Tuesday, October 29, 2019

"I know nothing"

Below is an excerpt from an interview with a Harvard hospital (BIDMC) based physician named Adam Rodman. What Rodman says is useful to keep in mind when considering debates over science. Rodman also has an enjoyable podcast called Bedside Rounds on medical history. His latest episode is titled "I know nothing" in which he details in a grand rounds lecture what he says in this interview.

Studying history has changed my entire approach to practicing medicine. So first, at a concrete level, it helps me question dogma. So, like I was mentioning before, the study of medical history will quickly reveal that so much of what we're taught in medical school stands on shaky foundations.

One of the classic examples is the definition of a “fever”. We’re all taught that a fever is 100.4 or 38 degrees Celsius. It’s scientific simplicity. You’ll even see some of our colleagues confidently announce, “it’s either a fever or it’s not!” and make fun of patients who say, “I run low, so 99.7 is a fever for me.” But even a cursory examination of history will show that this was based on mid-19th century data from Wunderlich, using an esoteric thermometer, axillary temperatures, unclear data analysis, and a, let’s just say...an imprecise method of measuring data. Moreover, numerous studies have shown that body temperatures are not only lower, but vary throughout the day — and in fact, the most important thing appears to be variation from the patient’s own baseline. It turns out, in this case, that taking an historical approach is, in fact, taking the scientific approach, critically appraising data that has real clinical impact. And while we’re at that, taking an historical approach also shows that our patients’ own experiences are probably accurate — they probably do “run low” because 98.6 F is high!

And once you start to realize this with one subject, you realize that a whole spate of medical knowledge is equally shaky or contingent. You’ll discover arbitrary drug dosing and durations, very real epistemological concerns about our ability to know what causes disease, and even reason to doubt some randomized controlled trials — I don’t want to turn this interview into a lecture about skepticism, but I’ll add that the more you read about the fragility index, the more you’ll see that the basis of our knowledge is often far shakier than we’d like to admit.

I don’t want to say that a study of history has made me cynical — it hasn’t; if anything, I’m far more aware of how much good we can do now compared to past eras. But it’s made me very humble about the limits of our knowledge. And it’s made me focus on many of the older qualities of being a physician — compassion, good communication skills, and being at the bedside.

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