A couple of weeks ago, Tu Youyou became the first Chinese national to win the Nobel Prize in Medicine “for her discoveries concerning a novel therapy against Malaria.” (Tu had already won the Lasker Award a few years ago for the same work, and had described her work this way.) There were cheers and hopes that with the prize, more people would become aware of Traditional Chinese Medicine (TCM), and the tremendous amount of work being put in to update the ancient arts with modern science and technology.
But very soon in the West, I see popping up everywhere “straw man” arguments 1.
First, there is the line of attack that goes something like this: so what if Dr. Tu found one drug from Traditional Chinese Medicine (TCM) that turned out to work. That per se doesn’t validate the whole tradition. As this Daily Kos post noted:
Sure Chinese herbal medicine gave us the treatment. But it took Dr. Tu’s real scientific research methods to find the one cure out of the 3,020 claims. So if you believe in cherry picking one success out of 3,019 failures or confirmation bias, sure Dr. Tu’s work “proves” TCM is real.
Then there is the line of attack that what Dr. Tu was really recognized for was in employing modern techniques to isolate and test Artemisinin (and related drugs) for the treatment of Malaria, not TCM per se. Further, even if the compounds Dr. Tu helped to isolate in the 1970’s did turn out to be the most effective treatments for a disease the world has known (and even if “[t]here are likely few other drug discoveries that have produced (or will produce) this magnitude and extent of benefit”), the U.S. FDA did not approve artemisinin-based drug until 2008, and most importantly, without big Western Pharma’s involvement in packaging, manufacturing and distributing the drug around the world, Dr. Tu’s discovery would never have made the difference it did.
I call these “straw man” arguments because few Chinese are looking to Tu’s Nobel as a vindication of Traditional Chinese Medicine. The Chinese are too busy pushing today to support and further develop TCM – an art developed some 3,000 years ago – with modern science and technology – with … or without … the Nobel.
There is this overwhelming presumption – in the West definitely but also in China – that “Western medicine” is objective, rational, scientific, evidence-based while everything else (TCM included) is … well … anything but.
[Western Medicine] differs from Eastern, or alternative, medicine, in its approach to treatment, which relies heavily upon industrially produced medications and a strict adherence to the formal scientific process. … The main benefit of [Western] medicine is that the work of [its] practitioners is subject to rigorous safety and effectiveness protocols. Treatments and medications pass a strict review before a patient can receive them.
But is this distinction based on an idealization or reality of “Western medicine”?
Consider this report from the Scientific American, which reports just how unscientific and subjective modern medicine actually is.
Most of us are confident that the quality of our healthcare is the finest, the most technologically sophisticated and the most scientifically advanced in the world. And for good reason—thousands of clinical research studies are published every year that indicate such findings. Hospitals advertise the latest, most dazzling techniques to peer into the human body and perform amazing lifesaving surgeries with the aid of high-tech devices. There is no question that modern medical practices are remarkable, often effective and occasionally miraculous.
… We believe that the vast majority of what physicians do is backed by solid science. Their diagnostic and treatment decisions must reflect the latest and best research. Their clinical judgment must certainly be well beyond any reasonable doubt. To seriously question these assumptions would seem jaundiced and cynical.
But we must question them because these beliefs are based more on faith than on facts for at least three reasons, each of which we will explore in detail in this section. …
Medical decision-making itself is fraught with inherent subjectivity, some of it necessary and beneficial to patients, and some of it flawed and potentially dangerous. For these reasons, millions of Americans receive medications and treatments that have no proven clinical benefit, and millions fail to get care that is proven to be effective. Quality and safety suffer, and waste flourishes.
The problem is that physicians don’t know what they’re doing. That is how David Eddy, MD, PhD, a healthcare economist and senior advisor for health policy and management for Kaiser Permanente, put the problem in a Business Week cover story about how much of healthcare delivery is not based on science. Plenty of proof backs up Eddy’s glib-sounding remark.
