The metric, the dialectic, and the chart electric

There is no document of civilization which is not at the same time a document of barbarism.                      -Walter Benjamin, Theses on the philosophy of history

It is 1940 and the Nazi horror is bearing down on Europe.  France has fallen, and refugees are streaming out, fleeing to safety through neutral states and America.  Walter Benjamin, a Jew and a German philosopher, joins a small group being guided through southern Spain with the hope of making it to Portugal and safety.  He has just completed his manuscript that would reverberate through modernity with its insight into how rationality brought us civilization and Nazism at the same time.

“Enlightenment was supposed to involve the use of reason to help humans free themselves from myth and superstition.” Scientific thought abolished foolish superstition, yet somehow the over-reliance on measurement and mechanization also had a downside.  The Enlightenment project, dominant in Western thought since the Medieval Age, created a new scientific future where mechanization and measurement improved innumerable lives.  Yet, the elimination of magical thinking also created a sterility of thought that enabled Nazism in Europe.

Benjamin’s colleague Theodor Adorno, a German Jew who succeeded in escaping to America, later expanded the ideas on the duality of development in The Dialectic of Enlightenment.  Here he details how the enlightenment project “has always aimed at liberating men from fear and establishing their sovereignty… the dissolution of myths and the substitution of knowledge for fancy.” But the other side of the dialectic also ends up with “men paying for their increase in power with alienation from that over which they exercise their power.”  For example, as we control the natural environment by building cities, we become alienated from authentic communion with our natural world.  As we harness social media to stay connected with people, we may become alienated from authentic human interaction.  So goes the dialectic of enlightenment and progress.

Western scientific medicine epitomizes the enlightenment process as it replaces superstition with rational diagnosis and treatment.  As modern medicine measured more and more with the goal of improving health, we also created the “quality metric”.  Rather than being subject to the vagaries of non-standard care, rather than individual doctors perpetuating treatment myths, we created the temple of evidence-based medicine, and measured the dimensions of the temple with quality metrics.  The electronic record then burst open the dam of myth in medicine and allowed us to measure, well… everything.  We now know what being a good doctor means because we measure blood pressures, and we know if patients have less than 140/90.  We know if you are talking to your patients about flu shots because it is in the electronic chart.

And yet… Benjamin’s eerily prescient warning about progress has also come to pass.  “For the Enlightenment, whatever does not conform to the rule of computation and utility is suspect.”  The art of medicine, whatever that might mean, is not measurable, and teeters on the verge of extinction.  Increased control over the body ended up bringing about domination over bodies: paternalism, futile end-of-life care, polypharmacy… and pay-for-performance. Pay-for-performance promises the quantification of the entire patient-physician relationship and then its optimization as providers become rational profit-maximizers.  Rather than the comforting hand of the healer, the invisible hand of the market will guide improved patient care.  So goes progress.

Adorno famously died before writing his views on the possibility of synthesis between progress and domination.  Perhaps he never meant to write such an essay, not believing it was possible to become civilized without also losing the humanistic values of civilization.  The ability to measure “quality” practically defines what it means to be “scientific”; science is that branch of human knowledge which measures things.  I fear that pay-for-performance represents the enlightenment run amok, “scientism” rather than science, with the loss of the realization that medicine is ultimately a humanistic profession, and not scientific.

My medical school each year granted a “Humanism in medicine” award to some deserving students.  The rich irony of the need for this award has only now, years later, begun to sink in for me.  The criteria for winning must have been more than simply being human, or even being A human.  I would forlornly hope that we would all have won this award, or even better, that there would be no need for such an award at all.  I recall that I won the award, by what criteria I know not, or have long forgotten, but I write this as a humanist, as a recognition of the potential barbarism of pay-for-performance everywhere.  

The day is not far off when the economic problem will take the back seat where it belongs, and the arena of the heart and the head will be occupied or reoccupied, by our real problems — the problems of life and of human relations, of creation and behaviour and religion.

-John Maynard Keynes

I have not heard a better apology for the “real problems” that preoccupy doctors than what the economist Keynes describes, and we might do well to heed his warning about economics taking the back seat. Is not medicine by definition “humanist”?  Will we succeed in merging the scientific and the relational, or will medicine end up separating patients and their healers?

