Trust me, I’m a doctor

There is a civil war raging within the world of health care. I’ve become increasingly aware of it when yet another of my patients with cancer kindly declined my meticulously devised treatment plan of major surgery and chemotherapy in favour of a regimen of marijuana oil and other hippie-esque botanicals. After months of fielding questions from patients and their families (including my own) about the varieties and potential benefits of alternative therapies, my frustration reached its peak. My sense that there was an evolving shift in perceptions was confirmed by the data: since the 1990’s there has been a steady increase in the use of alternative therapies with almost 40% of patients, most of them educated high income earners, choosing some form of complementary or alternative therapy. I needed to figure out what this was all about — what was causing this surge in interest in antiquated therapies and its corollary, the increasing distrust of conventional medicine.

The terms ‘alternative’ and ‘conventional’ have come to define the opposing sides of this conflict. A colleague, who feels particularly strongly about these things, once started a debate by saying that there should really not be a distinction between alternative and conventional medicine, only between those therapies that work and those that do not. Of course, those that claim to work would have to be proven to work; and therein lies the philosophical conundrum (and my colleague’s clear bias). The defining characteristic of these two perspectives on health is the religious-like reverence for the scientific method held by practitioners of conventional medicine, and the shunning of it by those in the alternative camp.

This divide along scientific lines wasn’t always as clear cut as it is today. The origins of modern medical practice are less than illustrious, famed by such elegant procedures as blood-letting and boring holes into skulls to release evil spirits. Ironically, these often fatal treatments became part of the medical establishment and dissenters who proposed gentler means were regarded as quacks and frauds. What defined ‘conventional’ and ‘alternative’ during this era depended more on which royal court or distinguished institution you were associated with than the evidence for your techniques. This all changed dramatically at the turn of the nineteenth century when two social movements began widening the divide even further. As the scientific methods which were used to great effect in the study of gases, galaxies and other inanimate bits of creation were increasingly applied to (mostly) animate human beings, a counter-revolution of naturalism was simultaneously gaining ground. The history is fascinating and complex but essentially, the combination of the major achievements of the scientific approach and the evolution of governments based on industrialisation created a social milieu ripe with deterministic thinking. And so, conventional and alternative medicine became very clearly defined, and very definitely opposed.

Science and medicine are not always happy bedmates. At medical school, fledgling doctors are force-fed knowledge in the form of evidence-based medicine. Anecdotes are ignored or used ironically to illustrate the point that, when faced with a patient gazing expectedly at you, data data data must back up every decision you make. But, as every young doctor soon discovers, there is a fly in the ointment of scientific medicine. I recall my first experience of this very vividly. As a new surgical trainee, bulging at the seams with textbook knowledge, I once questioned my professor about the lack of published evidence behind a certain technique he was performing. He responded by asking me to quote the published evidence supporting the use of a parachute in skydiving. His snarky response to my admittedly cocky question illustrated the point beautifully and succinctly: there are black holes of unstudied, unproven areas in medicine which often need to be filled in with common sense or just plain guesswork. As one progresses through medical training it becomes increasingly apparent that the difference between eminent seniors and green juniors is less in the extent of knowledge and more in the degree of hard-won experience. Despite all its scientific ambitions, medicine is still, at its heart, an art form.

And so it should be. The human body is a molecular work of art, a tapestry of cellular geniuses working deftly and silently to keep us in the mostly agreeable, but generally unappreciated state of being alive. The scientific revolution has taken us further in understanding this beautiful synergy than any other intellectual movement before, but we have still only scratched the surface of what lies beneath and within us. The rate of increasing knowledge is rapidly slowing down, with the number of major breakthroughs dwindling to a trickle. My rejected treatment plan of cutting, zapping and poisoning my patient was not very different from what would have been prescribed decades ago. The world of medical research is also currently in a state of organized chaos, a big bloated beast of inefficiencies and twisted motives which often have little to do with patient well-being and more with profit and professional ambition. Under these conditions, the truth is a grey, fuzzy, constantly moving target.

But:

Throwing the baby out with the bath water and looking back to superstitious nonsense is not going to solve our problems. The scientific approach remains the best method we have in our search for truth and has proven itself so again and again. My contention is that we only need to learn how to tweak it to better achieve our ends. The techniques used in the study of particles cannot be neatly applied in the study of people. People are too complex and their charming characteristics are too unpredictable for a one-size-fits-all solution. This is where the quacks have it right: in healthcare, the focal point needs to shift from the population back to the individual. How to go from here to there? That, I believe, will be the subject of the next revolution in medicine.

Watch this space…