Is Medicine really a Science?

“If your physician does not think it good for you to sleep, to drink wine, or to eat such and such meats, never trouble yourself; I will find you another that shall not be of his opinion; the diversity of medical arguments and opinions embraces all sorts and forms.”

So wrote Michel de Montaigne over four centuries ago.

Well, things have changed. Today, a growing body of information is attracting a consensus within the medical profession. However, the information is by no means stable. A journal of the Mayo Clinic in the US (its Proceedings) published a study in August 2013 of all the original research articles from the prestigious New England Journal of Medicine over a decade. It found that:

• 1344 articles examined a new or existing medical practice
• Over half of them (56.3%) suggested a new practice superior to an existing practice. This is known as ‘replacement’, where a new treatment is to be preferred to an old one
• Far more worrying, nearly one in nine (10.9%) found that a treatment in common use was inferior to what had preceded it and should be stopped. This is known as a ‘reversal’, where a new treatment is found to be inadequate and practice reverts to an older approach

That’s just one decade and just one journal, even if it is one of the publications with the most impact in medicine.

Maybe that means that Montaigne, if he were living today, would have to change his advice slightly: if you don’t like the advice your doctor’s giving you, you don’t so much have to find another doctor, just wait a bit – before long there’ll be some new advice coming along.

Of course, you do have to survive for as long as it takes to get that new advice.

Bloodletting: once one of the most common of medical practices
Now regarded as not generally beneficial...

What prompted me to think about all this? Why, the new advice from the Lancet, another of the most prestigious medical journals, that salt, against which we’ve been warned for so long and so loudly, for the harm it does to the heart, might actually be beneficial for cardiovascular disease if consumed in moderation.

Doesn’t this remind you of attitudes towards, say, aspirin? It was perceived as a panacea, a cure for practically any disease, when it was first discovered. Then the profession turned sharply against it, above all for its effect on the digestive system. But now the pendulum has swung back and aspirin, in moderation, is recommended for many conditions, and in particular as a preventative for certain heart problems.

As for red wine, I’ve lost track of where we stand now. Is it good for you? Is it bad for you? Maybe I should just take a leaf out of Montaigne’s book and just do what I like and, since I like red wine, keep drinking it.

In moderation, of course.

Naturally, all this progress is based on scientific work. Highly effective, intelligent research is slowly moving us forward. It’s causing us to question old remedies, and sometimes – maybe as often as one time in nine – even new remedies. Which means that medicine is becoming more scientific.

Gone are the days of bleeding patients, as in the eighteenth century, just because that’s what a physician does. After all a scientist might well come along and question the practice. But it seems that could also happen for many of the practices we still use, unlike bleeding. With so much of medicine subject to questioning, I’m not convinced that it’s reasonable to call it a science.

Perhaps it’s just a practice on the way to becoming more scientific…

There’s a great quote attributed to Mahatma Gandhi, though he probably never said it. Asked by a journalist what he thought of Western Civilisation, the story says Gandhi replied that he thought ‘it would be a good idea’.

Medical science? I don’t know what Gandhi would have thought. But to me it seems like it would be another good idea.

Medical Science: so hard to keep up with

It’s a lot of fun working for a company that has a product that actually does what it says. Sadly, rather a lot of people selling information technology to the National Health Service seem to regard it as a slightly dull but dependable, and above all uncritical, source of funding. You know, they’ll never make your fortune, but you can dump mediocre systems on them and they’ll buy them, not perhaps at the highest of prices but at a price that’s always paid, and with few questions asked.

Sadly, I’ve worked for a few of those companies. I remember being ambushed at one conference at which I was presenting, when a representative of a client hospital asked, in public, why on earth anyone should trust us, given how badly we’d let them down on another product?

Well, it’s a blessed relief to be away from all that unpleasantness. Today I’m working with an evidence-based medicine product that does exactly what it claims to do: provide rapid access to carefully evaluated, up-to-the-minute information reflecting the most recent understanding of medical knowledge.

To take them or not to take them?
The answer may depend on when you ask the question

It’s just as well it does so. One of my colleagues pointed out at a recent presentation that about 15% of all information affecting medical practice changes every year.

Fifteen per cent.

Every year.

That may seem extraordinary, but I have a personal anecdote which seems to confirm it.

A year or so ago, my general practitioner decided that it was time to have my blood tested and assess my level of risk of having a stroke or heart attack in the next ten years or so. You may well guess that at stake was whether or not I should be put on statins. I had wish to start taking those drugs but, then, I had even less wish of suffering a stroke or heart attack.

Well, the results were clear. My risk was above 10%. That was the threshold level. The doctor prescribed statins.

I didn’t take them for long. My digestion turned lousy, I started sleeping badly, I was getting headaches. Classic symptoms.

However, having looked into it a bit – well, to be honest, my wife did – I rather think the reaction was psychosomatic. I was, at the time, working for the worst of the purveyors of dire quality to the health service. My boss had cut me out from doing any actual work on the software, which was good for my conscience but lousy for my long-term employment prospects. It wasn’t a good time, which I think may have contributed to my poor reaction to the medication.

