This 90-second video clip is a “perfect provocation”
Allan Savory is a renowned ecologist from Africa. He is a global leader in environment and eco protection. He is making this famous comment, during one of his interviews from the deep forests of Zimbabwe, after years of ground-level work in the field of desertification and climate change. I can understand his feelings, as we also encounter similar situations at ground zero of the health care delivery system.(I wonder if there is anything called peer-reviewed bedside caring)
We realize wide gaps between academia, patient care, and research are the norm, not an exception. One reason for this is, even well-learned medical professionals find it difficult to comprehend, that the practice of medicine is essentially an art, administered with love, care, service-mindedness. A cost-effective infrastructure with an immense amount of teamwork is critical ( Of course, guided by a fair amount of knowledge, expertise based on good scientific principles)
Final message
As Savory says, let us hope, the future looks bright, that welcomes young researchers from the fringes of the scientific community. Let them be conferred with all courage and resources to course-correct medical science from its frequent aberrant and awkward turns.
Today is one of the most auspicious days in Indian traditional festive time. Saraswathi pooja, a celebration of the Goddess of knowledge and education. I would like to share one of the all-time great quotes on learning from Thiruvalluvar a sage poet who lived in the southern Indian state of (mine), Tamil Nadu in 4th -5th century BC 2500 years ago.
This Thirukural number 391 in the chapter of education goes on like this. (In the Tamil Language)
In English
Karka, Kasadara, Karpavai , Katrapin,
Nirka , Atharkku Thaga !
It says
Karka : Learn
Kasadara: Here comes the punch. Kasadara means pure. He says simple learning is not at all-sufficient. One has to learn from good sources, learn deep that should be devoid of errors, contaminations, and falsehoods.
Karpavai : Thus you learn all lessons in life meticulously.
Katrapin: So, after this hard and enlightened learning, what we should do? He answers next.
Nirka Atharkku Thaga: This means , don’t just stop with learning, follow it with action in a righteous way. Unless we do that he warns to conclude ( in another poem in the same chapter) there is no purpose of learning itself and we are again at risk of becoming illiterates.
So, what does this Thirukural teach the Nobel professionals who follow cutting edge medical research?
I think I need not elaborate . . . Acquiring knowledge and true learning has become two different processes.
It’s just a sample of one kural (Quote) among 1330 poetic quotes written in 133 chapters by this great philosopher of Tamil Nadu who shared the same timeline with Aristotle and Socrates of ancient Greece 5000 miles west of India. For those ,If you are interested in his monumental work on literature which can be referred to as the manual for effective living (I wish to call it as “Standard operating protocol” for human life) please follow the link.
Somehow the concept of Evidence based medicine (EBM )never excited me in spite of great strides it has made. Probably the main reason for this is, EBMs origin, quality, and credibility is currently severely compromised. (Though It appears to ooze science 24/7 and make us believe in it too !) Herewith, sharing some of the forbidden thoughts(with lots of pun) for a (un)successful practice of EBM. This is definitely not meant for young and novice medical professionals. Strictly for the ones who can segregate sense from non (S)
Unfortunately, there is a strong bias towards raw basic science when it is given in the filed of medicine.Do you know ,there is no Nobel prize exclusive for medical science ? It shares with human physiology the only field included for Nobel prize in medicine.
Evolution of human history reveals it is not the stunning scientific discoveries that impact the mankind . It is largely dependent on how we use them . It is true and natural ,invention of sub atomic particles , decoding quantum mechanics and trans-cellular signals always generate great interest than others.
In medical science, time and again we have seen problems arise in applying fruits of scientific research into practical usage in the patient domain in the bedside.
What is use of rewarding inventor of nitric oxide with a Nobel prize , when billion-dollar nitrate industry is thriving on a non existing life long indication of stable angina .
It is surprising to note , Nobel committee does give credit to wisdom & intellect while awarding prize in peace, literary or economic sciences. For some reason it lacks such a vision when it comes to medical sciences !
We have seen Nobel prize being awarded to organization that strive for peace and welfare of society and community like UN ,EU etc.The world health organization is the premier power supposed to provide and regulate the health in this planet.I do not recall any time WHO was close to considered for the Noble prize in medicine !
Nobel Ironies
Nobel committee rewards economists who point out lacunae in vital world macro and micro economics theories.
Dubious men(Heads of state ) are decorated with Noble peace prizes for preventing a war in one geographical area while doing exactly the opposite elsewhere !
