Medical education: an epistemiological enquiry.ML Kothari, LA Mehta
Dept of Anatomy, Seth GS Medical College, Bombay, Maharashtra.
Keywords: Education, Medical, Graduate, Education, Medical, Undergraduate, Ethics, Medical, Knowledge, Attitudes, Practice,
Medical science is privileged to be a meeting place of varied scientific disciplines. X-rays, lasers, computers and so on, developed by non-medical men in non-medical disciplines find their way into the armamentarium of a medical man giving him, not unexpectedly, the pardonable illusion that 'medical science continues to advance every day, if not every hour.' The unacknowledged obstinacy of many a medical problem forces the researchers, instrument makers and drug manufacturers to keep on inventing the 'n' th modification of what is basically the same old stuff. That too is presented and perceived as progress. At conferences, calculatedly advertised in the mass-media, and in the publications thereof, people over sing the glory of recent advances, modern trends, latest techniques in surgery and so on. The lay people world over, feel assured that, with the right amount of money, no disease is a problem. No wonder, that, in the Indian movies and on the streets of India, the melodrama staged by a hero or a beggar is his desperate need for money for curing his desperately ill mother. Social and religious organisations, tycoons, and NRI channelise their funds, as a top priority into ‘so and so hospital’ and research centre to which the Governments say 'yea' by this tax-exemption and that. And you end up with the current scenario wherein the 5-star hospitals have many patients who have no disease except money.
A medical student, undergraduate or post-graduate is shielded from all literature that questions the medical establishment, and is taught to treat as virtue his knowledge of the latest. The MCQ teaches him that not only all the medical problems have a logicisable answer, but that even a choice can be made. Such a person is groomed into refusing to accept a 'no' from a symptom, sign or a disease. With the patient's body as a battleground, modern medicine becomes a warfare between the technically expert doctor and the clinical features of a disease or a syndrome. And the warfare can yield no positive gain.
"To me, one of the biggest things I have come up against in medicine is that in the standard textbooks it is not stated that answers to major questions are not known"1.
What seems to have been clean forgotten, in this global drama of medical progress, is that genuine, solid, profitable progress can only reside in deciphering the cause of a disease, and in altering the course of a disease. The cause/s of congenital malformations, cancer, coronary disorder, stroke, diabetes, renal failure, arthritis are rife with speculation that has guided us into nowhere. The CT, USG, MRI, PET, Dopplers, the-scopes, and lasers and the likes give you better image, and an easier access to the lesion but can do nothing about the natural course of a cancer or coronary. The 4th generation cephalosporins come as costly cures of an identifiable bacterial cause, but the pyrrhic victory is negatived by the simple, rarely taught fact that the bacterial biomass outweighs the entire animal biomass by a factor of 20. The microbes are the host, man a parasite surviving at their pleasure or their mercy. The recrudescence of malaria, with cerebral malaria a routine in many parts of our country, ought to open our eyes to our limitations.
Epistemiology has been defined as 'a branch of philosophy that investigates the origin, nature, methods; and limits of human knowledge.' Medical epistemology is our knowledge of its scope and our consciousness of its limitations. Hughlings Jackson, teacher to Oliver Wendeli Holmes, generalised that anyone using the term 'cure' to mean removal/anelioration of a disease is a quack, for cure from L. curatio = 1 take care, implies taking care of a patient, which includes doing therapeutically nothing. To that extent 'curing' the death of a patient is to hold his hand in his final moments, and to ease his departure by indispensable fortitude and philosophy. Nearly 150 years after Jackson's advice, the convenient contortion of cure confounds the medical scene, medical lexicons not exempt. What is true about cure is relevant about therapist, (from Greek therapeutes) meaning an attendant. A therapist, Laing2 emphasized, is a specialist in attentiveness and awareness.
The authors of this article are deeply aware of the inevitable jaccuse that the foregoing is all philosophy and therefore, by pragmatic consensus, need be no practice. Philosophy, dictionaries define, is the science of all sciences - scientia scientiarum. Any science shorn of philosophy has always ended up being a tyranny.
The prestigious Rockefeller Foundations recently published a multi-authored tome 'Doing Better and Feeling Worse, Health in the United States', the refrain being that while many parties engaged in giving health care are 'doing' better, the receivers are 'feeling' worse. Wildavsky3 in a chapter titled 'Doing Better and Feeling Worse: The Political Pathology of Health Policy', sums up the book as follows: "According to the great equation, medical care equals health. But the Great Equation is wrong. More available medical care does not equal better health. The best estimates are that the medical system (doctors, drugs, hospitals) affect about 10% of the usual indices for measuring health: whether you live at all (infant mortality), how well you live (days lost due to sickness), how long you live (adult mortality). The remaining 90% are determined by factors over which doctors have little or no control, from individual life style (smoking, exercise, worry), to social conditions (income, eating habits, physiological inheritance), to the physical environment (air and water quality). Most of the bad things that happen to people are at present beyond the reach of medicine.
