I was recently listening to the book “Surely You’re Joking Mr. Feynman.” It’s the autobiography of physicist Richard Feyman, probably the only person about whom you could say that his Nobel Prize wasn’t in the top three most interesting facts about him. It concludes with an adaptation of a graduation address he gave to CalTech graduates in 1974, on the topic of “cargo cult science.” As I listened, I was struck by the call to intellectual rigor in the sciences and how far short we fell during the COVID era. His call for intellectual honesty and the ethic of doing everything you can to disprove your own theories stands in sharp contrast to the advocacy and ad hominem of recent years. From “The first principle is that you must not fool yourself—and you are the easiest person to fool” to “Trust the Science.” In not-quite-fifty years, that’s quite a fall.
But medicine is not science. It is fundamentally still an art, with science as one of its tools. This essay is about how medicine can advance while resisting the pull of the cargo cult, and the principles we should use as guides moving forward.
Medicine is Heterodox. This makes intuitive sense. Given the near-infinite variation in humans, there must be room for more than one approach to health. We saw the opposite of this on display in the initial stages of the COVID pandemic, when the Great Barrington Declaration was declared at the highest level to be beyond the pale and the product of a “fringe group of epidemiologists.” The goal wasn’t to debate the idea, but to delete it. How much better off would we have been if we’d been considering not just caseloads, but the consequences of the COVID strategy? We will have the work of a generation remediating the damage COVID policy caused to children’s emotional and educational growth, and we might have done less harm if we’d entertained the broadest range of ideas at the outset.
Medicine is Humble. This is a corollary of the first point, but I believe deserves its own discussion. Anyone who has practiced knows there are times when no good answers are available, or when we must admit to ourselves we’ve been going down a path that’s a dead end. Humility means having the ability to admit error. Beyond that, it means having the ethic that changing one's mind when given new evidence is not only a reluctant necessity, but actually a virtue. It also means listening. In an era where deplatforming is increasingly common, we should make the greatest effort to hear out our colleagues and patients, especially when their values differ from our own. We must never believe we are so educated that we can’t learn a new point of view.
Medicine is Human. Efforts to turn patients into commodities to be optimized cause moral injury on both sides of the stethoscope. Most practitioners recognize this, but the incentives of modern medicine work to subvert the instinct to care. The fundamental cause of burnout is not hard work, it’s doing work that we know ignores the dignity of the individual in front of us. Putting the person back at the center of medicine will not necessarily be the cost-effective, data-driven solution. But if we don’t find a way to do this, how can we defend the role of the professional at the heart of the patient-care relationship? If we haven’t shown that there’s a difference, we won’t have any grounds to object when humans-doing-algorithms get replaced by machines-doing-algorithms.
“Guiding Rules of Medicine” is far too broad of a topic to cover in a single essay, but these are core principles. If science is a tool in the Art of Medicine, then these truths nurture the Soul that animates the Artist.
Cheers, y’all.
David
Image by 🆓 Use at your Ease 👌🏼from Pixabay
Well said, sir! It will, however (IMHO) take more than a single generation to undo the harm that has been done.
'...we won’t have any grounds to object when humans-doing-algorithms get replaced by machines-doing-algorithms.'
This is so perceptive. It's a slippery slope.