The plain fact is that many clinical decisions made by physicians appear to be arbitrary, uncertain and variable. Reams of research point to the same finding: physicians looking at the same thing will disagree with each other, or even with themselves, from 10 percent to 50 percent of the time during virtually every aspect of the medical-care process—from taking a medical history to doing a physical examination, reading a laboratory test, performing a pathological diagnosis and recommending a treatment. Physician judgment is highly variable.
Here is what Eddy has found in his research. Give a group of cardiologists high-quality coronary angiograms (a type of radiograph or x-ray) of typical patients and they will disagree about the diagnosis for about half of the patients. They will disagree with themselves on two successive readings of the same angiograms up to one-third of the time. Ask a group of experts to estimate the effect of colon-cancer screening on colon-cancer mortality and answers will range from five percent to 95 percent.
Ask fifty cardiovascular surgeons to estimate the probabilities of various risks associated with xenografts (animal-tissue transplant) versus mechanical heart valves and you’ll get answers to the same question ranging from zero percent to about 50 percent. (Ask about the 10-year probability of valve failure with xenografts and you’ll get a range of three percent to 95 percent.)
Give surgeons a written description of a surgical problem, and half of the group will recommend surgery, while the other half will not. Survey them again two years later and as many as 40 percent of the same surgeons will disagree with their previous opinions and change their recommendations. Research studies back up all of these findings, according to Eddy.
Because physician judgment varies so widely, so do treatment decisions; the same patient can go to different physicians, be told different things and receive different care. When so many physicians have such different beliefs and are doing such different things, it is impossible for every physician to be correct.
Why are so many physicians making inaccurate decisions in their medical practices? It is not because physicians lack competence, sincerity or diligence, but because they must make decisions about tremendously complex problems with very little solid evidence available to back them up….
Most physicians practice in a virtually data-free environment, devoid of feedback on the correctness of their practice. They know very little about the quality and outcomes of their diagnosis and treatment decisions. And without data indicating that they should change what they’re doing, physicians continue doing what they’ve been doing all along.
Physicians rely heavily on the “art” of medicine, practicing not according to solid research evidence, but rather by how they were trained, by the culture of their own practice environment and by their own experiences with their patients.
The core problem we would like to examine here is that a disturbingly large chunk of medical practice is still “craft” rather than science. As we’ve noted, relatively little actionable science is available to guide physicians and physicians often ignore proven evidence-based guidelines when they do exist. A guild-like approach to medicine—where every physician does it his or her way—can create inherent complexity, waste, proneness to error and danger for patients.
When we look at how well physicians are really doing, it’s scary to see how off the mark they are. Anyone who feels self-assured about receiving the best medical care that science can offer is in for a shock, considering some eye-opening research that shows how misplaced that confidence is. Let’s start with how well physicians do when they have available evidence to guide their practices.
The best answer comes from seminal research by the Rand Corporation, a respected research organization known for authoritative and unbiased analyses of complex topics. On average, Americans only receive about half of recommended medical care for common illnesses, according to research led by Elizabeth McGlynn, PhD, director of Rand’s Center for Research on Quality in Health Care. That means the average American receives care that fails to meet professional evidence-based standards about half of the time.
The commission released a report in March, 1998, that stated: “Exhaustive research documents the fact that today, in America, there is no guarantee that any individual will receive high-quality care for any particular health problem. The healthcare industry is plagued with overutilization of services, underutilization of services and errors in healthcare practice.” The central problem, as the Rand study had revealed, is clinicians’ failure to follow evidence-based best practice guidelines that exist and have been proven to enhance the quality of healthcare delivery.
The commission’s report acknowledged that physicians may have difficulty keeping up with an explosive growth in medical research, noting that the number of published randomized, controlled trials had increased from an average of 509 annually between 1975 and 1980 to 8,636 annually from 1993 through 1997. That’s just for randomized, controlled trials. Several other types of studies considerably increase the number of annual research articles that physicians must keep up with to be current on scientific research findings. Plus, that was more than ten years ago; the numbers grow more rapidly each year.