Two quality metrics walk into a bar…

One demands, Give me the best beer you’ve got!  The other asks, Give me the second-best beer you’ve got.  The bartender pours the beers and states, You can have them both for free if you can tell me why this one is better than that one…

Quality metrics were invented to quantify the ineffable, such as the taste of a fine lager or IPA.  I see that my neighborhood pub now lists “International Bitterness Units” (IBU) for all its beers.  I wonder if this has helped me gauge which pint I should choose?  At least it gives me something to talk about while enjoying the beer.  

Just as listing the IBU is new in beers, metrics did not always exist in medicine.  The moment we really got serious about quality is often cited as Caper’s 1988 article “Defining quality in medical care”.  Even as medicine invented quality in the 1980’s, Caper pointed to some misgivings about the terminology. His Health Affairs article suggests abandoning the word “quality” and instead using three terms that correlate to desirable medical outcomes: efficacy, appropriateness, and the caring function.  We know that certain interventions are efficacious in certain conditions; we can measure that.  We know that certain interventions are appropriate and inappropriate in the sense of utilization; we can measure this.  And we know that patients want “caring providers”… We likely cannot measure this very well, but it may be the most important of all the factors.  But, the “quality” of care is more than all of these factors and perhaps quite different entirely.

Despite the prescient warning, we have not abandoned “quality” and its continued use has created an entire jargon: quality, measurement, and value.  Quality creates value.  We are all preoccupied with creating value now.  The term is rarely defined but often used: creating value to insurers, for payers, for health systems, even occasionally for patients.  It appears to have a vague but unacknowledged relation to quality.

No one used to ask whether they got value when they went to the doctor’s office.  We might have discussed whether we had a good doctor, but never whether the experience was valuable.  When I buy a car, I sometimes wonder whether I got a good deal and whether the exchange had “value”.  But when I sit with my friends for a beer at the pub I have never asked whether I got a good value out of the experience.  The use of value reflects an economic creep of the mission of medicine and a subtle deterioration of the relational aspect of “my doctor”.  

Those things that are most important to us, and in some sense are valuable, we never ask if they “provide value.”  Nor do I ask whether my evening at the pub was “quality time”, and rarely whether I just drank a “quality” beer.  Remember “quality time” spent with our loved ones?  Once we started asking this about the time with our children, it already represented an unacknowledged loss of the inherent relational component of life.  Just so, once we started using “quality” and “value” in medicine, we had already lost its primary relational component.  Although not stated in the original Health Affairs article, the discomfort with the term “quality” reflects a disquiet with conflating efficacy, appropriateness and caring with the much more subtle concept of quality.

Quality itself relates to the humanistic function of medicine, and not to its scientific trappings.  As such it is describable but not measurable.  As an individual patient, whether my A1C is less than 9% correlates only tangentially with the quality of the care my physician provides. I might do better to have a lower A1C, but the factors involved in lowering my A1C, and how I perceive the care I have received, are not measured by the A1C itself.  Presumably the A1C captures the “efficacy” of the care received.  It is a gross injustice to label this as “quality”.  Substituting “quality” for “efficacy” defines patients as lifeless objects rather than in accordance with their characteristics as human beings.

Pay-for-performance takes medical quality metrics to the next level by using them economically. Yet in our medical system they are not working to improve care; why?  Because the metric does not incentivize doctors to be more human.  Instead it rewards treating patients as commodities and lifeless objects.  Doctors resent this incentive because commodification is dehumanizing.  As incentives push doctors into becoming more mechanistic, we then invent new metrics such as “satisfaction surveys” to desperately  attempt to pull them back towards a humanistic ideal.  Satisfaction itself is now a commodity and subject to the rules of the market – massive, absurd inflation everywhere!

