Sunday, July 30, 2017

Medicine & Orthodoxy: Heresy & Knowledge!

It is often inconceivable that a small bird of the warbler family can play host to the Cuckoo, which obviously outsizes it by at least three to four times.

Collared Redstart©2008 Am Ang Zhang
This picture was taken in Panama, famed for the abundance of different bird species and as far as I know there are 14 species of Cuckoos in the country.

“It is as foolish to chuck out the old as it is to fully embrace the new.” 

My early guru was referring to the changes happening in the field of psychiatry as the new benzodiazepines were being introduced. How right he was and the same view could well apply to other branches of medicine as well as psychiatry today.

“There is much we can learn from the past. One may even save a life.” 
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
We have come full circle to some ancient Chinese CPR practice going as far back as 403 B.C.

I mentioned in passing in my book “The Cockroach Catcher” Jenner’s observation and the stir it caused. When I visited his home in Glouscestershire, the curator of the small museum, who was extremely knowledgeable, took pride in telling us how Jenner’s great work on Cowpox vaccination upset the medical establishment on the one hand, and how his observation on the murderous ways of the Cuckoo newborns upset the gentlemanly world of the Ornithologists on the other. It was the Royal Society that awarded him a Fellowship for his keen observation.

©2015 Am Ang Zhang
His work on Cowpox vaccination in the prevention of Smallpox was met with hostile responses. The medical world that was dominated by London at the time could not accept that a country doctor had made such an important discovery. Jenner was publicly humiliated when he brought his findings to London. However, what he discovered could not be denied and eventually his discovery was accepted – a discovery that was to change the world.

It is worth having another look at Brian Martin’s view on:
Dissent and heresy in medicine.

Social Science and Medicine, vol. 58, 2004, pp. 713-725.

Brian Martin is Professor of Social Sciences in the School of Social Sciences, Media and Communication at the University of Wollongong, Australia.

Brian uses models on politics and religion to illustrate the model of orthodoxy versus dissent/heresy. You can read his views here.

He noted that challenges from the inside - heresy and dissent - are far more threatening to an establishment than outside challenges. This is true of all establishments, not least medicine.

But why should it be? In a more co-operative environment, these differences become opportunities for learning. Medicine in particular will not progress if all dissenting views are suppressed and smallpox may have indeed killed for another 20 or 30 years or more.

After the discussion on politics and religion he turned his focus medicine.
He then analysed some methods of domination in medical research:

• State power
• Training
• Restriction on entry
• Career opportunities
• Research resources
• Editorial control
• Incentives
• Belief system
• Peer pressure

“Training to become a doctor is a process of enculturation and indoctrination. The heavy work-load of memorisation and intensive practical work discourages independent thinking.”

“Examinations provide a screening process that encourages orthodoxy. For those who pursue a research path through the PhD, the process of writing a thesis or dissertation further weeds out those who might challenge orthodoxy. Some dissidents and even fewer heretics may slip through the training and credentialing system, but then there are few desirable career paths.”

“In order to have a chance, dissidents and heretics need to understand that science and medicine are systems of knowledge intertwined with power, and that if their alternative relies entirely on knowledge, without a power base, it is destined for oblivion.”

FremantleMedical Heresy & Nobel

Peptic ulcer – an infectious disease!
In 2005, Nobel Prize in Physiology or Medicine went to Barry Marshall and Robin Warren, who with tenacity and a prepared mind challenged prevailing dogmas. By using technologies generally available (fibre endoscopy, silver staining of histological sections and culture techniques for microaerophilic bacteria), they made an irrefutable case that the bacterium Helicobacter pylori is causing disease. By culturing the bacteria they made them amenable to scientific study.
In 1982, when this bacterium was discovered by Marshall and Warren, stress and lifestyle were considered the major causes of peptic ulcer disease. It is now firmly established that Helicobacter pylori causes more than 90% of duodenal ulcers and up to 80% of gastric ulcers. The link between Helicobacter pylori infection and subsequent gastritis and peptic ulcer disease has been established through studies of human volunteers, antibiotic treatment studies and epidemiological studies.
Difficult 10 years:
The medical establishment was difficult to persuade - everyone accepted that ulcers were caused by acid, stress, spicy foods, and should be treated by drugs blocking acid production. The big Pharmas were not happy to see any change as patients will have to take medication for life.

He went to the US to try and persuade the US doctors.

A big battle was still going on. I went to America to fight the battle there, because unfortunately the American medical profession was extremely conservative: ‘If it hasn’t happened in America, it hasn’t happened’. We needed people in the United States to take the treatment which we had developed.

“Ideas without precedent are generally looked upon with disfavour 
and men are shocked if 
their conceptions of an orderly world are challenged.” 

Bretz, J Harlen 1928. Dry Falls-Thinking Outside The Box

Also, thinking out of the box can be a good idea. Sometimes it’s better not to know all the dogma, all the things about a very difficult disease. If it’s very difficult, that means people have been working on it for years and they haven’t figured out the cure, which means they haven’t figured out the cause. So having all that knowledge that’s been accumulated in the last 10 or 20 years is really not an advantage, and it’s quite good to go and tackle a problem with a fresh mind when no-one else has had any luck.
                                                                                      Barry Marshall

From a doctor friend:

The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.

Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.

Objectively, a reader outside of the UK would find some chapters in the book intriguing because a lot of space was devoted to explaining the jargons (statementing, section, grammar schools) and the NHS administrative systems. Of course, your need to clarify the peculiar UK background of your clinical practice is understandable.

Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.           More>>>>

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

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