Toward Scientific Medicine PDF
Preview Toward Scientific Medicine
O. S. Miettinen Toward Scientifi c Medicine Toward Scientific Medicine O. S. Miettinen Toward Scientific Medicine O.S.Miettinen JointDepartmentsofEpidemiology&Biostatistics andOccupationalHealth McGillUniversity Montreal,Que´bec Canada; and DepartmentofMedicine WeillMedicalCollegeofCornellUniversity NewYork,NY,USA ISBN978-3-319-01670-2 ISBN978-3-319-01671-9(eBook) DOI10.1007/978-3-319-01671-9 SpringerChamHeidelbergNewYorkDordrechtLondon LibraryofCongressControlNumber:2013950715 ©SpringerInternationalPublishingSwitzerland2014 Thisworkissubjecttocopyright.AllrightsarereservedbythePublisher,whetherthewholeorpart of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,broadcasting,reproductiononmicrofilmsorinanyotherphysicalway,andtransmissionor informationstorageandretrieval,electronicadaptation,computersoftware,orbysimilarordissimilar methodologynowknownorhereafterdeveloped.Exemptedfromthislegalreservationarebriefexcerpts inconnectionwithreviewsorscholarlyanalysisormaterialsuppliedspecificallyforthepurposeofbeing enteredandexecutedonacomputersystem,forexclusiveusebythepurchaserofthework.Duplication ofthispublicationorpartsthereofispermittedonlyundertheprovisionsoftheCopyrightLawofthe Publisher’s location, in its current version, and permission for use must always be obtained from Springer.PermissionsforusemaybeobtainedthroughRightsLinkattheCopyrightClearanceCenter. ViolationsareliabletoprosecutionundertherespectiveCopyrightLaw. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publicationdoesnotimply,evenintheabsenceofaspecificstatement,thatsuchnamesareexempt fromtherelevantprotectivelawsandregulationsandthereforefreeforgeneraluse. While the advice and information in this book are believed to be true and accurate at the date of publication,neithertheauthorsnortheeditorsnorthepublishercanacceptanylegalresponsibilityfor anyerrorsoromissionsthatmaybemade.Thepublishermakesnowarranty,expressorimplied,with respecttothematerialcontainedherein. Printedonacid-freepaper SpringerispartofSpringerScience+BusinessMedia(www.springer.com) Foreword While medicine hassplinteredintoamultitude ofseparatedisciplinesofpractice, medical academia too has become very diverse in its particular disciplines of scholarship. This diversity in medical academia has created a need for one of the disciplines to be focused on the ‘big picture’ of medicine, on the scholarly underpinningsofmedicineatlarge,especiallythegeneraltheoryofmedicineitself andalsothetheoryofdirectlypractice-relevantmedicalresearch.Eventhoughstill generally neglected, the scholarly underpinnings of medicine at large and of the research to advance the knowledge base of medicine should be areas of central concern in academic schools of medicine, for both the advancement and teaching ofthese. Asanoutstandingexception,thesemattershavebeenofcentralconcern,andfor averylongtimealready,forProfessorMiettinen.Inthisbook–theveryfirstofits kind by anyone – he first delineates the “daunting” needs for knowledge in medicine, and he then explores, critically, the “knowledge culture” that now prevails in and around medicine, focusing on examples from textbooks, journals, and educational programs. He makes plain how vacuous in substance the knowl- edgebaseofmedicinestillisandhowwantingeveningeneralacademicstandards ofqualitythesesourcesofmedicalknowledgestillarepronetobe,almostimplying that‘medicalacademia’remainsacontradictioninterms.Andfromthisnovel,and tomostmedicalacademicspresumablysurprising,diagnosisaboutthestatusquohe proceeds to presentation of what he sees to be the needed remedies. As the diagnosis reveals a severely anomalous state of the prevailing culture of medical academia – he points out that even the ‘knowledge-based medicine’ mantra is absentwhile‘evidence-basedmedicine’nowisallaround–theremediesheposits are correspondingly wide-ranging and radical, for both the knowledge culture of and surrounding medicine and the research to advance the knowledge base of medicine. AsIreflectonallofthis,twothoughtsareforemostinmymind.First,therange, depth,andoriginalityofmedicalscholarshipthataremanifestinthisbookkeepme