However, what does not work on an individual level, can work on a group or institutional level.  Some payors, government and private insurance, reimburse hospitals more or less depending on how they perform on various metrics.  With some exceptions, this tactic appears to overall have improved medical care in America. Companies should be held responsible, or rewarded, for the quality of their products.  Corporations have always responded well to financial incentives; it’s why capitalism works!  
The fallacy in pay-for-performance resides in the jargon: quality, value and now “aligning incentives”.  This innocuous phrase glosses over the distinction between corporations, which thrive because they transcend individual people, and doctors, who thrive because they are humans providing care to other humans.  Be careful with your jargon, and be wary of individual metrics.

What was the hypothesis in pay-for-performance?

Quality metrics and pay-for-performance have now been in existence long enough to start accumulating some efficacy data.  And the picture does not look good.  Paying doctors to improve their quality metrics does not, in general, improve those quality metrics (Ann Intern Med. doi:10.7326/M16-1881).  Like all good scientists, we can now either question the data, or discard the hypothesis.

Most payors and administrators appear to be reacting to the lack of efficacy data on pay-for-performance by questioning the data.  I certainly do not see any sign of a lessening of the fervor of belief in these quality metrics, or the promotion of their use to guide physician payment.  Instead, I hear excuses like, “we haven’t put enough money at risk,” or “we just need to do a better job with measurement so it is more transparent to providers.”

But what really was the hypothesis with pay for performance?  Did the medical community have a hypothesis when we embarked on this experiment?  Were we asking how to improve the quality of patient care, or rather could we incentivize professionals to change their behavior for more money?  Let’s look at a typical pay for performance plan in a medical group: 15% of physician compensation is “at-risk” under the plan, the rest is productivity from wRVUs.  The at-risk amount is subdivided into three equal quantities based on performance: percentage of diabetics with A1C<9%, percentage of patient visits where medication reconciliation was performed, and percentage of visits where tobacco cessation was discussed.  What noble goals these are!  Surely all doctors should be performing these basic tasks with their patients and thereby earning the last 15% of their salaries.

The rationale behind paying for improvement is that physicians are economic actors.  They are economic creatures who obey the fundamental rules of rational economic behavior.  We maximize personal gain based upon our own personal goals and predilections.  This behavior is why free-market capitalism, ebay and Amazon all work well.  Under this theory, as a doctor I would rationally calculate what the 15% of my salary is worth compared to the pain of complying with the measures.  As a primary care physician, if I make $180,000 per year, then each measure is worth $9000 over a year.  Fortunately I am a smart doctor, and I realize that I have 4000 patient encounters per year, so for each one I could earn $2.25 by doing what is required.  In essence, we are asking, “Doctor, can I pay you $2.25 to have a conversation and click a box?”  You see why administrators think there needs to be more money at stake!  While sitting in the room with my patient, the pay for performance incentive is laughable.  At the end of the month it may add up to something, but at that point we can only gnash our teeth and grumble about Medicare and administrators.

So what if we increased “at-risk” pay to 50% under these three quality measures?  That ought to be enough to coax us to improve!  And likely it would be, since everyone wants to get paid.  You can be absolutely sure that there exists an amount that would ensure 100% compliance with those three measures.  But what sort of doctors would you then have?  What sort of care would you then get?  As a patient, knowing my doctor was paid in this crude manner would be horrifying.  Can you imagine the patient-physician relationship, and what the visit would consist of?  I want my personal doctor to do more than check a few boxes in my chart.

We are stuck with an impossible dilemma with quality measures.  We can make them small and simply an annoyance, or we can increase them to the point they intrude on physician consciousness, thereby ensuring compliance, but also robotic care. The dilemma highlights the absurdity of the assumptions behind medical pay for performance.  Physicians are not economic actors maximizing their profits.  Yes, many doctors like to get paid well, and will even switch jobs for a better income.  But that does not translate into the reason why they are physicians.  If I were a clever fellow and wanted to maximize my income these days I would not go into medicine at all!

