Regimentation in Medicine and the Death of Creativity
Until quite recently, the practice of medicine was considered an art, which incorporated a significant modicum of science, yet was itself not a pure and applied science, such as physics, astronomy, biology and chemistry. William Osler, one of our greatest medical minds, not only in the science of medicine, but more so the art of medicine, has written:
What, after all, is education but a subtle, slowly-affected change, due to the action of the externals – of the written record of the great minds of all ages, of the beautiful and harmonious surroundings of nature and of art, and of the lives, good or ill, of our fellows? -these alone educate us, these alone mould the growing mind.
It used to be accepted that the aim of medical education was to produce physicians that would be well rounded, not only in the particulars of their specialty, but also, as members of a cultured and intellectually engaged society of men; men who could think critically and with a depth that brings wisdom. Osler recognized that medical education was a complex insertion of “varied influences of art, the highest development of which can come only with that sustaining love for ideas which “burns bright or dim as each are mirrors of the fire for which all thirst”.
In an essay on medical education, Doctor Osler goes into great detail as to what is necessary to train a young medical student in the “art of medicine”. He points out that in the “old days” a medical student was nothing more than an apprentice who worked with a seasoned physician. Yet, through their close association, the elder physician was quite adept in teaching his art to the young student, not just by depending on textbooks and rote memorization, but by carefully studying people suffering from a variety of diseases. I emphasize “people”, since so often, especially among specialists and the young physician, the human aspect of what we do escapes them.
I can remember in medical school we were told that our assigned patients were not the “gallbladder in bed 17” or the “adenocarcinoma of the breast in ward three”. Rather, they were human beings -somebody’s mother, or brother, or son. They had feelings and fears, just as we did. As a result, I got in the habit of always thinking of my patients from the viewpoint of either being myself or a member of my family and it helped keep me more empathetic.
Of great concern to Osler was how the art of medicine would be taught. He states:
Ask any physician of twenty years’ standing how he has become proficient in his art, and he will reply, by constant contact with disease; and he will add that the medicine that he learned in the schools was totally different from the medicine at the bedside.
As a consequence, Osler says:
Teach him how to observe, give him plenty of facts to observe, and the lessons will come out of the facts themselves. … The whole art of medicine is in observation, as the old motto goes, but to educate the eye to see, the ear to hear, and the finger to feel takes time, and makes a beginning, to start man on the right path, is all that we can do. … Give him good methods and a proper point of view, and all other things will be added as his experience grows.
This is the antithesis of what is taught today. Because of the rise of scientism, that is science as a religious faith, medical students are taught to rely on their technology and “hard” science. To the modern physician, every statement must be supported by accepted double-blind, placebo controlled, randomized, cross-over studies, ad nauseam. This is so deeply ingrained in our medical professionals, that they cannot bring themselves to believe what their experience demonstrates to them, often in shocking displays.
For example, I have advised a number of people on natural ways to treat their cancers. Most have been under the care of a “traditional” oncologist, usually receiving chemotherapy and/or radiation. In one case I remember very well, a patient was being treated at one of the quite famous cancer treatment centers and when she returned for her follow-up visit, her oncologist was quite surprised to see that not only was she feeling very well, but her metastatic tumors were shrinking significantly. He exclaimed to her that in his thirty years of practice he had never seen a tumor of her type respond so well.
The interesting part, is that when she told him what she was doing with her nutrition, he just shrugged and said-”I don’t want to know what you are doing, just keep doing it.” And this is one of the more positive responses. Most take on a look of shock as if they just sat on a tack and angrily tell the patient that they should stop immediately, because the antioxidants might interfere with their treatment.
In both cases we see just the opposite spirit Dr. Osler was discussing. Despite the fact that neither oncologist had ever seen his patients respond so well to the chemotherapy, it in no way interested either of them. It has been said that it is the anomalies of medicine (and of all natural sciences) that leads to new discoveries. Virtually every great advance in medicine was by men (and women) who noticed something all others had overlooked. That is, because of regimentation of thought, they were merely overlooked.
