Nov 23, 2017

There's none so blind as those who will not see

Unlike popular belief the advancement of teaching physicians to think like scientists, an unmet goal to this day, began before the 1910 Flexner Report. In the mid to late 1800's American physicians went to Germany to "study the fundamental medical sciences and learn the techniques of experimental medical research" reports medical historian Kenneth Ludemerer.1 At that time physicians in the U.S. did not find the relevance of laboratory research in their practice and were mostly concerned with clinical medicine. After graduating from medical school Henry P. Bowditch, nephew of Henry Ingersoll Bowditch, went to study in Germany and later returned to the U.S. and became dean of Harvard Medical School from 1883 to 1893.2 During his tenure, he advanced medical education by introducing laboratory research and with it created one of the best programs in the country at that time. In 1911 one of his students, Charles S. Minot, wrote,

He stood for the highest ideals of progress and maintained always that the old-fashioned "practical" physicians must be replaced by men scientifically trained and animated by the scientific spirit.3

In the late 1800's medical knowledge grew exponentially as a result of new scientific discoveries and modifications in diseases and treatments relevant to daily clinical practice. Also, medical information was spreading at a faster rate than before thanks to the help of new communication technologies. "Information overload from proliferating medical knowledge was noted by John Shaw Billings in 1881," Richard Lehman wrote in a recent article.4 According to Ludmerer, the physicians who returned from Germany were "versed in both bedside medicine and the application of the knowledge and techniques of the fundamental sciences to the study of human diseases."1 These novel practitioners, clinical scientists, were placed in the clinical department of medical schools where they shared the responsibility of teaching the new generations of physicians. Clinical scientists put less emphasis on didactic lectures, rote memorization, textbook knowledge, and authority, instead, medical education focused on the development of "problem solvers and critical thinkers who knew how to discover and evaluate information for themselves."5 These were also characteristics emphasized by the philosopher and educator John Dewey who, in 1910, wrote that science "has been taught too much as an accumulation of ready-made material, with which students are to be made familiar, not enough as a method of thinking, an attitude of mind, after the pattern of which mental habits are to be transformed."6

Sience as way of thinking was also emphasized by William Osler7 and W. S. Thayer, a former student of Osler, who in 1932 wrote: "our main objects should be to impress on the student that the clinician must reason for himself in a scientific fashion."8 The misunderstanding of science as more than memorization of facts was also addressed by Carl Sagan who wrote, "science as a method rather than a body of knowledge is not widely appreciated outside of science or indeed in, I’m sorry to say, in some of the corridors inside of science."9 In his 1910 report Abraham Flexner proposed training physician in scientific reasoning and discouraged the parrot-like memorization of facts. Flexner understood both fields and helped dispell the false dichotomy myth between the two when he wrote: "progress of science and the scientific or intelligent practice of medicine employ, therefore, exactly the same technique."10 Unfortunately, the misunderstanding of Flexner's conceptual reform continues to this day, a problem Kenneth Ludmerer has tried to clarify. One of Flexner's main goals according to Ludmerer was to develop "clinicians who could reason scientifically in the care of patients" with the understanding that a diagnosis was addressed as a hypothesis to be tested.1

The text above demonstrates that current hype about information overload, change in medical knowledge, and new technologies of communication are not new issues in medicine and medical education. Unfortunately, the medical curriculum continues to be stuffed with irrelevant information while not offering a strong background in how science works, current problems in publication, and questionable scientific practices. This creates an intellectual vulnerable environment where unfounded claims may be adopted without close scrutiny. This is something Carl Sagan warned us about when he wrote: "If you've never heard of science (to say nothing of how it works), you can hardly be aware you're embracing pseudoscience."11 Understanding science's critical method, instead of just accepting its products, is of utmost priority, Sagan alluded.11 Richard Feynman also wrote that scientific integrity is important if we don't want to make a fool of ourselves and/or others.12

The undermining of science as an inquiry process and the inappropriate use of its technical terms were addressed by Alan Sokal when he, and co-author Jean Bricmont, wrote Fashionable nonsense. They state "in our opinion, is the adverse effect that abandoning clear thinking and clear writing has on teaching and culture. Students learn to repeat and to embellish discourses that they only barely understand. They can even, if they are lucky, make an academic career out of it by becoming expert in the manipulation of an erudite jargon."13 The misunderstanding and misuse of science are more common than we can ever imagine, especially if we are not trained to learn how it works.14,15,16 The friction between the sciences and the humanities continues to this day as illustrated in a recent exchange between Steven Pinker and Leon Wieseltier. Pinker states that sources of errors in our beliefs include "faith, revelation, dogma, authority, charisma, conventional wisdom, the invigorating glow of subjective certainty" and what needs to be encouraged is "skepticism, open debate, formal precision, and empirical tests."17 In a different article, when prompted about adopting new technology Pinker wrote,