I predict using quality measures as a tool for pay-for-performance will fail in the goal of improving patient care.  Or worse, it will succeed because we lack the imagination to create something better, and we will destroy the master clinicians and replace them all with “clerks,” who can be incentivized to click boxes for money.  Instead, I want to start talking about what does make “master clinicians,” and how we can cultivate that.  I want to start the dialogue with doctors about high performance, because that is why young men and women go into medicine.  They want to be high performers in the face of others’ suffering and illness!  Doctors yearn to provide quality care; they do not need to be incentivized.  Our broken medical system should instead incentivize the creation of pathways so quality care is possible.  Instead of penalizing providers with metrics, we should invest in coaching to help providers rediscover their inner passion for quality.  Instead of creating “clicks” for quality, we need to invest in ways of removing the “screen” between doctors and patients to allow for genuine interaction; that is real quality.
Stay tuned next week for suggestions on how to actualize these ideals…

What is a true “encounter”?

“Every present consciousness is discovered to be exceeded by a horizon of perceivability which confers on the world its strangeness and abundance.” –Paul Ricoeur

I am probably crazy.  I ride my motor scooter to and from work at the hospital.  Some consider it unsafe.  Perhaps it is, but feeling the wind and rain, the unfiltered elements, after 12 hours inside a controlled environment is too refreshing to pass up.  So at 2am Friday night I am zooming (you always zoom on a scooter…) through the industrial district after a tiring admitting shift.  I see some kids messing around on bicycles, one pulling a trailer, all laughing and yelling.  The road is otherwise deserted.  “Joyriders,” I think, “out for fun on Friday night.”

I passed them by and was soon home in bed.  But the late night encounter sticks with me because of the way it showed how my medical mind worked.  As a hospitalist I never know what patient encounter awaits me until the pager buzzes from the emergency room.  Similarly, zooming down dark streets, my mind is empty, receiving the unfiltered stimuli of breezes, smells, and lights.  A vision impinges on my consciousness, bicycles with trailers, screaming kids.  I have no idea what they are really doing there on a deserted street in the warehouse district at 2am.   Just so, the ED doctor presents a case: fevers and trouble breathing.  My brain reacts the same way to both phenomena, I categorize a direct experience into some digestible: joyriders and pneumonia.  The human brain does not deal with pure experience very well, or for very long.  We love to categorize and digest.  Once classified, I pigeonhole the experience and am able to keep moving down the dark street, or entering admission orders.

The phenomenologists were philosophers who worried a great deal about humans’ propensity to categorize prematurely.  Phenomenology can be seen as a reaction to Descartes’ proclamation, “I think, therefore I am.”  That phrase was intended to start philosophy with the only stable, unshakable, preconceived notion: rational thought.  Starting with a basis of a human as a rational, thinking machine, Descartes deduced the existence of God and a whole lot more as well.  According to Cartesian thinking, which dominated Western philosophy for two hundred years, pure reason alone will yield up truth.  Instead, the phenomenologists wanted to focus on what we have to do prior to using reason.  We have to confront the “things in themselves,” the experiences prior to interpretation.  “Perception never ceases to reveal how living goes beyond judging,” is the phrase used to describe this never-ending cycle of perceiving and judging.

Medical practice relies on the doctor’s ability to make judgments.  When I make a diagnosis and start treatment I have assembled a jumble of perceptions into a coherent judgment, a classification of some kind.  Without this act of labeling, my patient would remain a pure individual, with an uninterpretable unique set of occurrences and symptoms.  I would be powerless to act.  Yet, treating a person as a label is dehumanizing and objectifying.

Many healthcare workers are familiar with the AIDET tool, coined by the Studer group to help provide better patient experiences.  It is an acronym for Acknowledge, Introduce, Duration, Explain, Time, and functions as a mnemonic for us to remember to humanize interactions with patients.  Examples of using AIDET include greeting the patient, introducing yourself, explaining why you are interacting with them and how long it will take.  This tool eases patient anxiety about the uncomfortable experience of interacting with healthcare.  In truth, AIDET is nothing but a method of putting phenomenology into practice.  Instead of jumping straight to the categorization of a patient, labeling them as “the next xray,” or the “the diabetic,” we acknowledge the direct experience of the other person.  Rather than “joyriders,” the kids on their bikes and at night are left as simply that, kids on their bikes at night, a wonderment to tired eyes, surging up on a deserted street.  

Every patient — every human — needs to be first a welling up of an experience, a consciousness of an other without a judgment.  Everyone has had their moments of zooming down dark streets at night, with a tired rational brain at idle, directly feeling the wind without analyzing it.   How can we let patients surge up into our consciousness?  And after this pure experience of another human, how can we then move on to the categorization we need to do as medical professionals in order to diagnose and treat?