Hospitals are on the hook as well and show wide gaps in their delivery of recommended care. … Results from the Leapfrog Group’s 2009 hospital survey show that just over half of hospitals meet Leapfrog’s quality standard for heart-bypass surgery; under half meet its standard for heart angioplasty; and under half of hospitals meet Leapfrog’s quality standards for six common procedures, including high-risk surgery, heart-valve replacement and high-risk deliveries, even though nationally accepted scientific guidelines for these procedures exist and have been proven to save lives.
Failing to follow existing guidelines is only part of what makes so much of medical practice “unscientific.” Another key reason is that there are so few solid, actionable scientific guidelines to begin with, and those that are available cover a relatively small slice of clinical care.
Part of the problem is that science, technology and culture are all moving targets. Today’s dogma is tomorrow’s folly, and vice versa. Many examples show that what physicians once accepted as truth has been totally debunked. Twenty years ago, for instance, physicians believed that lytic therapy for post-myocardial infarction would prolong a heart attack. The therapy involves clot-busting medication given to heart-attack patients. Today it is standard practice. Angioplasty and intracoronarylysis of clots are other examples. Years ago, surgery for benign prostatic hypertrophy (enlarged prostate) was one of the top DRGs (illnesses billed by hospitals) under Medicare. Today, we do far fewer of these procedures because of new drugs.
The public has little idea that physicians are playing a sophisticated guessing game every single day. …
To illustrate how little scientific evidence often exists to justify well-established medical treatments, David Eddy researched the scientific evidence underlying a standard and widely used glaucoma treatment designed to lower pressure in the eyeball. He searched published medical reports back to 1906 and could not find one randomized, controlled trial of the treatment. That was despite decade after decade of confident statements about it in textbooks and medical journals, statements which Eddy found had simply been handed down from generation to generation. The kicker was that the treatment was harmful to patients, actually causing more cases of blindness rather than fewer.
Similar evidence deficits exist for other common medical practices, including colorectal screening with regular fecal-occult-blood tests and sigmoidoscopy; annual chest x-rays; surgery for enlarged prostates; bone-marrow transplants for breast cancer; and common approaches to pain control, depression, immunizations, cancer screening, alcohol and drug abuse, smoking and functional disabilities. The problem is rampant across medicine; a huge amount of what physicians do lacks a solid base of scientific evidence.
In the past, many standard and accepted practices for clinical problems were simpler and more straightforward than those that today’s clinicians face—and these practices seem to have worked, despite the paucity of good research evidence. Physicians simply made subjective, intuitive decisions about what worked based on what they observed. The problem today is that the growing complexity of medicine bombards clinicians with a chaotic array of clinical choices, ambiguities and uncertainties that exceeds the inherent limitations of the unaided human mind. As a result, many of today’s standard clinical practices bear no relation to any evidence of effectiveness.
Instead, physicians frequently base their decisions on shortcuts, such as the actions of the average practitioner (“if everyone is doing it, the intervention must be appropriate”); the commonness of the disease (“if the disease is common, we have no choice but to use whatever treatment is available”); the seriousness of the outcome (“if the outcome without treatment is very bad, we have to assume the treatment will work”); the need to do something (“this intervention is all we have”); and the novelty or technical appeal of the intervention (“if the machine takes a pretty picture, it must have some use”).
Drug prescribing is another blatant example of medical practice that is often evidence-free. Drugs that are known to be effective may work well for only 60 percent of people who take them. But about 21 percent of drug prescriptions in the United States are for “off-label” use, that is, to treat conditions for which they have not been approved by the U.S. Food and Drug Administration. That’s more than 150 million prescriptions per year. Off-label use is most common among cardiac medications (46 percent) and anticonvulsants (46 percent). Here’s the real punch line: in 73 percent of the cases where drugs are used in unapproved ways, there is little or no evidence that they work. Physicians prescribe drugs well over a million times a year with little or no scientific support.
