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Science in medicine: Too much or too little and too limited in scope?
Science in Medicine: Too Much or Too Little and Too Limited in Scope?
LEON EISENBERG,
M.D.
Boston, Massachusetts
Contrary to the common assertion that there is too much science in medicine, it is precisely the application of the natural sciences in the clinic that has enhanced the diagnostic and therapeutic powers of the physician. Much of the criticism of science in medicine mistakes the technology made possible by science, and the way that technology is employed, for science itself. What has hampered progress is too narrow a view of the sciences relevant to medicine. The concepts and methods of the social sciences must be integrated into medical education if physicians are to be enabled to respond effectively to illness as a human experience. Nonetheless, without major changes in the social context of medical practice, efforts to improve performance through curriculum reform will be futile. It has become commonplace to hear it said, not only by the laity, but by medical students and physicians as well, that there is too much science in medical education. Indeed, some teachers of basic science believe such a view underlies Rrys~ciiansfor the 2 Ist Century, the report of the Panel on the General Professional Education of the Physician and College Preparation for Medicine. That interpretation was specifically rejected in the commentary on the report adopted by the Executive Council of the American Association of Medical Colleges [I], but many academics remain uneasy. The public seems to yearn for the icon of the physician portrayed in Sir Luke Fildes’ “The Doctor,” a physician, let us remember, who could do little more than be a comforting presence at the bedside while his young patient’s illness ran its course. Still, are those of us who celebrate the contribution of science to medicine merely deluding ourselves that the recent history of clintcal medicine is one of progress? Why, in John Knowles’ [2] trenchant phrase, are we “doing better and feeling worse”? APPLICATION OF SCIENCE TO THE CLINIC
From the Department of Social Medicine and Health Policy, Harvard Medical School, Boston, Massachusetts. This work was presented in part at a Conference on Biopsychosocial Medicine, May 13, 1987, Wickenburg, Arizona, and is to be published as a chapter in White KL, ed: The task of medicine: dialogue at Wickenburg. Palo Alto: Henry J. Kaiser Family Foundation (in press). Requests for reprints should be addressed to Dr. Leon Eisenberg, Department of Social Medicine and Health Policy, Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts 02115. Manuscript submitted November 12, 1987, and accepted November 16, 1987.
Paul Beeson [3] undertook the instructive task of comparing the treatments recommended in the first (1927) edition of Cecil’s Textbook of Medicine with those in its 14th (1975) edition. By contemporary standards, Beeson rated the value of 60 percent of the remedies in the first edition as harmful, dubious, or merely symptomatic; only 3 percent provided fully effective treatment or prevention. In the 46-year interval between the two editions, effective regimens had increased seven-fold and the dubious ones had decreased by two-thirds. The motor behind these accomplishments has been the systematic application of the basic biomedical sciences to the investigation of disease. Although research in the natural sciences began to exert a
March
1988
The American
Journal
of Medicine
Volume
84
483
LEON EISENBERG,
M.D.
Boston, Massachusetts
Contrary to the common assertion that there is too much science in medicine, it is precisely the application of the natural sciences in the clinic that has enhanced the diagnostic and therapeutic powers of the physician. Much of the criticism of science in medicine mistakes the technology made possible by science, and the way that technology is employed, for science itself. What has hampered progress is too narrow a view of the sciences relevant to medicine. The concepts and methods of the social sciences must be integrated into medical education if physicians are to be enabled to respond effectively to illness as a human experience. Nonetheless, without major changes in the social context of medical practice, efforts to improve performance through curriculum reform will be futile. It has become commonplace to hear it said, not only by the laity, but by medical students and physicians as well, that there is too much science in medical education. Indeed, some teachers of basic science believe such a view underlies Rrys~ciiansfor the 2 Ist Century, the report of the Panel on the General Professional Education of the Physician and College Preparation for Medicine. That interpretation was specifically rejected in the commentary on the report adopted by the Executive Council of the American Association of Medical Colleges [I], but many academics remain uneasy. The public seems to yearn for the icon of the physician portrayed in Sir Luke Fildes’ “The Doctor,” a physician, let us remember, who could do little more than be a comforting presence at the bedside while his young patient’s illness ran its course. Still, are those of us who celebrate the contribution of science to medicine merely deluding ourselves that the recent history of clintcal medicine is one of progress? Why, in John Knowles’ [2] trenchant phrase, are we “doing better and feeling worse”? APPLICATION OF SCIENCE TO THE CLINIC
From the Department of Social Medicine and Health Policy, Harvard Medical School, Boston, Massachusetts. This work was presented in part at a Conference on Biopsychosocial Medicine, May 13, 1987, Wickenburg, Arizona, and is to be published as a chapter in White KL, ed: The task of medicine: dialogue at Wickenburg. Palo Alto: Henry J. Kaiser Family Foundation (in press). Requests for reprints should be addressed to Dr. Leon Eisenberg, Department of Social Medicine and Health Policy, Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts 02115. Manuscript submitted November 12, 1987, and accepted November 16, 1987.
Paul Beeson [3] undertook the instructive task of comparing the treatments recommended in the first (1927) edition of Cecil’s Textbook of Medicine with those in its 14th (1975) edition. By contemporary standards, Beeson rated the value of 60 percent of the remedies in the first edition as harmful, dubious, or merely symptomatic; only 3 percent provided fully effective treatment or prevention. In the 46-year interval between the two editions, effective regimens had increased seven-fold and the dubious ones had decreased by two-thirds. The motor behind these accomplishments has been the systematic application of the basic biomedical sciences to the investigation of disease. Although research in the natural sciences began to exert a
March
1988
The American
Journal
of Medicine
Volume
84
483