Are you afraid of the truth at the end-of-life?

In her excellent book, Ordinary Medicine, on how advances in technology and payment continue to create treatment expectations into old age, Sharon Kaufman relates a conversation with a patient regarding a liver transplant:

“At his age, it’s difficult to say if transplant is best… So it’s trading risks.  It is controversial.  That is, everyone will have an opinion about it.  Do you want a transplant if we find you eligible?”  Mr. Chin responded, “If that’s the best option, of course.”

All conversations clinicians have with their patients today follow this paradigm.  The doctor presents a set of options with their risks, then frames the debate in terms of “no right answer,” and inquires about what the patient wants.  The patient responds by asking for the best choice.  We have a mismatch of fundamental orientation: the ethical versus the philosophical.

The philosophical register corresponds to the age-old quest for stable truth, truth in speech, thought and action that conforms to some underlying, often hidden, reality.  Ethical thought, particularly in our postmodern world, coincides with an implicit concession that of a lack of underlying truth leads to relativism.  Ethical statements always could be otherwise, in a different circumstance, with a different person, in endless ways.  Philosophical statements exclude other possibilities in order to pin down the truth.

Rigorous medical training leads doctors to always consider the possibility that diagnoses are wrong, that prognoses are uncertain, and that biological systems are complicated and therefore fundamentally precarious.  Yet our patients have little interest in this ethical ambiguity.  They are asking for the truth in a situation for their lives.  Nothing is ever ambiguous for the patient: I can choose to use warfarin to prevent a stroke or I can take aspirin.  I can have the surgery or not have the surgery.  And so on.

Our perspective mismatch is never more apparent than at the end-of-life.  We approach medical care near the end-of-life from an ethical perspective, that is, we try to understand what is the right thing to do.  We use ethics to inform us on “the line between enough and too much intervention.” (Kaufman).  I wonder if we might try harder to understand what is true, that is, use a philosophical perspective.

As hospitalist medical director I have coaching conversations with my team of doctors.  During the last one I heard, “Patients seem to prefer it when I am a little more paternalistic.”  I think he was referring to a move out of the ethical register and into a more philosophical one.  In other words, paternalism in his mind equates to truth-telling, rather than concerned, caring, and patient-centered, all of which are ethical modes.  

Why have doctors retreated from truth into ethics? Perhaps it reflects a legitimate retreat from scientism and paternalism.  Statements of truth in the face of value questions have a medieval ring to them today.  As doctors, and as world citizens, we no longer believe in value-free facts.  The public is so accustomed to high-decibel controversies in abortion and climate change that “spin” is part of any scientific fact or philosophical statement.  Perhaps this was an inevitable sequela of Kant’s 18th century Critique of Pure Reason; humans have no subjectivity-free access to objective truth.  And so, after 200 years of modernity and postmodernity, we have abandoned the quest for objectivity entirely.  But we often forget that Kant himself had no doubts as to the validity of philosophical, truth-bearing, speech.  He just desired a more careful approach to the problem.

A careful path to truth is surely required, particularly at the end-of-life.  However, as my partner has discovered in his conversations with patients, they expect physicians to still be able to speak “truth.”  In a jaded populace, the medical profession is one of the last ones still trusted to transcend “spin” and endless ethical relativism.  Let us not be afraid of the philosophical mode.  Is it ever untrue to say, “Your loved one (or you) are dying?”  Somehow Americans have forgotten this fundamental fact, the fundamental fact, that we are born to die.  As a statement of truth, this statement of the inevitability of death is accurate.  There may be circumstances when it is misguided to say, “You are dying,” but it is never not true.  Doctors have worried so much about being wrong that we often do patients a disservice by avoiding the truth.

 

References

Kaufman, Sharon. Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line. Duke University Press, 2015.

Kant, Immanuel. Critique of Pure Reason, 1781.

