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Doctors are not scientists

BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7454.0-h (Published 17 June 2004) Cite this as: BMJ 2004;328:0-h

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The clinical method is the scientific method applied to the care of a patient

Dear Editor:

We carefully read the interesting Richard Smith editorial “Doctors
are not scientists” (1)

Is medicine art or science? This debate began in the Western
countries 25 centuries ago and it continues today. (2,3) We think that
clinical medicine is art and science. So, clinical doctor has to be, at
the same time, artist and scientist if we want to fulfil both
characteristics of our profession.

The present clinician should not be a passive professional, receiving
“the truth” from others (teachers, books, journals, scientific meetings,
clinical guidelines, systematic reviews, etc.) that give “the truth” to
him and he applies in his daily practice, based on his own “experience”.

The scientific method is not only related with the biomedical
research or clinical trials in Medicine, as it is suggested in the
mentioned editorial (1) but also, and especially, with the clinical method
applied to the patient care. (2-5)

It is known that in all sciences there are many different particular
methods, but there is a unique, general and universal method, which is
applied to the completed cycle of all research because it is common to all
sciences. This is the scientific or experimental method that was
definitively elaborated by Claude Bernard in his book “Introduction to the
study of experimental medicine”, published in the second half of the 19th
century. (3)

Clinics is a practical science, which is expressed in the final
result of the medical care of one sick person. (research study n = 1).
This type of science requires the knowledge of all components of the human
process and its method.

We agree that “a scientist is somebody who constantly questions,
generates falsifiable hypotheses, and collects data from well designed
experiments” (1) Precisely, this is the way of the clinical method, the
correct thinking process for diagnosis, prognosis and treatment of a
patient, when we actively intervene in the always new and natural
“experiment” that represents the health-disease process of one person.
(4,5)

In the diagnostic process the physician goes from the concrete
reality (symptoms and signs obtained by anamnesis and physical
examination) to abstractions and to the concrete them in his thinking.
Later, the medical doctor has to create his diagnostic hypothesis, and
after he indicates lab and imaging studies for its confirmation or
rejection. (2)

The prognosis is also an inherent condition of the modern science. It
is always probabilistic and complex. Here, clinical medicine needs the
assistance of social medicine, epidemiology and health statistics, with
the focus on the individual health problem. (2)

Decision making and therapeutics are the last part of the clinical
method, going to the active contemplation to action, and from
identification and knowledge to transformation until it is permitted by
science and individuality of each patient. (2) This step has to combine
the best available evidences (science) to solve each case and the best
clinical expertise (art).

However, the reality is not always acquired in this methodical way. A
long time ago it is known that in some situations, intuitive diagnosis can
also catch the reality through a synthetic and comprehensive judgment, and
this ability is part of art and humanities. (2,4)

We can assure that the scientific-technological advances of the last
60 years mainly changed the technique, but not the clinics. (4)

Furthermore, Clinical epidemiology brought to medical doctors, in the
last 30 years, new methodological tools for the evaluation of efficacy,
efficiency and effectiveness of many diagnostic and therapeutic procedures
that clinicians daily use with our patients, in order to improve the
quality of care that we offer. (2,3)

So, we can ask: Is it only science the quantitative one, the
experiment, the randomized clinical trial? Where we put the logic
thinking, the rational faculty and qualitative variables as life,
happiness, suffering…? But all these aspects are frequently overviewed or
discriminated. They are considered as “pseudoscience”, soft science or
second class science because those variables can not be exactly measured
and, therefore, they can not be evaluated with “scientific strictness”.
(2,5)

It is true that this type of qualitative research has been less
developed among clinicians, and frequently it has culminated with a
theoretical speech without efficient fruits to medical practice. This does
not minimize its importance, but shows us its backwardness and the
emergent necessity of its development, the only one way to make more
humane our scientific clinical profession.

Alvin Feinstein, one of the fathers of Clinical Epidemiology, looking
for linking quantitative and qualitative approaches of clinical medicine,
has created two classical terms: “Clinimetrics” and “iatrotherapy”. The
first was a meritorious intent to improve quantitative measures based on
clinical variables obtained in our patients, and the second, a qualitative
complement of all different actions that we as physicians do, besides our
“technical” activity. (2,3)

Finally, we think that in spite of many “scores”, risk calculations,
sensitivity, specificity, positive and negative predictive values, and
many other tests, that would support our technical and scientific
diagnoses and treatments, they will never fulfil all expectations of the
patients as human beings, and that so called “art” of our profession will
have the same, or maybe more value than in the past. We do not say that
the medical doctor will not be a practical scientist, but we have to
complement it with the solidarity and humane purpose of our work.

Sincerely,

Prof. Alfredo Espinosa-Brito, MD, PhD

José M. Bermúdez-López, MD

Internal Medicine Department

Teaching Hospital "Dr. Gustavo Aldereguia Lima",
Ave 5 de Septiembre and Calle 51A, Cienfuegos, 55100, CUBA


E-mail: espinosa@perla.inf.cu

References.

1. Smith R. Doctors are not scientists BMJ 2004;328 (19 June),
328.7454

2. Espinosa A. Medicina Interna, ¿qué fuiste, qué eres, qué serás?” Rev
Cubana Med 1999;38(1):79-90.

3. Moreno MA. El arte y la ciencia del diagnóstico médico. Principios
seculares y problemas actuales. La Habana: Científico-Técnica, 2001.

4. Ilizástigui F. El método clínico: muerte y resurrección. Rev Cubana
Educ Med Super 2000;14(2):109-27

5. Rodríguez L. La Clínica y su método. Reflexiones sobre dos épocas.
Madrid: Díaz de Santos, 1999.

Competing interests:
None declared

Competing interests: No competing interests

27 June 2004
Alfredo D. Espinosa-Brito
Calle 37 #5404, Cienfuegos 55 100, Cuba
José M. Barmúdez-López
Hospital Dr. Gustavo Alderguía Lima, Ave 5 de Septiembre and Calle 51 A, Cienfuegos 55 100, Cuba