These are fighting words, saying that such a big chunk of medical practice is not based on science. To illustrate just how provocative this topic is, look at what happened in the 1990s when the Federal Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) released findings from a five-year investigation of the effectiveness of various treatments for low back pain—one of the leading reasons that Americans see physicians.
Between 1989 and 1994, an interdisciplinary Back Pain Patient Outcomes Assessment Team (BOAT) at the University of Washington Medical School in Seattle set out to determine what treatment strategies work best and for whom. Led by back expert Richard A. Deyo, MD, MPH, the team included orthopedic surgeons, primary-care physicians, physical therapists, epidemiologists and economists. Together, they examined the relative value of various diagnostic tests and surgical procedures.
Among the researchers’ specific findings: no evidence shows that spinal-fusion surgery is superior to other surgical procedures for common spine problems, and such surgery leads to more complications, longer hospital stays and higher hospital charges than other types of back surgery.
Disgruntled orthopedic surgeons and neurosurgeons reacted vigorously to the researchers’ conclusion that not enough scientific evidence exists to support commonly performed back operations. The surgeons joined with Congressional critics of the Clinton health plan to attack federal funding for such research and for the agency that sponsored it. Consequently, the Agency for Healthcare Policy and Research had its budget for evaluative research slashed drastically.
The back panel’s guidelines were published in 1994. Since then, even though there are still no rigorous, independently funded clinical trials showing that back surgery is superior to less invasive treatments, surgeons continue to perform a great many spinal fusions. The number increased from about100,000 in 1997 to 303,000 in 2006.
What are physicians to do? They need a great deal more reliable information than they have, especially when offering patients life-changing treatment options. Before recommending surgery or radiation treatment for prostate cancer, for example, physicians and their patients must compare the benefits, harms and costs of the two treatments and decide which is the more desirable.
Even guidelines that are rooted in randomized, controlled trial research do not make clinical decisions for physicians; rather, they must be applied to individual patients and clinical situations based on value judgments, both by physicians and their patients. … For example, should a physician recommend an implantable cardioverter-defibrillator (ICD) to his or her patient when a randomized-control trial shows that it works? … A published randomized trial compared ICDs to management with drugs for heart-attack patients and found that ICDs reduced patients’ probability of death at 20 months by about one-third.
Armed with such a guideline, the physician and patient must still make a value judgment: whether the estimated decrease in chance of death is worth the uncertainty, risk and cost of the procedure….
The lesson here is that there are huge gaps in the scientific evidence guiding physician decision-making, and it wasn’t until healthcare-quality gadflies like David Eddy began to demand to see the evidence that we learned about those gaps. … “Nothing should be affirmatively promoted unless there is good evidence of at least some benefit,” writes Eddy. It is simply amazing that applying such a statement to modern medicine represents such a ground-breaking development.
Moving from the doctor to the drug part of modern medicine, things don’t seem to get that much more “scientific” or “objective.” In an article titled “One big myth about medicine: We know how drugs work,” the Washington Post reported:
Here’s how we think we discover powerful new medicines: Scientists dig deep into biology and zero in on a molecular Achilles’ heel that could disable a devastating disease, be it cancer or an infection. They concoct experimental drugs that hit the target. Then they conduct trials to find one that is safe and effective in people.
Here’s how we actually develop a surprising number of treatments: good old-fashioned observation, trial and error, and luck. Detailed scientific understanding of how a drug works often comes, [if it does come at all … ] ironically enough, near the end of the process.
“It’s sort of a fairy tale,” said Jon Clardy, a professor of biological chemistry and molecular pharmacology at Harvard Medical School, of the idea that drugs are born mostly from reason and not serendipity. “If you think of it as an aspirational goal, it’s fine.”
“We’re not as smart as we look,” said Michael Jordan, a physician in the immunobiology division at Cincinnati Children’s Hospital Medical Center.
