For the past two weeks I have had the pleasure of having a 3rd year medical student doing a rotation here in my medical practice. Be clear, do not infer or guess anything else; he was a very bright, motivated, honest and hardworking example of the species.
Having him here was my privilege. I relearned a painful lesson that matters on a global scale.
Medical education as it is currently taught is a terrible failure at providing the kind of education one needs in the current socioeconomic environment. Let me explain.
A graduate of any American medical school is a wonder of competence and knowledge about triage. I use that seemingly limited term intentionally. If you suffer trauma, cancer, a sudden near cardiac death, or many of the typical infectious disease scourges of history then right here right now American medical schools turn out the best technicians that money, brains, and power can provide. We should all be grateful for that; I know I am.
However, if you suffer from the statistically most common and practically more serious diseases, such as high blood pressure or diabetes and its sequela like amputations, blindness and heart attacks or mechanical pain of the back and shoulders, to offer a very short list of mechanical woes, then you are in the wrong place at the wrong time and in the hands of someone who doesn’t even really know what is wrong with you or what to do about it. ‘Cut here, take this’ is almost always the wrong approach and yet the most common advice.
Strong statements. I make them having just worked with a wonderful young man who incorporates all of the traits you would ever hope to find in a future physician to minister to just such a list of problems.
On questioning he summarized just how much formal education he had received about exercise, nutrition, tranquility, relaxation, spiritual discipline, or how to tailor the processes that address these issues to each genetic and cultural substrate. His answer? The sum total of educational hours devoted to these topics was less, embarrassingly less, than 10 hours in his entire two years of basic science and none, really, so far in his clinical rotations. To vex me and your future even more, he attends an institution probably more attuned to these issues than most.
Well, there goes any chance I had of ever again being asked to address a medical school class. Well, it was fun before but not worth being shy about my opinion on this important issue.
Part of the problem is conceptual and lies at the heart of what biomedical science believes constitutes research, I will address this, and part of it is practical and historical.
The conceptual or theoretical problem stems from the early days of human and veterinarian research. The short version, hopefully adequate for here, is that the whole experimental model was premised on the idea of observing a certain, necessarily limited, physiological process, producing insulin, for example, and then finding a substance that reproducibly mimicked that function; something insulin-like. Once that was found you put it in a pill and sold it; an example of this class of drugs works on the ATP sensitive potassium channels and increases insulin secretion in adult onset diabetics. The problem is more insulin is bad for you; the use of this type of drug, going on now for decades, is for most people most of the time worse than the blood sugar it helps to control. Well, that should be easy to fix you might think; just change the effect you are looking for; in this case not more insulin and lower glucose but being less dead and with better kidneys. This change, what constitutes the proper end point of testing, is going on as I write but it truly is a case of rearranging the deck chairs on the Titanic.
It doesn’t change the research and education paradigm to look for the detailed mechanisms of biological change inherent in the human condition, physiology and psychology. Knowing how to do this, heck even knowing that you should do this is almost nowhere to be found in the research literature or the medical educational process.
The ever faithful phrase ‘eat right and exercise’ does not empower the researcher to analyze deeply the behaviorally modifiable pathways of energy use and production for example. Advocating societal rules and laws to outlaw certain behaviors does nothing to equip that loneliest of all, that one doctor with that one patient, giving detailed advice and direction on how to save and improve that patient’s life. Even worse, such generic advice, remember ‘low fat’ for 50 years killed millions, such generic advice is always, always, I said always, the wrong advice for someone, sometimes for many, see above ‘low fat’ advice, and not helpful for those for whom it might actually be the right advice because almost no one, with good reason, any longer believes the claims of institutions.
Take calcium, don’t take calcium, take Vitamin D or C or walk or run, or does that arm numbness that needs a neurosurgeon really just need very careful posture training and the information and direction to believe such a change is possible? Well, don’t even ask these questions and be sure to give routine, reproducible and rigid advice to everyone be they short, tall, thin and frail or large and strong. That is the medical way.
Well, that was a quick pass at the conceptual and theoretical problem. Now for a short pass at the practical. Part of the problem is the legal environment; if you work outside the ‘standard of practice’ that is ‘what everyone else does’ then you can be sued, driven nearly to the brink of crazy and actually over the brink of financial ruin. How could I, even in good conscience, advise a medical student to think on his own? The paradigm will never change if the price of doing so is a near death experience. Have pity on my poor profession. Please.
Another aspect of the practical, there are many aspects to the practical limits of changing institutional medicine, another aspect is that the triage model made so much sense for so long that there is an amazing institutional inertia to overcome. Imagine, if you will, how wonderful it was to have antibiotics in the first decades of their widespread use outside of war; medicines seemed almost miraculous; the model that produced them seemed like alchemy and the practitioners, the dispensers like priests of the new truth. It takes generations to change such a revered model. Well, now is the time.
Help me do this. I know, right down to graphs, models, and deep detail how to do this; the research model, the pedagogical model, the practice model. While my ego, in this, obviously knows no bounds, my scope of action, my financial resources are very earthbound. I’m poor old me shouting into the wind.
The answer is neither ‘alternative medicine’ nor ‘complimentary medicine.’ It is medicine done right: logicodeductive, Western-science based research, teaching and practitioners directed at knowing, teaching and practicing the deep wisdom, chemistry and electromechanical realities of the human body.
Expect more, demand more. Insurance to pay for more trips to the doctor to take another pill is the worst thing to ask for; ask for the whole institution to change. As Mahatma Gandhi said: “be the change you wish to see in the world.” Not more drugs, not more surgery, not more supplements, but better days and nights and families and exercise and food and don’t forget the love. Lots of that.
Smile, Have Fun, God Speed,