The Story Addict

Listen to the patient history taken by my partner last night while admitting:

HISTORY OF PRESENT ILLNESS:  Mr. B is a very pleasant 60-year-old male with extensive past medical history who presented for evaluation of extreme weakness.  The ambulance reports that the patient had a witnessed fall while walking to the store to purchase some cigarettes.  He states that he is currently homeless, but compliant with medications and follow-up with the clinic.  He did not report any syncopal episodes, or chest pain, but does report significant shortness of breath.

It’s just the beginning of a story really, or perhaps the end of a long and complex story of a difficult life. Like any story, it conceals as much as it reveals, a mystery.  This snippet already lets the doctor start sifting through medical possibilities, thinking of other questions to ask, or tests to run.  The focus on the patient’s story has led to the modern methodology of “narrative medicine,” with its attendant conferences, schools and papers.  Narrative medicine is nothing new really; the doctor’s job has always been to listen to the patient and to be a witness, and to show empathy by somehow connecting to the story that the patient tells.  Even the most technical of the subspecialties listen to patient stories: surgeons, electrophysiologists and interventional radiologists.  And those of us in more holistic specialities, we have made this our bread and butter.  For better or worse, doctors are often evaluated by patients nearly entirely based on our ability to listen and empathize.

HISTORY OF PRESENT ILLNESS: Mr. X is a 70-year-old man without known cardiac history who was transferred here for management of ventricular fibrillation arrest.  This morning the patient was loading boxes into a truck and went back into the house. His daughter heard a crash and found the patient on the floor, unconscious and unresponsive. The history was obtained from the patient’s family and daughter who lives with him.  Per brother’s report, patient had been complaining of left shoulder pain for the last few weeks.  He does not seek medical attention and has not seen a doctor for many years.  Apparently 5 years ago he saw any eye doctor who told him that he needed to see a primary care physician based on the findings in his eyes.

In this case, Mr. X does not tell his own story.  In fact, in some sense, none of us may ever tell our own stories.  People use the cultural baggage that they inherit in order to make sense of the events of their lives, and this “baggage” actually determines the course of the story.  Nowhere is this more evident than in medicine.  We are a culture currently obsessed with “health” and medical advances.  All my patients have filtered their health experiences through a myriad of lenses before I hear about them: grandmother’s herbal tea, House MD, and so so many others.  We all tell filtered stories, and the physician’s job is to be the literary critic and detective.

Taking relatively undifferentiated symptoms, and preconceived notions, and weaving these into a medical story is the skill that distinguishes a master clinician.  At its best, it is what makes primary care so exciting, because nowhere else are we exposed to raw stories prior some other clinician’s interpretation.

If we wish to know about a man, we ask “what is his story – his real, inmost story?” – for each of us is a biography, a story. Each of us is a singular narrative, which is constructed, continually, unconsciously, by, through, and in us… (Oliver Sacks)

When I have medical students on my service, we often spend time reviewing pathophysiology, but even more time may be spent teaching how to construct the patient’s story.  Medical students quickly learn to assemble “facts,” such as blood pressure, symptoms and lab values.  But not until they start to create a plausible narrative with the facts do they become doctors.  Sometimes this is called the art of medicine, as opposed to science, but it is also true that “scientific reasoning often makes use of causal narratives.” (Solomon)  In some ways, doctors function as the close readers of books, matching patterns against what we have already read.

Alas, as clinicians there is a hard edge to our stories.  The stories the patient tells, and then the ones we tell, do not always harmonize with actual events.  Even more concerning are the selective memories that we hear every day, the downplaying of drug use, and the dissembling in order not to alarm family members.

Humans are… in general susceptible to the ‘narrative fallacy’ in which the attempt to weave experience into a coherent story results in the omission of facts, or even in their (intentional or unintentional) distortion or fabrication.” (Solomon)

Doctors are not immune to the narrative fallacy.  In fact, in order to ‘package’ a patient into a “History and Physical,” “Progress Note,” or one of the other codified narratives that physicians use for communication, we are required to commit the narrative fallacy by assigning a diagnosis.  We cannot complete a patient assessment of any kind without constructing this story.  And the story must fit one of the accepted and routinized narratives that scientific medicine has authorized in its repertoire.  In other words, we have to assign one or more diagnoses, and these diagnoses are always the conclusion of the story that we construct.  