Knowing why a drug works has historically trailed the treatment, sometimes by decades. Some of the most recognizable drugs — acetaminophen for pain relief, penicillin for infections, and lithium for bipolar disorder, continue to be scientific mysteries today.
In a 2013 article titled “Do Clinical Trials Work?”, the New York Times further reported:
[A]t the annual meeting of the American Society of Clinical Oncology last month, much of the buzz surrounded a study that was anything but a breakthrough. To a packed and whisper-quiet room at the McCormick Place convention center in Chicago, Mark R. Gilbert, a professor of neuro-oncology at the University of Texas M. D. Anderson Cancer Center in Houston, presented the results of a clinical trial testing the drug Avastin in patients newly diagnosed with glioblastoma multiforme, an aggressive brain cancer. In two earlier, smaller studies of patients with recurrent brain cancers, tumors shrank and the disease seemed to stall for several months when patients were given the drug, an antibody that targets the blood supply of these fast-growing masses of cancer cells.
But to the surprise of many, Dr. Gilbert’s study found no difference in survival between those who were given Avastin and those who were given a placebo.
Disappointing though its outcome was, the study represented a victory for science over guesswork, of hard data over hunches. As far as clinical trials went, Dr. Gilbert’s study was the gold standard. …
That we could be this uncertain about any medicine with $6 billion in annual global sales — and after 16 years of human trials involving tens of thousands of patients — is remarkable in itself. And yet this is the norm, not the exception. We are just as confused about a host of other long-tested therapies: neuroprotective drugs for stroke, erythropoiesis-stimulating agents for anemia, the antiviral drug Tamiflu — and, as recent headlines have shown, rosiglitazone (Avandia) for diabetes, a controversy that has now embroiled a related class of molecules. Which brings us to perhaps a more fundamental question, one that few people really want to ask: do clinical trials even work? Or are the diseases of individuals so particular that testing experimental medicines in broad groups is doomed to create more frustration than knowledge?
Researchers are coming to understand just how individualized human physiology and human pathology really are. On a genetic level, the tumors in one person with pancreatic cancer almost surely won’t be identical to those of any other. Even in a more widespread condition like high cholesterol, the variability between individuals can be great, meaning that any two patients may have starkly different reactions to a drug.
HUMAN drug trials are typically divided into three phases. … Rigorous statistical tests are done to make sure that the drug’s demonstrated benefit is genuine, not the result of chance. But chance turns out to be a hard thing to rule out. When the measured effects are small — as they are in the vast majority of clinical trials — mere chance is often the difference between whether a drug is deemed to work or not, says John P. A. Ioannidis, a professor of medicine at Stanford.
In a famous 2005 paper published in The Journal of the American Medical Association, Dr. Ioannidis, an authority on statistical analysis, examined nearly four dozen high-profile trials that found a specific medical intervention to be effective. Of the 26 randomized, controlled studies that were followed up by larger trials (examining the same therapy in a bigger pool of patients), the initial finding was wholly contradicted in three cases (12 percent). And in another 6 cases (23 percent), the later trials found the benefit to be less than half of what was first reported.
It wasn’t the therapy that changed in each case, but rather the sample size. And Dr. Ioannidis believes that if more rigorous, follow-up studies were actually done, the refutation rate would be far higher.
Donald A. Berry, a professor of biostatistics at M. D. Anderson, agrees. He, too, can rattle off dozens of examples of this evaporation effect and has made a sport, he says, of predicting it.
“Listen, it’s not lost on anybody that about 95 percent of drugs that enter clinical testing fail to ever get approved,” says Dr. Barron. “It’s not hard to imagine that at least some of those might have failed because they work very, very well in a small group. We can’t continue to have failures due to a lack of appreciation of this heterogeneity in diseases.”
So what’s the solution? For subtypes of disease that are already known, it may be feasible to design small clinical trials and enroll only those who have the appropriate genetic or molecular signature.
But given the dismal success rate for drug development, this piecemeal approach is bound to be slow and arduous. Rather than try to fit patients, a handful at a time, into the decades-old clinical-trials framework, we’d be far better off changing the trials themselves.
