentages of success or failure without any empathic rendering of a personal nature to the patients? Did the experts not realize that medicine takes a little bit of the physician’s soul to heal the sick? Did they not graft into their thinking that without the emotional desire to heal the possibility of success in caring would suffer? Did they consider in their equation the thoughtful musings of many years of experience at all? The answer might be “Oh Yes of course!” and they would pepper it with, “That is why these are considered “Guidelines.” And yet the use and abuse of that word is in full display. Guidelines for physicians are similar to guidelines for teachers. No emotions: No impact. No desire to teach: its only a paycheck. No inspiration: No result! In fact write all you want in the annals of wisdom the dogma of “streamlined efficiency” and I will give you the perjured soul of Tantalis.
The other day some months ago a young student asked me of what I thought about medicine?
“Why do you ask?” I inquired.
“Oh, just your opinion?” he chimed.
“I think it is the greatest of all disciplines in all the fields of science.”
“You really believe that?” he asked with some incredulity.
“Yes, don’t you?”
“Well,” he said with a sigh, “ I thought there was a lot more that needed to be discovered. It turns out that all that remained is in the books. There is an algorithm for everything.”
“Yes but that is just current information.” I replied.
“Not really. If I punch in a diagnosis of colon cancer for a patient, the computer spits out all the required tests that need to be done and as I plug in that data the treatment is outlined.” He said with some dejection. “Where do I fit in. Am I just a keyboard puncher?”
I reflected on that for a while. This seemed like a heady statement from this intelligent youth.
“No the information is for your reference only. It is and will be your knowledge and experience that will guide you into helping your patient. Most of the time what the computer spits out will not be for the best for your patients and you will realize it as you develop your knowledge-base. And by the way we haven’t even unearthed the beginnings of the basics of what makes human life tick. That is a long ways away. Plenty of discoveries and inventions and innovations await you and the next generations to come. You just have to be on the lookout. It was not long ago when the medical field realized that the heterogeneity of cancer is governed not by the morphology of the cell but by the genetic riot within it. And also recently the questions about a stem cell as the precursor for all cancer are being raised because the field theory of cancer seems to be gaining some momentum. When single pathways cannot curb one cancer because discoveries of cross talk between disparate pathways within the cell continue to jangle the machinery that makes the cell double and grow. These are all recent phenomena. More of such low-hanging fruit is within grasp of anyone willing to take a swipe at it.”
He seemed pleased with my answer. His eyes opened wider with some thoughts running deep in his brain. His frown lines smoothed. There was hope for us after all.
In any field, individual thought renders the greatest success and equally the greatest failure is found when it is lacking. A Freeze-dried Medicine is an assembly-line of percentages bereft of the human element, one without richness of color and flavor and eventually good care.
The Doctor (painting by Luke Fildes)
Let us fatten medicine with the juices of tempered thought, of the warmth of individual care and with the luxury of individual experience. In an ideal world we would not equate medicine with money, so lets not. Let us foster individual responsibility for self-health and not resort to a “pill” for everything wrong with our universe. Let us all inspire the best in all of us. Let us encourage the true scientific reality and not devise methods that mimic real innovation. Let us once again be men and women of medicine and have individual thoughts and ideas. In the end it will be the best for us all.
Henry E. Sigerist, A History of Medicine, Oxford University Press, 1987, p27-28
Albert R. Jonsen, The New Medicine and the Old Ethics, Harvard University Press, 1990, p122-123