This narrative urge ties directly to the case-based, practical, knowledge of the doctor.  Physicians are not scientists, we are a humanistic profession and would starve without a constant diet of stories.  However, perhaps not all illnesses should fit a narrative.  Chaos and its acknowledgement might serve medicine’s interest from time to time.  But I’m unlikely to let that happen; it’s what I am paid to do, commit the narrative fallacy. I’m hooked. There are three patients waiting in the emergency department.  Let me tell you about the first one…

 

References

Charon, Rita. Narrative Medicine: Honoring the Stories of Illness. Oxford University Press, 2006.

Solomon, Miriam. Making Medical Knowledge. Oxford University Press, 2015.

Sacks, Oliver. The Man Who Mistook His Wife for a Hat. Touchstone, 1998.

To Reductionism and Beyond

My patient has a cough, fever and crackles at the left lung base.  The chest radiograph shows an infiltrate.  “You have pneumonia,” I tell him.  “The Thoracic Society guidelines recommend a macrolide antibiotic to cover for Streptococcus pneumoniae and atypicals. Here is your prescription…”

“But doc, how do you know I will get better?  I don’t feel well.  My grandmother died of pneumonia and she was given the exact same prescription.”

Such questions often draw empathetic platitudes, or perhaps a discussion of clinical trials if time allows.  But the real answers strike at the core of what we do as physicians, and reflect on the troubled relationship of medicine to society.  We are not taught to provide comprehensive answers to questions of why we do what we do. Yet this ignorance undermines the trust that “is essential to patients in their willingness to submit to treatment.  They must be willing for us to be able.” (Jacobs 2005)

We practice medicine in certain ways because we have seen them work, and because we have read about them working — in “the literature” — but do we know why we trust our experience and our studies?  The instinctive reaction to cite studies does not really explain why your patient should trust his or her life to those studies.  Studies simply aggregate many cases of a similar disease in sophisticated “evidence-based” ways.  “What does that study have to do with me?” asks the astute patient.  The question is as old as civilization itself, and one that Aristotle (384–322 BCE) pondered in his discussions of “primitives”, or individual cases, in the context of making a general conclusion.

Now some think that because one must understand the primitives there is no understanding at all… for it is impossible to go through infinitely many things.

–Aristotle, Posterior Analytics

Trying to review “infinitely many things” raises the fundamental philosophical question of induction, or drawing conclusions about the general case from examining numerous particular instances.  We make a leap, from the individual to the general.  In Aristotle’s model, without a conception of scientific investigation, this leap was derived from tradition, and required the use of “phronesis” or practical wisdom.  Much of current medical practice continues to rely on practical wisdom in a way that Aristotle would recognize.  After all, most of medical practice is still not “evidence-based.”

However, we also believe that pneumonia will improve with azithromycin because we believe that induction works.  After studying many cases of pneumonia, we can make a prediction about a future case of pneumonia.  The statement sounds fairly bland when put this simply, but actually reflects a fundamental leap in philosophical reasoning that we often take for granted as medical providers, and that our patients may not deeply understand.

David Hume (1711-1776) reacted to the entire tenuous edifice of pre-scientific thought by introducing a deep skepticism towards causation and inductive knowledge.  He realized that the attempts to explain scientific facts by appeals to phenomena such as “the humors” — Hippocrates–, or by observing that the stars turn and thereby “…establish that the earth occupies the middle place in the universe” — Ptolemy — were fruitless and prone to error.  There was no logical connection between the conclusions and the supposed facts given to reach those conclusions.  For Hume, humans are left only with our experience of an event that we use as a “reason” to justify a conclusion about what caused it.

“Causes and effects are discoverable, not by reason but by experience…” Hume realized.   And based on our experience, we expect the “future to be conformable to the past.” (McGrew 2009)  However, without some theory, or rational explanation, behind our investigations, we have no basis beyond experience to predict the future.  And experience can be a fickle master as he demonstrates in his famous quote about fresh eggs:

Nothing so alike as eggs; yet no one, on account of this appearing similarity expects the same taste and relish in all of them.