The same theme was echoed a few years earlier in this 2010 Huffington Post article:
There is an implied faith here that if a new drug manufacturer has paid for the research for FDA approval, then it is scientifically proven to be effective. As it turns out, this belief is by no means fully justified.The British Medical Journal recently undertook an general analysis of common medical treatments to determine which are supported by sufficient reliable evidence. They evaluated around 2,500 treatments, and the results were as follows:
- 13 percent were found to be beneficial
- 23 percent were likely to be beneficial
- Eight percent were as likely to be harmful as beneficial
- Six percent were unlikely to be beneficial
- Four percent were likely to be harmful or ineffective.
This left the largest category, 46 percent, as unknown in their effectiveness. In other words, when you take your sick child to the hospital or clinic, there is only a 36 percent chance that he will receive a treatment that has been scientifically demonstrated to be either beneficial or likely to be beneficial. This is remarkably similar to the results Dr. Brian Berman found in his analysis of completed Cochrane reviews of conventional medical practices. There, 38 percent of treatments were positive and 62 percent were negative or showed “no evidence of effect.”
For those who have been paying attention, this is not news. Back in the late 70’s the Congressional Office of Technology Assessment determined that a mere 10 to 20 percent of the practices and treatment used by physicians are scientifically validated. It’s sobering to compare this number to the chances that a patient will receive benefit due to the placebo effect, which is between 30 percent and 50 percent, according to various studies.
We all marvel at the technological advances in materials and techniques that allow doctors to perform quadruple bypass surgeries and angioplasties without marveling that recent studies indicate that coronary bypass surgery will extend life expectancy in only about three percent of cases. For angioplasty that figure sinks to zero percent. Those numbers might be close to what you could expect from a witch doctor….
It would be one thing if any of these unproven conventional medical treatments were cheap ….
Then there is the myth that this vast expenditure results in excellent health care, usually touted as the best in the world… But this myth has been completely undermined. In 2000 Dr. Barbara Starfield, writing in the Journal of the American Medical Association, estimated that between 230,000 and 284,000 deaths [perhaps much more] occur each year in the US due to iatrogenic causes, or physician error, making this number three in the leading causes of death for all Americans.
In 2005 the Centers for Disease Control and Prevention reported that out of the 2.4 billion prescriptions written by doctors annually, 118 million were for antidepressants. It is the number one prescribed medication…. The theory behind standard antidepression medication is that the disease is caused by low levels of key brain chemicals like serotonin, dopamine, and norepinephrine, and thus by manipulating those imbalanced neurotransmitters, a patient’s depression will be reversed or at least alleviated.
This turns out to be another myth. Prof. Eva Redei of Northwestern University, a leading depression researcher, has discovered that depressed individuals have no depletion of the genes that produce these key neurotransmitters compared to people who are not depressed. This would help explain why an estimated 50 percent of patients don’t respond to antidepressants, and why Dr. Irving Kirsch’s meta-analysis of antidepressants in England showed no significant difference in effectiveness between them and placebos.
You have a right to be shocked by these findings and by the overall picture of a system that benefits far fewer patients than it claims. The sad fact is that a disturbing percentage of the medicine we subject ourselves to isn’t based on hard science, and another percentage is risky or outright harmful. Obviously, every patient deserves medical care that is evidence-based, not just based on an illusory reputation that is promoted in contrast to alternative medicine.
Now don’t get me wrong. I am aware of and thankful for the many marvels of modern medicine has brought, including anesthesia, knowledge that germs cause infectious diseases, knowledge of how immune systems work, vaccines, diagnostic technologies such as x-rays and MRI. So many promising innovations exist today (see e.g. this or this or this) – that some even think immortality may achieved in the foreseeable future.
