A post came over my twitter stream yesterday (thanks @sara_johnson!) and piqued my attention enough that it actually distracted me from the completely insane Penguins-Flyers NHL playoff series. That automatically makes it worth writing about.
I hate writing a post only to critique another post but sometimes you learn more from ideas that are wrong than from those that are right. My problems, however, start with the title: “Why medicine is not a science and health care is not health.” Definitely eye-catching but a title that doesn’t match the text very closely (particularly when the first two sub-headlines seem to confirm that medicine is, in fact, a science as does a portion of the text). A minor issue maybe, but the point of the article, as far as I can tell, is that medicine doesn’t focus enough on the difficult to measure aspects of health, which I agree is an important point, and that might be, in part, due to the fact that the powers that be have no motivation to dredge up these complex issues. Bringing the discussion of medicine as a science is neither informative or, I think, accurate.
Here’s an example of this confusion:
My real objection to medicine as a science is that by focusing on what can readily be quantified, it ignores what cannot, such as the social determinants of health and disease.
I can see that point here is that we don’t focus enough on the social determinants of health and being a social epidemiologist, I couldn’t agree more. But why confuse this important idea with the idea that medicine isn’t a science? Ignoring problems doesn’t make something not a science.
Further, is she talking about medical practice here or research? She can’t be talking about research because there is an entire field of research, social epidemiology, that addresses this. Is it difficult to study? Are social determinants of health difficult to quantify? Yes and yes. But what’s being done is still clearly science and, at least some of the time, of value.
If she’s talking about medical practice, are we now expecting our already overburdened front-line physicians to be addressing questions as complex as the social determinants of health? I very much wish we could do this. Actually, I’m told at least one physician has made a good start by inventing what is essentially social pediatrics (unfortunately the website is in French only). It would seem to me more effective to address the social determinants of health at the level of public health and policy, where science is both possible and being done, rather than at the point of care.
As a kind of technical aside, and as I’ve mentioned in a previous post, epidemiology in this case, will never be able to say why an individual gets a particular disease precisely because it is a science and inference on that level isn’t possible (without a time machine!). Epidemiology can answer the question, “why do people get sick?” but not, “why did this person get sick?”
Now into the health care is not health section:
Science prefers to isolate and understand one thing at a time, but the ideas I just mentioned are difficult to separate from their social context and cannot readily be studied in a controlled environment. The topics for medical research that seek and receive funding are those that investigate ‘reductionist’ theories of disease: things that fit neatly into categories sanctioned by the medical establishment and that can be readily measured, compared, and replicated. The cause and effect relationship between stressful living conditions and the health of individuals does not fit neatly into any simple mechanical model with the potential to make successful predictions.
First, science isn’t limited to ‘controlled environments.’ If that were true then, yes, clinical medicine or observational epidemiology wouldn’t be science but then neither would astronomy, climate science (which the writer admitted earlier was a science!) or a number of other alleged sciences. Science is more difficult without ‘controlled environments’ but not impossible.
Second, we can and do study all of the things mentioned. Is it difficult? Yes. Are we as confident in our results as we would be if they came from a trial? Not by a long shot. But these things are being studied to the best of our abilities (although at our social epidemiology journal club I’d probably be more likely to say ‘to the worst of our abilities’!).
I fully agree that the social determinants of health need higher priority in our health system both from the points of view of research and practice. I also agree that it’s disingenuous to say any kind of for-profit health system can have health as its true bottom line. But why drag whether or not medicine is a science into this discussion? Even if there were good arguments for this being true, which is not the case here, why distract from the main points of the post? Then again, if this article hadn’t had these particular quirks, I would have had nothing to write about! Actually, I have a couple partly finished posts that I should really get around to…