Sunday, 21 August 2011

The frontiers of knowledge - the unspoken truth

Something is afoot in the world of chronic fatigue syndrome - an article in today’s Observer highlights new levels of intimidation by activists who disagree with some of the recent evidence that has been published on the causes and the treatment of Chronic Fatigue Syndrome (see What particularly struck me was the story of abuse suffered by the authors of a Lancet article which suggested that Cognitive Behavioural Therapy could help relieve the symptoms of ME. It turns out that rather than being reassured at the availability of effective treatment, some ME sufferers were enraged that someone could have the gall to suggest that there might be a psychological component to their illness.

Such a reaction belies the social view of illness that prevails: we live in a world that is addicted to a scientific model of health and illness, and when explanations fall outside of this model, they tend to rebuffed or accepted with reluctance. This is well captured by the French - go to a French pharmacy, and you will see people queuing up to buy bucket loads of drugs for all sorts of ailments. Until fairly recently, French citizens could go and see as many doctors they liked for a particular problem (presumably so that they could find the doctor that gives them the answer they are looking for). This has led to a health care system in which the patients have created a tendency to over investigate, over prescribe and over operate. In America, the demand is driven by doctors being paid for on a fee-for-service basis, but the outcome is the same.

And I don’t think we are much different in the UK: empricism and evidence-based medicine are our watch words, and yet I am not sure that we are as honest as we should be about how uncertain our knowledge often is. For example, when dealing with acute strokes, we still have no really clear idea about how blood pressure should be controlled - we continue to fly blind, without the kind of evidence that we really need to inform our decisions. And the flip side is also true - there are many examples of failure to implement evidence that we know makes a difference: for example, we have known for years that prophylaxis for thrombo-embolism can save thousands of lives a year, and yet it takes a government target to actually get us to focus on doing it right.

Clearly, there have been massive improvements in the quality of diagnostics and treatments available to us, but often I feel that the fact that we have a better understanding of some things persuades us that we have a better understanding of everything. I have met a few renal physicians who make out that there is nothing about the human body that they do not understand, and the only way that I can explain such breathtaking levels of arrogance is to say that they must have allowed the fact that they have a good understanding of the workings of the kidneys to mean that they must also have a good understanding of how all the organs work, through some process of physiological extrapolation.

I know that the social views of health and illness are influenced by a great many factors, but surely doctors are important opinion formers, and perhaps there is greater scope for us to admit that our knowledge is limited, particularly when it comes to psychological and psychiatric illness. I have often wondered whether the limits of our knowledge in this field are due to imperfect data and the absence of the right hypothesis, or due to a more fundamental limitation of our scientific model to allow us to understand. It will be interesting to find out.

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