As humans, we tend to think that all discoveries have already been discovered, or will be discovered by the abstract “great minds”. We tend to think of the discoverer as some distant (always distant) person, who is essentially beyond our intellect and posses powers of observation almost god-like. In fact, many of our greatest discoveries were made by ordinary men, who though sharpened powers of observation and deep thinking, saw what escaped others- even the so-called giants of the profession.
The Case of Dr. Barry Marshall and Dr. Robin Warren
While many examples abound in scientific and medical history, there is one contemporary example that is most instructive; that of Dr. Barry Marshall. Dr. Marshall, like all great discoverers, was a keen observer and listener. Another medical iconoclast, Dr. Robin Warren in the 1980s, in fact, suggested the link between an infectious organism and stomach ulcers. A pathologist, Dr. Warren observed that stomach specimens from patients with inflammatory stomach disorders, including ulcers, frequently contained a microbe, later identified as helicobacter pylori.
Dr. Warren tried to inform his colleagues about this connection, but they instead made him the butt of their jokes. After all, I am sure they concluded, how could some obscure, local pathologist from
Dr. Barry Marshall didn’t laugh, instead he listened and conducted carefully controlled experiments to see if Dr. Warren was correct. His evidence should have convinced anyone, but the power of the preconceived notion, especially one that emanates from the elite members of the medical establishment, is a very difficult thing to overcome.
As occurs so commonly in our modern world, he had great difficulty overcoming the reticence of the medical establishment to at least give him a respectful audience. His articles were rejected by the major gastroenterology journals and he was refused an audience at respected gastroenterology meetings. Except for his dogged determination, as admitted by his friend Dr. Warren, the theory would never have seen the light of day, which even then took 10 years.
It was only through one influential doctor’s assistance that he was given the audience he sought; the rest, as they say, is history. Yet, that is not the end of the story. In the year 2005, Dr. Marshall and Dr. Warren shared the Nobel Prize in physiology and medicine for their discovery. Today, there are thousands of articles confirming their findings and we now know that this same organism is linked to cancer of the stomach and possibly atherosclerosis.
There are several lessons to learn from this sordid episode other than the obvious one- the medical elite’s resistance to ideas outside its control. First, Dr. Marshall himself admitted that his training in medical school left him with the impression that “ everything had already been discovered in medicine”. Most of us who attended medical training were given this same impression, that we were just ordinary “doctors” and that only the elite of the medical centers held sufficient intellect to formulate meaningful discoveries, and then only from the “chosen medical centers”.
One of the other lessons is that in most areas of medicine today there are powerful, most often financial, forces that have a vested interest in maintaining the status quo. One of these forces is the entrenched elite of the medical world, usually subdivided among each of the specialties of medicine. In the case of Dr. Marshall and Warren, it was the gastroenterologists.
To have spent one’s life in the study of a particular problem and arrived at no new discoveries is painful enough, but to have some young upstart suddenly appear on the scene proclaiming to have the “answer” is especially disconcerting to those holding prestigious positions.
A second, less obvious force to the casual observer, is the financial influence on rigidity in medicine. The pharmaceutical companies were making a fortune in selling antacid medications for the treatment of ulcers. Cimetidine (Tagamet) and ranitidine (Zantac) were the leading ulcer medications at the time and to the CEO makers of these medications, they were the dream drugs of the industry-primarily because they did not cure ulcers and therefore, required a lifetime of the medication.
The largest pharmaceutical companies are major funding institutions of research in the medical centers, especially the more influential medical centers. Consequently, the leaders of specialty societies are often financially connected to the pharmaceutical manufacturers, which affect their decision-making, both consciously and subconsciously. Even the ethically centered physician will come under this influence. It took me a long time to admit this myself when I was practicing neurosurgery.
When pharmaceutical detail men and women are giving you abundant supplies of free medications for your office, treating you and your staff to lunches and office parties, and offering free trips to meetings in exotic places, one has a propensity to, even subconsciously, yield to their influence. Why else would pharmaceutical companies spend billions on such programs to influence doctors prescribing habits?
Drug detail personnel used to be mostly men. Yet, over time they found it very difficult to get appointments to see the doctor. Quickly catching on, the pharmaceutical companies began to hire women, mostly young, very attractive women. It worked like a charm; suddenly doctors made time to see the pretty drug detail lady. More than a few left their wives and married the drug rep.
