Jul 30, 2017

How does medicine make progress?

As a music major in college we studied among other topics music history, theory, harmony, and performance. I would say this provided a strong background in which to base not only our performance but also our knowledge of how music works. A person can still play music without knowing these, but even if done well that is just mere competence without comprehension. I am grateful to have received a music education that provided tools which allowed me to independently examine my performance and that of others. We were not made theoreticians or historians, but this background knowledge provided a common language with which to examine our private practices, group practices, and music works in history. A person can memorize solos from great musicians and even learn how to improvise over the chord changes of a tune, but that doesn't imply they know the context of a piece of music or even why it works. Learning theory, harmony, history in the context of present and historical performance is not an academic exercise in the abstract, but essential components to understanding music as a profession.

It was interesting then to find that the medical curriculum doesn't place strong emphasis on subjects such as the history of medicine, philosophy of medicine, or subjects pertaining to the understanding how medicine and science work. Reading the history of science and medicine we can find evidence of significant progress and failures, learning about these can illuminate understanding about the why of our current practices. But this is not emphasized in the curriculum and this, I believe, makes it difficult to understand and communicate how medicine makes progress and the rationale of its current practice. One of the major contribution to the history and philosophical progress in the practice of medicine was the Flexner Report. Unfortunately, its contributions continue to be misinterpreted (PMID 20107341) by many to this day. I don't know the exact cause of its misinterpretation, but I would guess it is related to how little the history and philosophy of medicine are emphasized in medical education. Flexner emphasized mastery of the scientific method, exactly what the scientific method is continues to be debated, a debate which also includes the demarcation between science, pseudoscience, and non-science. Although not a philosopher or a scientist, Abraham Flexner was an educator well aware of the scientific attitude and the advances and contributions from science and philosophy. Later in life Flexner founded the Institute for Advanced Studies, an institution that promotes academic freedom and independent-curiosity driven research. He also helped many scientists, including Albert Einstein, come live in the United States.

As mentioned before, what science is and how it works continue to be frequently debated, especially amongst scientists, historians, and philosophers. One of the most cited and well-respected philosopher on this subject is Karl Popper, who determined that criticism is one of the most important habits in science and the progress knowledge. Although his work was not around when Flexner worked on his report they both drew their conclusions from scientists and philosophers. They both learned that science was the most successful knowledge-seeking human endeavor when it comes to understanding how the world works. Karl Popper wrote:

Although I shall confine my discussion to the growth of knowledge in science, my remarks are applicable without much change, I believe, to the growth of pre-scientific knowledge also-that is to say, to the general way in which men, and even animals, acquire new factual knowledge about the world. The method of learning by trial and error-of learning from our mistakes-seems to be fundamentally the same whether it is practised by lower or by higher animals, by chimpanzees or by men of science. My interest is not merely in the theory of scientific knowledge, but rather in the theory of knowledge in general. Yet the study of the growth of scientific knowledge is, I believe, the most fruitful way of studying the growth of knowledge in general. For the growth of scientific knowledge may be said to be the growth of ordinary human knowledge writ large (as I have pointed out in the 1958 Preface to my Logic of Scientific Discovery).

But is there any danger that our need to progress will go unsatisfied, and that the growth of scientific knowledge will come to an end? In particular, is there any danger that the advance of science will come to an end because science has completed its task? I hardly think so, thanks to the infinity of our ignorance. Among the real dangers to the progress of science is not the likelihood of its being completed, but such things as lack of imagination (sometimes a consequence of lack of real interest); or a misplaced faith in formalization and precision (which will be discussed below in section v); or authoritarianism in one or another of its many forms.

Since I have used the word 'progress' several times, I had better make quite sure, at this point, that I am not mistaken for a believer in a historical law of progress. Indeed I have before now struck various blows against the belief in a law of progress, and I hold that even science is not subject to the operation of anything resembling such a law. The history of science, like the history of all human ideas, is a history of irresponsible dreams, of obstinacy, and of error. But science is one of the very few human activities-perhaps the only one-in which errors are systematically criticized and fairly often, in time, corrected. This is why we can say that, in science, we often learn from our mistakes, and why we can speak clearly and sensibly about making progress there. In most other fields of human endeavour there is change, but rarely progress (unless we adopt a very narrow view of our possible aims in life); for almost every gain is balanced, or more than balanced, by some loss. And in most fields we do not even know how to evaluate change. Within the field of science we have, however, a criterion of progress: even before a theory has ever undergone an empirical test we may be able to say whether, provided it passes certain specified tests, it would be an improvement on other theories with which we are acquainted. This is my first thesis. To put it a little differently, I assert that we know what a good scientific theory should be like, and-even before it has been tested-what kind of theory would be better still, provided it passes certain crucial tests. And it is this (meta-scientific) knowledge which makes it possible to speak of progress in science, and of a rational choice between theories.

