mandarine

I have recently seen Le Malade Imaginaire for the second time. As I remembered it from my youth, this play was pure comedy, making fun at how grotesquely irrational and arrogant XVIIth century doctors were in the eye of icon playwright Molière. This time, I was taken aback at how contemporary this depiction of medicine suddenly looked to me.

Is medicine a science?

As already mentioned in an earlier post, I believe proper science can be summed up in three words: rationality, creativity and doubt. Creativity is the pillar of discovery. Rationality is the mortar of theory. Doubt is the cornerstone of proof.

I believe that a discipline forgetting either of the above is no true science. Without creativity, we keep old knowledge and make no progress; without rationality, we are unable to connect truths together; without doubt, we lose credibility.

What I saw in Moliere’s play immediately told me what I was diffusely feeling: since the 1950’s, conventional medicine seems to have forgotten the doubt part. Following the fabulous advances and discoveries of the XXth century, medicine has reached a consensual mental frame that unconsciously rules out the expression of doubt.

Triumphant early XXth century physicists, after all the fabulous advances or discoveries of the XIXth century, were quite arrogantly confident that all had been done, and it was just a matter of years before Kelvin’s two dark clouds could be swept away (namely black body radiation and the Michelson-Morley experiment). In fact, these last two small questions respectively required quantum physics and relativity to find an explanation.

I believe that medicine in the early XXIst century has reached the same mental stage as physicists a hundred years ago: we know almost everything, the final questions will be answered quite soon. Out of 100 things we ignored just a few decades ago, biochemistry, biophysics and genetics can explain 98 or 99. No wonder we should be under the impression that we just need to extend their application and make progress in that direction to have all answers.

But just like physics, I believe there are unsuspected terrae incognitae ahead, probably even bigger than quantum physics or relativity (which respectively gave us computers and nuclear energy). If we consider how much more complex a living organism is compared to an atom, I often think it is a whole universus incognitus that we still have to discover. And yet, medical science and medical practice do as if doubt is now out of the picture, so that there seems to be no salvation away from the mechanical model of the human body (dating back to the ancient Greek) and its three pillars (medication, surgery, and now genetics).

I am not pretending medicine is inefficient: it would be too obvious if conventional medical science had not brought so many great advances over the past decades. Just like XIXth century physics, XXth century medicine is furiously efficient. What I resent is the arrogance and the undisputable assurance. Assurance leads to dogma and totalitarianism.

Let me be clearer and give examples of practices that were undoubtedly regarded as true and that could not be challenged because they were a part of the holy dogmatic corpus:

• Antituberculinic vaccination based on BCG (a French invention) had been compulsory in France for the greater part of the XXth century. Until just a few years ago, questioning the efficiency of this specific vaccine was tantamount to questioning medicine as a whole. Even if BCG vaccination was gradually abandoned by all other countries (and the US had never used it on a systematic basis), people not renewing their immunization were accused of being irresponsible. Suprisingly enough, the vaccine is now not compulsory anymore (2005 CSHPF recommendation), even though tuberculosis is more frequent by the day. Had they used more caution and doubt, well-intentioned doctors could have avoided the immunization of so many children for so little immunity benefit.
• Up until last year, episiotomy was a standard obstetrical practice for many good reasons. In France, refusing it was an act of rebellion that took a very courageous woman, generally unarmed against the OB-GY’s undisputed arguments. In 2005, based on numerous studies, some of which were as old as the eighties, the very formal ‘college of gynecologues obstetriciens’ issued a recommendation to drastically reduce the practice, having failed to demonstrate any clear benefit, and certainly little positive risk-benefit relationship.

At times, it looks like Pasteur, Mendel and Fleming have replaced Gallenus as icons, and good old medical assurance lingers on.

EBM: a blinding light in the tunnel

Even the name sounds like a mocking dent in the established medical theory: evidence-based medicine. Emphasizing the need for evidence, it immediately tells something about traditional medicine, in negative image. It is just one step away from calling traditional medicine: ‘dogma-based medicine’.

Evidence-based medicine is not a new medical theory on any specific subject. It is about the mentality and the methods to raise and settle doubts.

Traditionally, for any medical situation in which there can be several possibilities, a ‘most likely’ theory ends up prevailing. If it is backed by documented clinical observation, however scarce, it turns into a dogma, without further proof.

Now EBM offers methods and tools to put a fact, a practice or an explanation to the test. Using the very straightforward tools of probability and statistics, it allows to give unbiased elements of scientific proof to many aspects of medical research. By gathering a lot of data, combining them with mathematical impartiality, cohort studies are gradually becoming the key for any new medical theory, and the killer of many a medical myth.

The power of such a method is that it does not even need a rational explanation to check a fact. Recently for instance, several studies have tried to establish whether distant healing (volunteers praying for sick people, without them knowing) had any incidence in the course of an illness. This would have been impossible without EBM: you would first have had to suggest an explanation that was consistent with the generally accepted medical dogma. Although in this particular case the results were (predictably) negative, I find this example revealing: the expression of doubt or heretic theories is now more politically correct, as everybody can agree on a way to prove or disprove them: this adult use of doubt and reason is how science is supposed to work.

Some say that as large studies are extremely expensive, this will naturally create a bias towards theories and doubts that get sufficient funding to buy a proof, and to a large extent, I agree. However, EBM does provide means to exploit data that were not specifically destined for a given study: data mining and exploitation of previous studies often allows to draw novel conclusions from old data, hence sometimes giving support to financially weak theories.

I have a dream that the Chinese take this new neutral scientific arsenal and their rising financial wealth to put through a riddle the enormous mass of traditional asian medical practice, light-years away from the beaten track, away from the mechanical vision of the body. I am sure that hidden deep in the haystack of worthless hotchpotch, they can find amazing nuggets that could pave the way for this century’s medical revolutions, of the same magnitude as quantum mechanics or general relativity for last century’s physics.

Read on

An apologia of the scientific mind
On co-sleeping

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