v vi Foreword wonderingwhether anyone otherthan Miettinencouldhave writtena treatise like this,andIjusthaven’tbeenabletothinkofanyoneelseasbeinganywherecloseto measuring up. For all I can see, this book, timely and very important, had to be writtenbyMiettinen. Andsecond,Iammindfulofhowmedicalacademiainthepasthasinitiallydealt with ideas about necessary corrective innovations in medicine itself, before ulti- mately accepting and implementing them. In some cases the innovator has been driven out of town and also out of his mind (Semmelweis, inter alia), and so I wonder about the academia’s initial reception of Miettinen’s ideas about the need for wide-ranging, radical innovations in and around medicine, most of which,atleast,deservetobeacceptedandimplemented. A propos, Miettinen commonly quotes Francis Bacon’s counsel about reading (theearlier,moresuccinctversionofthis):“Readnottocontradict,nortobelieve, buttoweighandconsider.”Thisindeedisthewaythisbookofhisownalsoshould be read, and I add that his ideas about scientific medicine and medical science deserve particularly careful weighing and considering by leading academics concerned with medicine. The way in which, the extent to which, and the pace with which this will be done will be telling measures of how academic our particular, proud province of academia truly is. I hope it’ll adopt a posture of humilityandcommitmenttoearlyimplementationoftheneededinnovations. Preface Inthe1990s, therewasareunionofmymedicalschoolclasssuchthattwoofthe members – both professors abroad – had been invited to give a talk to stimulate thoughtbytherestofus. Thefirstspeaker,a‘basic’scientist,focusedonabookthathadbeenpublished 20 years earlier. This book had specified various innovations that the ‘basic’ sciences serving medicine will bring to the practice of medicine in the next two decades. The point of this talk was that none of those predicted innovations had materialized. Asthesecondspeaker,Icalledattentiontotheevidentfactthat,after6yearsof shared studies we diverged to different lines of knowledge-dependent work, and thatpracticallynoneoftherequisiteknowledgeforthese variedlinesofworkdid welearninthe6yearsofsharedstudyof“medicine.” Various colleagues who listened to us speakers subsequently expressed agree- mentwiththedisturbingimplicationsofwhathadbeensaid,butthistheydidonly furtively,treatingthoseimplicationsasthoughtheywerecloselyguardedsecretsof the medical guild. Open speaking about them was seen to be detrimental toone’s careerandwasshunnedonthisbasis. Decadesearlier,asamedicalstudent,Iwasinvitedtojoinagroupofphysicians working on laboratory-based medical research (cardiologic), and I did, but the remotenessofthisresearchfrom thepractice ofmedicine andthe expecteddefer- enceinittoincomprehensibleinputsfromastatisticianinanotherinstitutewhetted my interest in more directly ‘applied’ medical research and a concern to achieve true and comprehensive understanding of the theoretical underpinnings of this much more heavily statistics-dependent genre of medical research. I was advised togoandstudyepidemiologyandbiostatistics,whichIdid.After4yearsofthese studies I accepted an invitation to become an Assistant Professor of both of these vii viii Preface disciplines (at Harvard), which was soon followed by promotions to the ranks of AssociateProfessorandProfessorofthesetwodisciplines. Throughouttheensuingfourdecadesof(full)professorshipinthesedisciplines I’ve continued my quest – monomaniacal and quite lonely – to truly understand the nature of medicine’s requisite knowledge base and the research to advance this knowledge. Even though this understanding of mine still is quite incomplete, I now feel it’s time that I come out and share with others what my journey in medicalacademia,whichbeganin1956,hasthusfarledmetounderstandaboutthe scholarlyunderpinningsofthevastindustryofprofessionalhealthcare. A physician’s practice of healthcare can be in the service of a population, as a population, or it serves individuals one at a time. Correspondingly, medicine comprises community medicine or epidemiology and clinical medicine, the