A LARGELY STAND-ALONE DISCUSSION FROM THE APPENDIX OF MY UPCOMING BOOK ON OBESITY:
I have concerns about how the academic elite of medicine develop clinical practice guidelines intended to direct the care given by other physicians, as well as to inform insurers what ought and ought not be covered. There is a special need for scrutiny in this era where legitimate cost-containment, coupled with the increasing influence of third party payers, like federal and state governments, and the massive private insurance industry—which prioritize costs often over the wants and needs of patients and doctors—are driving “evidence-based medicine” and risk denying patients care and treatments not anointed by the “evidence.”
By this I mean a certain treatment or test, unless called for by a few top docs, at major medical schools, in their published guidelines, or supported by excellently conducted research reported in a scientific journal, might not be available to real-world patients. Perhaps worse, I think physicians today come out of training cowed by these top experts, devaluing their own thoughts and practice styles, subjugating them to evidence-based (“cookbook”) medicine. Keep in mind that every licensed medical doctor has an undergraduate degree, a four-year medical degree, and usually three-to-five-or-more years of post-graduate training. Such professionals are well trained enough to formulate their own preferred ways of managing patients, if encouraged and allowed (that is, paid) to do so, which they are often not.
Now, don’t misunderstand. Well-conducted research and peer-reviewed papers and clinical practice guidelines are necessary to good medicine. But once that information is out there, it should be the independent physician figuring out how to apply that data to each unique patient. No matter how good the research and conclusions, they can never anticipate all the variables confounding a real-world situation. And even if evidence-based medicine’s answers could be accepted as 100 percent valid, there will never be adequate evidence to answer every question faced by every physician in the course of one routine week.
Our original question from the text was:
Why did it take until less than ten years ago for low-glycemic-index dieting to get taken scientifically seriously? Smart people were talking about it. Why didn’t opposing theories get a fair shot at the height of the gung-ho all-fat-is-bad days? Isn’t the job of science to consider all possibilities, test for them, throw out ideas proved wrong, and refine ideas proved right, until gradually, inexorably we approach some great universal truth?
I used to think so.
Yet my experience has not always shown science to work that way.
There are several questions—low-fat versus low-carb being one, but there are others—in just my subspecialized area of medicine, where it seems to me experts wear bizarre blinders about even contemplating dogma-threatening new ideas. And I stumbled upon an explanation—or at least, objective confirmation of what I’ve observed—a mere few weeks prior to this writing.
Harvard-trained physicist, turned historian and philosopher of science, Thomas S. Kuhn (1922–1996) published a landmark book in 1962 titled, The Structure of Scientific Revolutions. In it, he threw out the notion that I had, and most of us have: That romantic view of science as, in the words of North Carolina State University philosopher, Jeffery L. Kasser, “straightforwardly cumulative, progressive, or truth-tracking.”
This traditional, romanticized image of science includes an “openness to criticism,” an almost obsession with disproving itself, that Kuhn felt did not exist in real-world science.
Normal science, according to Kuhn is governed instead by paradigms. A paradigm is an object of consensus, not open to criticism. The paradigm is assumed to be correct. It is dogma. It determines the puzzles to be solved, which involve fitting nature into the paradigm, and defines the expected results and the standards for evaluating those results. Science doesn’t seek truth, it seeks to prove the paradigm. “Dietary fat is unhealthy and the main promoter of obesity” was the paradigm in our discussion, and few mainstream researchers were allowed to, funded to, do research other than to prove that proposition. Read More
I have concerns about how the academic elite of medicine develop clinical practice guidelines intended to direct the care given by other physicians, as well as to inform insurers what ought and ought not be covered. There is a special need for scrutiny in this era where legitimate cost-containment, coupled with the increasing influence of third party payers, like federal and state governments, and the massive private insurance industry—which prioritize costs often over the wants and needs of patients and doctors—are driving “evidence-based medicine” and risk denying patients care and treatments not anointed by the “evidence.”
By this I mean a certain treatment or test, unless called for by a few top docs, at major medical schools, in their published guidelines, or supported by excellently conducted research reported in a scientific journal, might not be available to real-world patients. Perhaps worse, I think physicians today come out of training cowed by these top experts, devaluing their own thoughts and practice styles, subjugating them to evidence-based (“cookbook”) medicine. Keep in mind that every licensed medical doctor has an undergraduate degree, a four-year medical degree, and usually three-to-five-or-more years of post-graduate training. Such professionals are well trained enough to formulate their own preferred ways of managing patients, if encouraged and allowed (that is, paid) to do so, which they are often not.
Now, don’t misunderstand. Well-conducted research and peer-reviewed papers and clinical practice guidelines are necessary to good medicine. But once that information is out there, it should be the independent physician figuring out how to apply that data to each unique patient. No matter how good the research and conclusions, they can never anticipate all the variables confounding a real-world situation. And even if evidence-based medicine’s answers could be accepted as 100 percent valid, there will never be adequate evidence to answer every question faced by every physician in the course of one routine week.
Our original question from the text was:
Why did it take until less than ten years ago for low-glycemic-index dieting to get taken scientifically seriously? Smart people were talking about it. Why didn’t opposing theories get a fair shot at the height of the gung-ho all-fat-is-bad days? Isn’t the job of science to consider all possibilities, test for them, throw out ideas proved wrong, and refine ideas proved right, until gradually, inexorably we approach some great universal truth?
I used to think so.
Yet my experience has not always shown science to work that way.
There are several questions—low-fat versus low-carb being one, but there are others—in just my subspecialized area of medicine, where it seems to me experts wear bizarre blinders about even contemplating dogma-threatening new ideas. And I stumbled upon an explanation—or at least, objective confirmation of what I’ve observed—a mere few weeks prior to this writing.
Harvard-trained physicist, turned historian and philosopher of science, Thomas S. Kuhn (1922–1996) published a landmark book in 1962 titled, The Structure of Scientific Revolutions. In it, he threw out the notion that I had, and most of us have: That romantic view of science as, in the words of North Carolina State University philosopher, Jeffery L. Kasser, “straightforwardly cumulative, progressive, or truth-tracking.”
This traditional, romanticized image of science includes an “openness to criticism,” an almost obsession with disproving itself, that Kuhn felt did not exist in real-world science.
Normal science, according to Kuhn is governed instead by paradigms. A paradigm is an object of consensus, not open to criticism. The paradigm is assumed to be correct. It is dogma. It determines the puzzles to be solved, which involve fitting nature into the paradigm, and defines the expected results and the standards for evaluating those results. Science doesn’t seek truth, it seeks to prove the paradigm. “Dietary fat is unhealthy and the main promoter of obesity” was the paradigm in our discussion, and few mainstream researchers were allowed to, funded to, do research other than to prove that proposition. Read More