Take the intellectual values that are timeless and indisputable: objectivity, truth, factual discovery, soundness of argument, insight, explanatory depth, openness to challenging ideas, scrutiny of received dogma, overturning of myth and superstition. Now ask, are new technologies enhancing or undermining those values? And as you answer, take care to judge the old and new eras objectively, rather than giving a free pass to whatever you got used to when you were in your 20s.18

Without understanding how science works current fads, labels, and pseudo-debates about technology and information overload only serve as distractions from the real debate: Why isn't learning how science works a top priority in medical education? How can physicians claim expertise in taking care of patients without understanding how science works and its current problems? Also, doesn't expertise include mastering a domain's history and philosophy, two subjects severely absent in medical education? Other subjects absent in medical education include statistics, decision theory, and cognitive science. Anders Greenland has raised some related issues, he states,

I believe other educational omissions besides causal models have been major contributors to the currently lamented research ‘‘crises’’. Two topics in dire need of early and continuing education are basic logic and cognitive psychology (Gilovich et al. 2002; Lash 2007). Especially important are the logical and statistical fallacies manifested in routine misinterpretations of basic statistics, and the biases built into current teaching and practice that encourage these fallacies (Box 1990; Greenland 2011, 2012b, c, 2016; Greenland et al. 2016). Their persistence attests to the fact that degrees in statistics and medicine do not require substantial training in or understanding of scientific research or reasoning, but nonetheless serve as credentials licensing expressions of scientific certainty (Greenland 2011, 2012c).19

There's none so blind as those who will not see



References:

  1. Ludmerer, K., Let me heal: The opportunity to preserve excellence in American medicine., 2015
  2. "Henry Pickering Bowditch.", Wikipedia: The Free Encyclopedia. Wikimedia Foundation, Inc. 22 July 2004, Accessed November 22, 2017
  3. Minot, C. S., Henry Pickering Bowditch., Science, 1911 Apr 21;33(851):598-601.
  4. Ludmerer, Kenneth M. "Commentary: Understanding the Flexner Report." Academic Medicine 85.2 (2010): 193-96.
  5. Richard Lehman. Sharing as the Future of Medicine. JAMA Intern Med. 2017;177(9):1237–1238. doi:10.1001/jamainternmed.2017.2371
  6. Dewey, J., Science as Subject-Matter and as Method., Science, vol. 31, no. 787, 1910, pp. 121–127
  7. Osler, W., The old humanities and the new science., Br Med Jrnl, July 5, 1919, 2(3053):1-7
  8. W. S. Thayer,. Thoughts on medical education in the United States., JAMA. 1932;99(1):3–9. doi:10.1001/jama.1932.02740530005002
  9. Kerry Klein and Sarah Crespi, Science 12 Oct 2012: Vol. 338, Issue 6104, pp. 274, DOI: 10.1126/science.338.6104.274-b
  10. Flexner, A., Medical education in the United States and Canada., 1910
  11. Carl Sagan, The Demon-Haunted World: Science As a Candle in the Dark, 1996
  12. Feynman, R., Cargo Cult Science., 1974
  13. Sokal, A., Bricmont, J., Fashionable Nonsense: Postmodern intellectual's abuse of science., 1998
  14. Ioannidis, J., Evidence-based medicine has been hijacked: a report to David Sackett., J Clin Epidemiol. 2016 May;73:82-6. doi: 10.1016/j.jclinepi.2016.02.012.
  15. Ioannidis, J., Hijacked evidence-based medicine: stay the course and throw the pirates overboard., J Clin Epidemiol. 2017 Apr;84:11-13. doi: 10.1016/j.jclinepi.2017.02.001.
  16. Ioannidis, J., How to survive the medical misinformation mess., Eur J Clin Invest. 2017 Nov;47(11):795-802. doi: 10.1111/eci.12834.
  17. Pinker, S., Science is not your enemy., New Republic, August 6, 2013, Accessed November 23, 2017
  18. Pinker, S., The age of the informavore., edge, October 25, 2009, Accessed November 23, 2017
  19. Sander Greenland, For and Against Methodologies: Some Perspectives on Recent Causal and Statistical Inference Debates. Eur J Epidemiol. 2017 Jan;32(1):3-20.

1 comment:

  1. If, as you point out, so much emphasis has been placed on making medical education more scientific, why do you think it has not panned out? Also, if Germany was the model, what happened to German medicine?

    ReplyDelete

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