Thursday, June 1, 2017

Medicine as a "Black Art"

I got an email blast today--one of more than a dozen I get each day--from Medpage Today. A medical blogger and physician, Christopher Johnson, asks "Is medicine still a black art?" He describes the well-known idea that for centuries physicians practiced medicine on the basis of theories about how the body works. This continued until the 19th century, when the scientific method matured to the point at which we began to have evidence for how the body actually does work. The era of Scientific Medicine was born.

Johnson asks a compelling question about medicine using a label which suggests "magic"--basically a kind of inspired guesswork founded on mental pictures of how Nature works. Black art connotes wizardry and a connection to divine power that in turn influences Nature on our behalf. Astrology and the magical practices of various belief systems are other examples. "Black" of course suggests "dark" or "evil", but really it can also mean "unknown" or "mysterious." A "black box".

That article cites another article from February of this year in The Atlantic which details the conflicts between evidence-based medicine, the vastness of medicine and the individual ways in which we all experience health and disease, and the human desire for hope and cure.

If you get a chance, follow the link and check out the article, which I included here in the interest of any of my patients who may have been told to get something or other done when they might not really need it!

The gist is this:

  • First, although we've made a great effort to study medicine's methods for what works and what might not (or even causes harm), we still have a long way to go.
  • Second, A lot of what passes for "evidence-based medicine" is weaker than we're often led to believe.
  • Third, human nature--both among doctors and patients--drives more of what we do (and do not) more than good evidence.
I teach research methods, so for me a lot of this doesn't come as a surprise. Research findings are routinely published as "breakthroughs"--but a lot of that is hype. Research findings aren't often replicated, to verify earlier work. And of course negative findings (that is, what didn't work) is often ignored, because it's more interesting to publish articles about things that did work!

But what interested me more about the Medpage Today article was the use of this term "black art" in the title. 

Homeopathy could be considered a black art, and certainly most docs view it as worse than that. I find it interesting that most positive clinical research about homeopathic treatment is ignored or dismissed as flawed. It seems that most allopathic medical research suffers from the same problem. 

I have and continue to practice both homeopathic, and when it's needed, allopathic medicine as part of my nursing practice, and one thing I have learned is that patients are individuals, problems are often strange, and the methods for addressing both of these concerns still do rely more often on art than science. One thing I emphasize with my students is that Evidence Based Practice (whether nursing or medicine) is both non-individualized and probabilistic.

Ok, what I mean is that EBP examines groups of people, not individuals, and its conclusions are aimed at increasing the likelihood of a good outcome, and minimizing the chance of a bad outcome. In short, it assumes that all people are pretty much the same (at least in the researched population), and it doesn't offers any certainties--it merely offers good and bad chances.

I think it's important to remind my students of this because as clinicians, our aim at the end of the day is to treat people, not groups. One size does not fit all. Of course I don't mean to excuse the practices of providers described in the Atlantic article for engaging mass practices based on faulty evidence! One such practice is the use of the blood pressure medicine atenolol to prevent a first heart attack in people with somewhat elevated blood pressure. You can read their article for details. But my point is: people are still unique, and we ought to be careful giving people things that could potentially harm them when our certainty-of-outcome is only slightly better than placing a bet at a roulette table.

The problem is two-fold. Medical providers are being rewarded for following practices that may not always be well-supported by science--at least not as well-founded as we are taught. Furthermore, much of the evidence we do get is skewed by small sample sizes, greed, publication bias, and the low rewards that flow from health care science that emphasizes non-medical interventions, like diet and exercise. 

Which brings me back to homeopathy. Granted, it's weird, and it does seem to fly in the face of classical science like chemistry and physiology. But it also has a low risk of immediate and intermediate harm, and certainly doesn't itself put people in the hospital! (Albeit sometimes homeopaths would do well to abandon homeopathy when it's not working, and use something more effective for the problem at hand.)

I like the fact that I have a lot of less harmful tools at my disposal: homeopathy, herbs, nutritionals, and of course lifestyle modification, which I try make happen with a technique called motivational interviewing, basically a fancy term for discussing with people their goals and readiness for change, and of course continually encouraging and commending them on the small changes they are willing to undertake at a given moment in their lives. Too often the lifestyle advice I hear providers give goes something like this:

You should eat better and lose some weight and stop smoking.

That's about as helpful as swinging a stick to catch butterflies!

Then there are the many stories I hear from my RNs of nurses and doctors scolding patients for not being more effective changers of their lifestyles. What could be less helpful to motivating a patient who has now achieved remembering to check her blood sugars at home than to tell her:

Humph. These aren't very good. If you don't get these down I'm going to put you on insulin shots.

There is hope. There are agents out there trying to make real sense out of the research, to give better context to what works and what doesn't. I'll be touching on some of this in coming blog posts. And while I emphasize more effective change methods like motivational interviewing and therapeutic listening with my students (I hope they'll put these into practice!) I am seeing some evidence that other clinicians are doing this too. Finally, there's more momentum pushing general hygiene measures such as decreasing one's intake of processed foods (the whole foods movement and urban gardens), getting more exercise (anything at all helps!) and getting more help to kids, such as early childhood interventions and measures to relieve poverty.

The next time you hear about a great new study that says something that sounds marvelous, especially if it's expensive and technically complex, you might think, "Really?" Maybe not.