Patients frequently commit the error of equating their experience with causation.  With a little reflection, we see that we all do so.  The philosophical school of logical positivism developed to show how observational evidence could provide genuine support for a scientific theory.  Hans Reichenbach (1891-1953) introduced the idea of the wager, or the odds of an induction being true.  We justify our use of induction by arguing that if there is any reliable method of predicting the future on the basis of the past, induction is it.

Hume demanded too much when he wanted for a justification of the inductive inference a proof that his conclusion is true.  What his objections demonstrate is only that such a proof cannot be given.  We do not perform, however, an inductive inference with the pretension of obtaining a true statement.  What we obtain is a wager; and it is the best wager we can lay because it corresponds to a procedure.

The positivists abandoned the idea of objective truth behind scientific knowledge in favor of simply reproducible explanation.  And certainly much of my day to day medical advice and treatment reflects this loss: “I don’t know why this works, or what is going on in the body, but studies show that it does.”  The logical positivists represent a form of empirical thought that posits that the only source of knowledge is experience.  Empiricist explanations are often not very satisfying, especially for patients and their families, but they do get the job done in the form of Evidence Based Medicine.

Modern medicine has made its most spectacular advances applying empirical observation to ever smaller biological processes by isolating single variables and testing them, a process known as Reductionism.  But biomolecules are not humans, and complex questions of how attitude or prayer might affect cancer outcomes is left to the “art of medicine.”  Contemporary philosophers such as Thomas Nagel in Mind and Cosmos question whether further scientific advances will require studying whole systems rather than just parts.  Nagel does not see reductionism as satisfactory for explaining the operation of the mind; neuroscience can tell us how molecules cause nerves to fire, but not how consciousness is created.  

The existence of consciousness seems to imply that the physical description of the universe, in spite of its richness and explanatory power, is only part of the truth…

For modern scientific medicine, the physical description of the body is what we rely on implicitly, and everything else is compartmentalized as “bedside manner.”  Nagel’s critique goes on to show that the existence of mind challenges Darwinian “blind” evolution.  Only if there exists some teleology, or intrinsic destination, for evolution can one explain the emergence of consciousness.

To explain consciousness, a physical evolutionary history would have to show why it was likely that organisms of the kind that have consciousness would arise… There [might be] natural teleological laws governing the development of organization over time, in addition to laws of the familiar kind governing the behavior of the elements.

Patients facing serious illness or death often find comfort in the idea that their lives have meaning — even if it is not always religious meaning.  The holistic consciousness that Nagel describes is currently scientifically inaccessible to us.  Will humanity’s yearning to be seen as more than a collection of parts always remain at the level of clinical art, or could it emerge in a scientific manner and become amenable to reproducible study?  Will the line between the “art” of medicine and the “science” always remain drawn where it is now?

As our culture becomes increasingly diverse and skeptical of claims about “truth”, a working familiarity with the philosophy of science becomes helpful to medical providers.  Scientific medicine is more openly debated in the marketplace of ideas now than ever.  Every one of my patients wonders whether he or she should be seeing me rather than the curandera, the naturopath, or Google.  And if they do see me, they wonder if I know what I am doing, and why they should trust me with their lives.  And these are good questions, ones that we should embrace because they deserve answers rather than trite statements like, “Because this is how I was trained.”

 

References

Jacobs, A. K.. “Rebuilding an Enduring Trust in Medicine: A Global Mandate: Presidential Address American Heart Association Scientific Sessions 2004.” Circulation 111.25 (2005): 3494-3498. Print.

Aristotle. Posterior Analytics.  In McGrew, Timothy J. ed. Philosophy of science: an historical anthology. Chichester: Wiley-Blackwell, 2009. Print. Page 46.

McGrew, Timothy J. ed. Philosophy of science: an historical anthology. Chichester: Wiley-Blackwell, 2009. Print. Page 220-224.

Godfrey-Smith, Peter. Theory and reality: an introduction to the philosophy of science. Chicago: University of Chicago Press, 2003. Print. Page 173.

Nagel, Thomas. Mind and cosmos: why the materialist neo-Darwinian conception of nature is almost certainly false. New York: Oxford University Press, 2012. Print.