"Everyone knows that doctors do help. They can mend broken bones, stop infections with drugs, operate successfully on swollen appendices. Innoculaltions, internal infections, and external repairs are other good reasons for keeping doctors, drugs, and hospitals around. More of the same, however, is counterproductive. Nobody needs unnecessary operations: and excessive use of drugs can create dependence or allergic reactions or merely enrich nation's urine."
"More money alone, then, cannot cure old complaints. In the absence of medical knowledge gained through new research, or of administrative knowledge to convert common practice into best practice, current medicine has gone as far as it can. It will not burn brighter if more money is poured into it. No one is saying that medicine is good for nothing, only that it is not good for everything. Thus the marginal value of one - or one billion - dollars spent on medical care will be close to zero in improving health. And, for purposes of public policy, it is not the bulk of present medical expenditures, which do have value, but the proposed future spending, which of dubious value, that should be our main concern."
Medical students are forever taught the side-effects of drugs, but they are never made aware of the side-effects of advances, much less the nature of an advance itself. "Plus ca change, plus c'est meme chose - The more things change, the more they remain the same." Medical science, priding over its advance every hour, should shame itself into being proved wrong every hour. Archibald Joseph Cronin, the celebrated author, circa 1930, had finished his viva in MRCP, and was holding a towel for the senior examiner washing his hands: "Son, you have done well. But before I declare you a member of the Royal College of Physicians, tell me what is most important in medicine?" Cronin gave the correct reply: "Sir, to take nothing for granted." A German University, known to have spawned Nobel Laureates in physics, has in its entrance, the bronze statue of a girl symbolically emptying out a pitcher. The entrant-student is expected to kiss the feet of the girl and take an oath: "Here I've come not to worship what's known, but to question it." A Canadian journalist bemoaned the fact that medical rounds abound in a lot of yessirring. A resident doctor, brought up on rich diet of yessirring, learns to follow suit be it a lecture, a conference, or the debating by a medical propagandist euphemistically called a medical representative. All these runaway forces end up enforcing a Parkinsonean law: Medical science expands to contract its affordability by an average patient.
The chief side-effect of medical advances is the fiscal bloodletting it inflicts on a society, especially in the poorer countries. In USA, medical bills are the fifth largest cause of personal bankruptcy. What to talk of India, now busy gearing up for an epidemic of 5-star hospitals, seen as blue-chip investment! Surgeons who become skilled at laparoscopic operations can remove virtually any organ from the abdomen using the technique. A study at the Cleveland Clinic, Florida, reported in 'Diseases of the Colon and Rectum' showed that laparoscopic removal of the whole colon was technically feasible - but it also concluded that as yet the procedure 'does not appear to offer any immediately recognisable benefits to the patient. 4 This news-report in the BMJ, September 5, 1992 should, at least, jolt our fiscal consciousness as to how much of foreign exchange, through means fair and not so fair, to be armed with latest -scope, the smallest of which not costing less than 6 figures. As to the benefit to the patients, a clerihew sums up the situation in words few:
What I like about WHO
Is no one knows what they do.
We still wait to be told
The cure for a cold.
(Sir W. M. James)
Lest it be construed that medical students, the world over remain unaware of the seamy side of medical advances or the limitations of medical knowledge itself because they don't read enough. In fact, they read a little too much, an exercise in which there is no room for works that question a medical man's locus standi. The outcome is that their corpus of knowledge becomes a powerful Mercedez sans brakes. This runaway rukus has the blessings of teachers and planners and the eminent casualties are rationality, avoidance of iatrality (so-called iatrogeny), checking of costspiral, and reliable cost-benefit analysis. Medicine/machine manufacturers matter most in the mind-manipulation of medical man: "What I would like to know is why the major journals put out among medical professionals are financed by pharmaceutical companies. The medical profession is the only profession which allows that. In other professions people pay to produce their own journals. But the medical profession allows the pharmaceutical companies to do that"5.