Medical history is littered with such episodes, yet we learn nothing. I like to say that the medical profession’s learning curve is a flat line. As Arthur Schopenhauer has stated, “Every truth passes through three stages before it is recognized. In the first, it is ridiculed, in the second it is opposed, in the third it is regarded as self-evident.”
What Medical Education Should Teach
The arrival of science as the preeminent mode of understanding the universe can be traced to the 18th and 19th centuries, according to F.A. Hayek in his magnificent book, The Counter-Revolution of Science. Studies on the Abuse of Reason (Liberty Press, 1979), with
Over time, scientists become convinced that their view of the universe was not only the most accurate, but the only one that should be allowed. This tendency of a discipline to demand that its intellectual competitors yield the public forum is legendary. Many today are of the opinion that if something cannot be verified by the scientific method, it is not to be accepted as valid and is labeled as speculation or worse (in their lexicon), a superstition.
Wiser men of science have long recognized that there are things in this universe that cannot be understood by utilizing a scientific viewpoint, that is, that science can only tell us about material phenomenon or forces that have a repetitive nature, which then lends itself to examination and measurement. In fact, outside the realm of science there exist a tremendous number of phenomenon that will remain unknown and that contain many secrets that only God can know.
Early educators of physicians knew this very well and accepted that the best man could do was use his powers of observation to approximate the truth as closely as possible to the prediction of reality. Medical history teaches us that often times we can effect treatments based on little knowledge of underlying mechanisms. For example, 100 years ago herbalist didn’t know why
Today we have turned it around- treatments are not to be used, despite demonstrated usefulness or even their ability to save lives, until we have a scientific explanation as to how it works and proof-positive double-blind, placebo controlled studies proving that it is efficacious. I would wager to say that millions are dying every year because of this worship of the scientific method and imagined scientific purity.
Dr. Osler hints at the danger of this narrow-minded view of medicine by his advice to the medical student:
The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, ending only with death, for which the work of a few years under teachers is but a preparation.
Further he says that the student must have an “ absorbing desire to know the truth, and unswerving steadfastness in its pursuit, and an open, honest heart, free from suspicion, guile and jealousy”. Yet, most graduates of medical schools and residency programs are not given this valuable advice, rather they are told that the elite of medicine will inform them of what they need to know and how they will treat their patients, and do so by a series of preconceived prescriptions.
This becomes especially frightening when you consider the mindset of the elite in medicine already elucidated above -that is, that nothing is true until “our” science says it is true. The bodies continue to pile up while we are told to wait patiently for their anointed approval to magically appear.
The Origin and Modern Appearance of Regimentation in Medicine
As with most ideas making their appearance as “new” and ”progressive”, regimentation of society is not new. Writers and philosophers from antiquity toyed with the idea of a structured and a centrally ordered society, but it was not until the arrival of the gnostic prophets of the Enlightenment philosophies of Helvetius, Comte, Turgot, d’Alembert and later Marx and Lenin that we observe the development of this philosophy of collectivism. For an excellent analysis of the modern positivist ideology I would suggest Eric Voegelin’s book From Enlightenment to Revolution (Duke University Press, 1975).
Richard Weaver has crystallizes for us the modern dilemma:
The modern knower may be compared to an inebriate who, as he senses his loss of balance, endeavors to save himself by fixing tenaciously upon certain details and thus affords the familiar exhibition of positiveness and arbitrariness. With the world about him beginning to heave, he grasp at something that will come within a limited perception. So the scientist, having lost hold upon organic reality, clings the more firmly to his discovered facts, hoping that salvation lies in what can be objectively verified.
In essence, he is saying the scientist, because he has abandoned true understanding and wisdom, must concentrate his efforts with greater tenacity upon what he does best, and that is to break the material world into smaller and smaller pieces, never quite seeing even a glimpse of the whole. This is exactly what medicine has done with it inordinate divisions of its science into smaller and smaller degrees of subspecialization. As Osler has observed, the man of medicine must be much more than science and textbooks, he has to have an intuitive sense of the effects of disease upon the whole human being and be able to respond to that intuitive sense appropriately, that is, with a certain degree of extra-scientific understanding based on reason and spirituality. In essence, we must not see our patients as merely part of a collective, but rather as individuals.