A year or so on, and in a satisfactory job at last, I felt I should take a look again at whether I ought to be taking statins after all. I made contact with the GP again. Once more, he had my blood tested. And, again, the risk of stroke or heart attack was above 10%.

But, lo and behold! Medical science had changed. As he explained to me.

“We used to think the threshold for statins was 20%. Then it was reduced to 10%. But now it’s back up to 20%. And your risk is under 20%.”

So? What did this mean? Could I still live statin-free?

“So,” he went on, “I’ll not be prescribing any medication for now.”

Wonderful! My conscience is clear. I did all that was necessary. And science made the decision for me.

Isn’t it great? But doesn’t it just underline the importance of keeping current? Because how serious your condition is doesn’t just depend on your health – it also, apparently, depends on when you ask the question.

How eating cheese helps puncture overbearing medicine

Doctors aren’t generally known for their modesty.

There are noble exceptions, of course, and they’re all the more impressive for being self-effacing. But in 34 years’ experience in healthcare informatics, I can tell you that they’re in the minority. For most, it’s a matter of where on the arrogance spectrum they fall, between barely tolerable and downright monstrous.

Now it has to say that they often have plenty to be arrogant about. They’re usually bright and well-informed. Unfortunately, however, a lot of them aren’t quite as bright or well-informed as they think.

It’s the quiet form of arrogance that amuses me most. This is where the doctor makes no claim to superiority but his – or her – quiet demeanour, the tilt of her head, the tone of his voice, simply floats that superiority out there as an unstated presumption of any conversation. None of us questions it, least of all her, because it’s simply beyond question.

This isn’t an attitude limited to medicine. It’s found at the rarefied top of many walks of life. Ever had a passport query abroad? Embassy and consulate staff make it clear that they’re doing you a favour by allowing you the privilege of being with them; why, they go so far as to be gently and ever so condescendingly polite to you. You see it too in the upper reaches of business in the leadership of political parties. These people are at the top because they deserve to be and, in a neatly circular demonstration, we know they deserve to be there because they are.

What I particularly enjoy about this attitude in medicine is that I know that, however authoritatively convinced they may seem today about, say, the dangerous effect of cholesterol, their predecessors spoke with exactly the same conviction two or three centuries ago about the benefits of leeches or bleeding. Aspirin was a panacea, then a dangerous toxin that wrecked your stomach lining, now a remarkable drug to be taken to avoid cardiovascular disease. Smoking was good for you until it was found to be lethal. Opium had a salutary effect on the system until it was deemed a dangerous drug.

Just as sure of themselves then as they are now
but marginally more likely to be wrong

There were doctors as patronisingly convinced of the good effects of a substance before it was found to be noxious as they were of its bad effects afterwards. Often, it was the same doctors.

That’s why I’d like to see them using phrases such as “I think” or “in the present state of our knowledge”. It’s not going to happen, though, and for two good reasons.

In the first place, a doctor taking a decision that might affect a patient’s life chances, or chances of quality of life, needs to feel confident that the decision is correctly based. Even if it isn’t.

Secondly, in most cases doctors are actually right, or as right as the state of science allows us to be. For instance, most of them know that childhood inoculation is vital both for the children inoculated and for the population as a whole: by maintaining general (“herd”) immunity, we prevent outbreaks of a disease, and therefore those who for one reason or another aren’t immunised (e.g. because they’re too young). Doctors’ defence of inoculation is strongly to be supported; populist refusal of it by prominent figures in some cases, including most recently the US president himself, is dangerous and needs to be resisted.

On the other hand, it is fun to see the arrogance punctured from time to time. I greatly enjoyed reading an article in the Guardian reporting on a study that shows that there is no evidence of increased risk of cardiovascular problems associated with consuming dairy products, including cheese.

All that skimmed milk? Forget it.

Low-fat yoghurt? You can have the stuff that actually tastes right.

Avoiding cheese? Get right in there and indulge. Well, in moderation…

This merely reinforces my long-held belief that, far though medicine has progressed in the last couple of centuries, it’s still in its prehistory. We’re constantly making new discoveries, but there’s still a lot more to discover than we already know. Besides, a lot of what we think we know is wrong.

It seems to me, for example, that if there are still people around a century or two from now, they’ll be looking back at our treatments for cancer as we look back on leeches. “What?” they’ll say, “they pumped patients full of toxins? As a curative measure? Didn’t it kill them?”

Having lost a friend to chemotherapy, I’d have to answer “yes” to that question.

This makes me pleased to be doing my present job. It’s based on a service aimed to put the latest, most reliable information at the disposal of physicians and nurses. The information may be superseded later – we update the system every single day – but at least it’s as good today as it can possibly be.

My job is to get clinicians to use it. I’d like to succeed, because I’d like them to admit, at least to themselves, that they don’t actually know everything. That it’s worth checking from time to time.

Meanwhile, when you’re next with a doctor and you find him arrogant, try to humour him. He may well be right. And even if he isn’t, he needs to think he is.

Still, it can’t do any harm to check your doctor’s opinion if you can. Her arrogance may be a defence mechanism that allows her to do her job. But don’t forget that one of the people she’s defending herself against may well be you...