In this modern millennium where scientific pursuits are contaminated and many of the research questions are misdirected or irrelevant , Nobel committee needs a through rejig in the manner in which medical Nobel prize is being awarded. We know ,Noble’s death wish was to award the brightest mind with highest scientific breakthroughs in those world . . . but
I guess Alfred Nobel if alive would have changed his rules .He wouldn’t have imagined modern science would systematically devalue common sense and reinventing it would also deserve an award equivalent to Nobel !
Some of the medical discoveries that deserve noble medical prize
States which excel in school health nutrition and other basic health programs for the downtrodden
Doctors who promote bed side clinical skills
Tobacco eradication networks
Organisations like medicine san-frontiers which strives for basic life saving medication for all
Journal houses that specialise on Medical ethics and clinical sciences
Medical professionals and institutions provide value education
Medical economists who expose the wasted financial resources that widen the gap between sick and rich
How about Nobel prize in cardiology for preventive cardiologist who successfully terminates a million statin prescription and restoring natural exercise directed lipid regulation in them ?
How about Noble prize for a noble physician sitting in corporate hospital infested with all commercial ingredients who could resist and argue successfully against inappropriate tonsillectomies and appendectomies ?
I am sure , such a man will be a laughing stock for most of us !
An appeal to Nobel committee
It is a wish , Noble prize in medicine is to be included for people who do yeomen services in preventive and clinical care and professional who carry forward the legacy of caring for the sick with clinical application of available scientific wisdom !
In this scientifically obsessed world , It will be a new beginning in the way future medical research will be directed and nurtured ! Only then the true power of Noble prize in medicine will be realised !
In one of my meetings , I told a small gathering , that regular exercise can shrink atherosclerotic plaquesand regress CAD. I also quoted , a recent large study which has proven this fact convincingly !
I concluded, simple exercise and other life style changes,risk factor correction may convert a 90% lesion to 70 or even 50 % . I stressed the importance of this study and asked my colleagues to avoid misuse of Angioplasties .
When many seemed to agree with me , one angry Interventional cardiologist questioned me, and asked the name of the study, and in which journal it came , What was quality of the paper ?
I told him , It is an Imaginary studydone in my back yard . It never got published in print. You may call it as E-journal* , not exactly though.It is not available in any websites , but located in the biological servers, and neuronal circuits as digital imprints in learned brains !
*Journal of experience
You may call it , a scientific forgery , to quote a non-existent study,
“But this study benefits whole lot of my patients”.
He was amused , and became agitated !
He told over the mike , “You are making foolish statement. . . don’t corrupt young minds” !
May be , he is true !
I asked him to be calm and requested to listen to another study which I was about to quote . . .
He couldn’t sit any more and rushed out of the hall !
Final message
We are ready to believe all those rubbish stories about a fourth generation self disappearing BVS that is able to scaffold a coronary artery and maintain a MLD by 2.5mm and TVR by 20 % and prevent near MAZE at 30 days by 9 % and improve long term survival by 6 months at the cost of 100, 000 Rs per month .Only to realise, it may be a farce . . . 5 years down the lane !
How to cleanse the darkened face of science ?
When falsehoods come with evidence and harm people , Good deeds can be preached without evidence to save our fellow human beings !
One of the important principles of medicine is “Diagnosis should always precede treatment”
This quote , though appear reasonable , can not be practiced always especially in emergencies, where we have to first stabilise the patient without a prior diagnosis .(Like administering IV fluids in hypotension , acetaminophen for fever , etc)
Modern medicine considers treating a patient without a diagnosis as unscientific.
But, it is a well recognised fact , millions of decision in everyday medical practice is not based on scientific diagnosis but on clinical acumen and empirical therapy . There are many instances wherein , we are never near the diagnosis even after exhaustive investigations.
Ironically , in this era of evidence based medicine , when we are unable to conclude , we are forced to do the most funniest thing , namely converting patient’s symptom itself as disease entity and be happy in labelling them. Like , Motion sickness , poly-arthritis, , chronic fatigue syndrome, adult respiratory distress syndrome , pre mature ejaculation, fever of unknown origin , attention deficit disorder , etc (The list is endless . . .)
This happens because physicians always feel guilty if they are unable to label a patient with a disease entity.
Is the guilt justified ? Not necessarily so ! Symptomatic treatment without diagnosis is the most dominant theme even today (Fever, pain etc ).So don’t feel unduly negative* when one is not able to fit a patent’s symptom into a disease entity but ensure he gets relief from his symptom.
*Except of course , one has to rule out a serious disorder.
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Please Note
The author acknowledges all the queries posted by the readers and wishes to answer them .Due to logistic reasons only few could be responded. Inconvenience caused is regretted.
Dr.S.Venkatesan MD 