But a brief perusal of history of Western medicine also reveals so many things that used to be touted as “medicine” look today barbaric and cruel. Here, for example, are 10 dangerous drugs previously marketed as medicine. Here are 10 barbaric treatments in modern medicine. Given how little of what goes on in the human body is understood scientifically, how objective and evidence-based can today’s medicine be?
When the human genome was sequenced around 2003, there was much talk of a new era where we will start learning about diseases at the most fundamental level, unlock the ailments, and design drugs – as engineers design say cars – to fight diseases … on a personal level. I worked in the bioinformatics for about five years around 2000: the ultimate dream for all my colleagues and I was to help find a cure for cancer in silico (vs. in vivo or in vitro). Medicine would finally be turned from an art to science and engineering.
That’s still the vision the public seems to have of medicine. But it’s more science fiction than reality.
Almost two decades later, that vision still hasn’t worked out. To this day, no drug has been identified and proven to be safe and effective by this new method of science-based medicine. It turns out that our body works in complex ways … and mere sequencing of genes isn’t going to give us the insights into disease mechanisms … much less treat diseases. Most drugs today are still discovered the traditional way: by trial and error, or serendipity (think e.g. penicillin and insulin), or extracted from nature (some 50% of all drugs on market today remain natural products). Truly innovative and new drugs are hard to come by.
Now as I reflect back, I wonder if “Western medicine” as an objective and science-based endeavor – so vivid in people’s mind – exists in reality.
Are the many “benefits” ascribed to “Western medicine” truly a product of “Western medicine” … or do they just part of the more general story of how scientific and technological advances have been changing all aspects of human circumstances since the start of industrial revolution?
a “Western model” of evidence-based practice for diagnosing and treating disease. Mainstream medicine assumes that all physiologic and pathological phenomena can be explained in concrete terms, and “best practice” is the end result of a stream of objective analyses which begin with nonhuman model systems, evolve through blinded studies and statistical analysis of those results, and end with guidelines to which doctors adhere to achieve optimal patient outcomes.”
First and foremost, intrinsic to the notion of “modern medicine” is the notion of “evidence-based.” But is this notion really unique to “Western medicine”?
Do you actually think there ever was a time and place where people didn’t demand that medical treatments work? When treatments didn’t work, did other societies merely accept that doctors practice the same way regardless?
The term “evidence-based medicine” within the Western medical community – surprisingly – was not formally defined until 1996 by David L. Sacket et al. to mean specifically “the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients.”
“Evidence-based medicine” today involves the institutionalized peer review of medical claims (through peer-review publications) and government oversight of claims through rigorous blind statistical studies (e.g. overseen by the F.D.A.).
The ancient practitioners would have been hampered by a much smaller sample size of patients, and wouldn’t have been able to share knowledge as effectively as today, and would not have had access to modern science and technology, but that doesn’t mean they would have dispensed with objectivity and evidence.
Critics of “evidence-based “medicine” have actually been arguing that given where medicine is today, a formal requirement that doctors must be bound by rigorously to “external” best practices will inadvertently limit clinical freedom, reduce medical arts to a “cookbook,” and/or destroy doctor-patient relationships and replace it with patient-insurance or even patient-lawyers relationships. Adherents have been forced to respond that “evidenced-based medicine” is not that formal and rigid: it only requires that doctors – in their individual care of their patients – be more aware of general best practices.
So the key cornerstone of “Western medicine” – when one comes hard on it – is just that its doctors are “more informed” about the latest advances?
Another key feature of “Western medicine” is the presumption that “all physiologic and pathological phenomena can be explained in concrete terms.” Again, this is a nice ideal. But the truth is that few if any diseases have been cured through the systematic understanding of the underlying processes, and the design of a treatment to fix those processes. Most treatments have come about by serendipity, by studying nature, or by trial and error. Many of diseases remain not well understood even years after cures have been found.
Another key distinction of “Western medicine” is supposedly the notion of rigorous double-blind statistical evaluation. Underneath the practice is the notion that treatments should be repeatable and reproducible across human populations. But even this idea is being challenged today.