latter byfarthedominantsegment.Inthisbookthefocusisonclinicalmedicine,andthe term‘medicine’isusedinthissomewhatlimitedmeaningofit. Two,verydifferent,conceptionsofscientificmedicinecametoeminenceinthe twentieth century, both of them still very influential, but my concept of scientific medicine isvery differentfromboth ofthose.To me,medicine isscientifictothe extentthatitstheoreticalframeworkisrationalanditsknowledgebasederivesfrom medicalscience–fromresearch toadvancetheknowledge-baseofrationalmedi- cine, from this quintessentially ‘applied’ genre of medicalresearch. This research encompassesoriginalresearch,producingnewevidencetoadvancetheknowledge- base of rational medicine, and derivative (review-type) research, collating and synthesizing evidence from such original research. The evidence on a given topic servestoadvancetheknowledgeaboutitthroughreflectionandpublicdiscoursein thescientificcommunityconcernedwiththetopic. Thisbookisaboutthisrationalistconceptionofscientificmedicine.Itcomprises three parts.PartIfirstoutlines thenature andrequisiteformofcodificationofthe knowledge-baseofrationalmedicine–ofgnosis(dia-,etio-,andprognosis)init– and then, against this backdrop, it depicts the present state of directly practice- relevantknowledgeandoftheresearchtoadvancethisknowledge.Consequentto what thus emerges, Part II presents the innovations that now are needed in the knowledge culture of medicine. Part III is mainly an introduction to the theory – conceptsandprinciples,cumterminology(English)–oftheresearchtoadvancethe knowledge-base of genuinely scientific medicine, but to an extent it also is an introduction to the development of practice-guiding expert systems, initially pre-scientific but gradually also scientific. This Part III also is, in many ways, criticalofthestatusquo,whilemainlyoutliningthenatureoftherequisiteresearch forgenuinelyscientificmedicine. Preface ix Thisbookisdirectedtotwoverydifferenttypesofreader:academicleadersof medicine for one, and researchers concerned to advance the knowledge-base of medicine for another. For the former, all of Part II is very relevant, and so is the Epilogue,whileperhapsonlythechapterAbstractsinPartIandPartIIIare.Forthe researchers,PartIandPartIIconstituteanintroductiontowhatultimatelymatters tothem,namelyPartIII.Relevantbackgroundreadingsfortheresearchersalsoare, I suggest, the books listed below, given that quintessentially applied clinical research is meta-epidemiological in nature, as it too addresses rates, though not rathernon-specificrates,perse,asdoesepidemiologicalresearch,butveryspecific ratessoastolearnaboutprobabilities(gnostic). My critical judgments about the status quo and corresponding remedial propositions concerning the knowledge culture surrounding and characterizing medicine likely will not be received with pleasure by many academic leaders of medicine, just as conveyance of diagnoses about serious illnesses and needs for radical interventions challenge patients’ acceptance of such unwelcome truths about themselves. But receptivity to previously unrecognized troublesome truths isaprerequisiteforremedyingtheminmedicineitselfjustasinitsclients,andthe ultimate, constructive aim here is to prod the leaders, and the researchers too, to become agents of the much-needed innovations of the knowledge culture around andinmedicineand,then,ofactualprogresstowardgenuinelyscientificmedicine. Inthebalancehangsnotonlythesomaticwell-beingandsurvivalofpeoplebut people’smaterialwell-beingaswell,forfromprogressinmedicalacademiaflows improved quality of the practice of medicine, and from improved quality of the practice of medicine flows not only improved health and enhanced longevity of people but also improvement in the societal affordability of the healthcare peopleneed. Suggestedintroductoryreadingsforresearchers: 1. Miettinen OS. Epidemiological Research: Terms and Concepts. Dordrecht: Springer,2011. 2. Miettinen OS, Karp I. Epidemiological Research: An Introduction. Dordrecht: Springer,1212. 3. Miettinen OS. Up from Clinical Epidemiology & EBM. Dordrecht: Springer,2011.
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