The cardinal role that medical epistemiology can play is to provide an effective check-and- balance against any medical pill, potion, or procedure, routine or advanced. And that kind of ethos can only develop if medical students are taught to read between the lines, to exercise intelligence rather than brilliance. The word intelligence is rooted in inter + legere, literally meaning to read between the lines, to choose, to understand. We have, as all university results and medals show, too many brilliant students, but not may intelligent ones. Schumacher6, now the patron-saint of 'Small is Beautiful', talked of the difference between "science for understanding" and "science for manipulation", the former promoting enlightenment, wisdom and liberation, the latter profit, power and paranoia. "The progressive elimination of wisdom has turned the rapid accumulation of knowledge into a most serious threat. Western civilisation is based on the philosophical error that manipulative science is the truth, and physics has caused and perpetuated this error. Physics got us into the mess we are in today. The great cosmos is nothing but a chaos of particles without purpose or meaning, and the consequences of this materialistic view are felt everywhere. Science is concerned primarily with knowledge that is useful for manipulation, and the manipulation of nature almost invariably leads to the manipulation of people."
How do we mutate from brilliance and intelligence? By making medical epistemiology integral to the undergraduate and postgraduate curricula. The texts for such a subject are aplenty. Rene Dubos pioneered some texts in this direction, but the current pace-seter has been lvan Illich, through his 'Medical Nemesis'. Andrew Mallesen's 'Need Your Doctor Be So Useless?8 may seem too caustic but is worth a perusal. The feast7-22 is worth its while and assuredly broaden one's medical perspective and enables one to give his better than the best to the patient. A passage from the 'Encyclopedic Oxford Companion to Medicine'2, 3, in ordinary terms, spells out why really an epistemiologic perspective is indispensable for the better future of the noble calling:"Doctors, even with their superior knowledge of medicine, often behave in exactly the same way: this may seem strange but doctors have a healthy scepticism about the efficacy of the art they practise. They see patients recover from their illnesses without, or in spite of, medical help. They learn, too, to respect the healing force of nature - vis medicatrix naturae. Doctors, above all, know that from most illnesses there is spontaneous recovery. Only comparatively rarely is medical or surgical intervention needed to save life, which is the dramatic part of medicine: much more often an illness makes the patient uncomfortable and he wishes to have relief from this in the shortest possible time and with the least inconvenience. Moreover, the ordinary patient may have no inkling of whether his present disorder is life-threatening, or relatively trivial and likely to pass without medical help. It needs to be more generally recognised that most of medicine is about relief of, and comfort in, suffering, and in the main very little to do with saving life."
In case the overcrowded curricula give no room to medical epistemiology, the following set of points will serve as a ready reckoner for any programme of medical education, treatment or research.
1. The lead-terms disease, sickness and illness are ill-defined, thus empowering the assumption of their presence when they are not, and vice versa.
2. Human development begins in the womb and ends in the tomb. Diseases of aging blood vessel disease, cancer, diabetes, arthritis are innately programmed and are in no way 'caused', and for that very reason, cannot be 'cured'.
3. Disease and death are poorly related casually. It is a common experience that the healthy do not necessarily survive, nor, the diseased necessarily die. Disease-as-cause-of-death is convenient institution that has several medical illusions for too long, and is now overdue for retirement.
4. Many a disease, including congenital malformations, are a herd function, the distribution being such that the disease-free majority determines the occurrence of the disease in a miniscule minority. The occurrence of cleft-palate in 1 out of 1000 births, and of cancer in 1 out of 5 adults is a corporate decision of the group expressed through an individual. Herdity, and not causality, operates.
5. Friendship between microbes and man is a rule, enmity an exception. From nitrogen-synthesis in the soil for protein manufacture to vitamin-synthesis in the human colon is microbes' mercy to mankind. The enmity between microbe and man is due to the proclivity of the soil, comprising the human tissues.
6. The nobility of the medical profession lies in its licensing the provider to have an access to the soma, psyche, and the soul of a fellow-being in distress, to be able to provide ease to the disease.
7. The idea of health-care as an industry full of profit is to ignoble part of the noble calling. Persistence in the pernicious practice because of the eye on profit has already estranged the patient from the doctor, USA being the best example, and other countries, including ours following suit.
8. The repeatedly demonstrated fact that doctors refuse to treat their own illnesses the way they treat their patients speaks volumes for the scientificness of medical practice.
9. The 'when' of the diagnosis and/or of the treatment does not alter the course of innately programmed diseases. 'Early' / 'late' appellation for diagnosis betrays medical ignorance of the natural course of a disease, and serves as a convenient ploy to damn the patient and exonerate the doctor.
10. A global survey revealed that 9 out of 10 prescriptions, potions or procedures are unnecessary.
The admission of epistemiology into medical ethos will lessen the lead of lay expectations, reduce the work load on doctors, and make medical care less costly, more comforting, compassionate and rewarding.