In a 1978 lecture Popper stated:

This growth [of knowledge], this self-transcendence, has a rational side and a non-rational side. The creation of new ideas, of new theories, is partly non-rational. It is a matter of what is called ‘intuition’ or ‘imagination’. But intuition is fallible, as is everything human. Intuition must be controlled through rational criticism, which is the most important product of human language. This control through criticism is the rational aspect of the growth of knowledge and of our personal growth. It is one of the three most important things that make us human. The other two are compassion, and the consciousness of our fallibility.

Popper, K., Three worlds, The Tanner Lecture on human values., Delivered at The University of Michigan. April 7, 1978

In his 1959 book The Logic of Scientific Discovery, he emphasized what he called critical rationality; self criticism, knowing what others think, and what others have done in the past in order to have a critical discussion. He wrote:

I have italicized the words ‘rational discussion’ and ‘critically’ in order to stress that I equate the rational attitude and the critical attitude. The point is that, whenever we propose a solution to a problem, we ought to try as hard as we can to overthrow our solution, rather than defend it. Few of us, unfortunately, practise this precept; but other people, fortunately, will supply the criticism for us if we fail to supply it ourselves. Yet criticism will be fruitful only if we state our problem as clearly as we can and put our solution in a sufficiently definite form—a form in which it can be critically discussed.


Among the many methods which he may use—always depending, of course, on the problem in hand—one method seems to me worth mentioning. It is a variant of the (at present unfashionable) historical method. It consists, simply, in trying to find out what other people have thought and said about the problem in hand: why they had to face it: how they formulated it: how they tried to solve it. This seems to me important because it is part of the general method of rational discussion. If we ignore what other people are thinking, or have thought in the past, then rational discussion must come to an end, though each of us may go on happily talking to himself. Some philosophers have made a virtue of talking to themselves; perhaps because they felt that there was nobody else worth talking to. I fear that the practice of philosophizing on this somewhat exalted plane may be a symptom of the decline of rational discussion.


I wish to refer here only to one example of the kind of problem I have in mind: the problem of the growth of our knowledge. A little reflection will show that most problems connected with the growth of our knowledge must necessarily transcend any study which is confined to common-sense knowledge as opposed to scientific knowledge. For the most important way in which common-sense knowledge grows is, precisely, by turning into scientific knowledge. Moreover, it seems clear that the growth of scientific knowledge is the most important and interesting case of the growth of knowledge.

Although certain elements in medical education have not changed since they were put in place via the recommendations by the Flexner Report, this dogmatic approach was not the original intention of the author. Because Flexner understood how science works and how knowledge progresses, he knew his recommendations were only to be in place until better ones emerged. Kenneth Ludmerer, who has written about the report and its common misconceptions wrote:

Many have faulted the Flexner Report for fostering a crowded, inflexible curriculum. Here again, the criticisms have resulted from a misunderstanding of what Flexner actually wrote. In discussing the medical school curriculum, Flexner decried the “absurd overcrowding” produced by 4,000 hours of prescribed work. He warned medical educators against too much rigidity. Medical schools, he argued, must be trusted “with a certain amount of discretion.”1(p76) He believed that “the endeavor to improve medical education through iron-clad prescription of curriculum or hours is a wholly mistaken effort.”1(p76)

Contrary to widespread popular opinion, the Flexner Report was not envisioned by its author as a final document. “This solution,” he wrote, “deals only with the present and the near future,—a generation, at most. In the course of the next thirty years needs will develop of which we here take no account. As we cannot foretell them, we shall not endeavor to meet them.”1(p143) The report thus contained much more flexibility than commonly supposed. It recognized that academic medical centers would need to change as the demands on them changed. Flexner’s specific proposals were designed only to address the problems immediately at hand.


Yet it is certain that Flexner would be at the vanguard of efforts to reform medical education today. As he discussed in his report, medical education is destined to change. He charged each generation of medical educators with the task of adapting medical education to evolving scientific, professional, and cultural circumstances. To Flexner, no educational idea should ever be considered off limits for review, no educational strategy or approach too sacrosanct to revise or discard. He undoubtedly would be disappointed to find so many of his specific recommendations still current a century later, even though today’s physicians face scientific and social conditions far different from those of his own generation.

There is more to a profession than its performance, I learned this from my music studies in college. We acquired the necessary tools and common language to examine our performance and that of others. These tools included not just mastery of the music instrument, but also theory, harmony, and history. A training without understanding its history, philosophy, how it makes progress, and how to examine our performance and that of others is not a profession.

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1. You should attempt to re-express your target’s position so clearly, vividly, and fairly that your target says, “Thanks, I wish I’d thought of putting it that way.
2. You should list any points of agreement (especially if they are not matters of general or widespread agreement).
3. You should mention anything you have learned from your target.
4. Only then are you permitted to say so much as a word of rebuttal or criticism.
Daniel Dennett, Intuition pumps and other tools for thinking.

Valid criticism is doing you a favor. - Carl Sagan