It turns out that there may be vast differences in the way our bodies work, in the way they respond to medical intervention. “Personalized medicine” thus is no longer a hocus pocus chant of alternative medicine, 2 but the future of mainstream medicine. But if that’s so, it also means that the way we conduct double-blind statistical evaluation – a key pillar of “Western” or “objective” medicine – need to change also 3 (see also New York Times titled “Do Clinical Trials Work?” referenced above).
Today, the overall life expectancy of Mainland China is 75 while that of the U.S. is 79, but the U.S. outspends China some 22 times in health care (U.S. total health expenditure per capita is $8,233 while China’s is $373). Given the staggering costs (and lack of efficiency), there is a growing unease that “Western medicine” may have over-delivered on its promise to be scientific, objective and rational.
The BBC recently aired a documentary titled “The Truth about your Medicine Cabinet” that shows that many over-the-counter medicine are overkill, with some being dangerous unless used carefully, and many simply unnecessary.
There is a palpable suspicion whether drugs really work; whether patients – or even doctors – have been misreading statistics and duped into systematically overestimating the positive effects of drugs; whether the FDA process really produce scientific, effective, safe, and needed drugs as claimed; whether vaccines are as safe as claimed; whether there is the conflict of interest between doctors and pharmaceutical industry have become systematic and pervasive); whether democratic institutions (including the F.D.A.) have been fundamentally hijacked (“captured”) by special interests.
Of course, none of this unease shows that Traditional Chinese Medicine is a viable alternative per se.
One might wonder: what is the role of “qi” in the human body? What are the scientific meanings of “yin” and “yang” forces … or of the “five elements”? Are there corresponding analogs we can find in the human body – or are they merely organizing principles helpful for practitioners to focus in in diagnosing problems? Or perhaps … are they all just old obsolete superstitions? Is TCM a viable approach to practice holistic, personalized treatment … or will it be reduced to providing merely a library of potential natural materials from which modern techniques are to be employed to harness as drugs?
Time and more research will tell.
As this Economist Article noted, “IT IS easy, in the arrogance of scientific advance, to forget that less than a century and a half ago most medicines were herbal remedies. To this day, some of the best-known, including aspirin, morphine and digitalis, are either made from plants or based on plant molecules.”
Perhaps one day, we will understand how human body works from chemistry up, from physics up, perhaps even quantum mechanics up … and all the nuances of diseases and medical conditions will be understood in detail. Perhaps one day robots will be able to scan the vast library of medical knowledge, combine it detailed knowledge of each person’s genome and health conditions, and diagnose each individual patient’s conditions with perfect accuracy, and proscribe corresponding treatments optimally. But until we understand how the human body in that level of scientific detail, medicine will always be an “art” – an art informed by science, perhaps, but not science per se.
Just as an expert sailor can learn the art of sailing by the feel of the winds, boat, and waters without formal knowledge of physics, mathematics, fluid dynamics or materials science – just as an adept artist can learn to paint master pieces without direct knowledge of material science, neurosciences or optics – so can a skilled practitioner learn to practice medicine without grounding every aspect of his art in biochemistry or molecular biology.
It’s far too early to eulogize about TCM … or any specific schools of non-Western medicine … on grounds of “science” and “objectivity” … far too premature … and somewhat hypocritical as well.
- From a wikipedia entry, a straw man is a common form of argument and is an informal fallacy based on giving the impression of refuting an opponent’s argument, while actually refuting an argument which was not advanced by that opponent. ↩
- TCM is inherently personalized. For example, as this WebMD article notes: Research in China and worldwide has shown Chinese medicine to be helpful for many types of illness. Because Chinese medicine differs from Western medical practice in diagnosis and treatment methods, it is difficult to apply Western scientific standards to it.
For example, in Western medical practice, any two people with a similar infection (such as sinusitis) may be treated with a standard course of antibiotics. In Chinese medicine, each person might receive a different treatment for the same illness depending on the person’s own qi and yin-yang balance. ↩
- official abstract here ↩